Neuro
Administration within 3
1. A 68-year-old male patient who had a left-sided stroke is admitted to the hospital. The
patient has right-sided weakness and is unable to perform activities of daily living
without assistance. The nurse is providing oral hygiene to the patient and is preparing
to use a padded tongue blade to open the patient’s mouth. Which nursing measure is
inappropriate when providing oral hygiene to the patient who had a stroke?
Correct Answer: A. Placing the client on the back with a small pillow under the
head.
A helpless client should be positioned on the side, not on the back. This lateral
position helps secretions escape from the throat and mouth, minimizing the risk of
aspiration. Observe the patient for paroxysms of coughing, food dribbling out or
pooling in one side of the mouth, food retained for long periods in the mouth, or nasal
regurgitation when swallowing liquids.
2. A 64-year-old client with a history of hypertension is admitted to the emergency
department with sudden onset right-sided weakness, facial droop, and difficulty
speaking. Which nursing intervention is the highest priority in the initial management
of this client?
Correct Answer: C. Schedule for A STAT computer tomography (CT) scan of the
head.
A CT scan will determine if the client is having a stroke or has a brain tumor or
another neurological disorder. This would also determine if it is a hemorrhagic or
ischemic accident and guide the treatment because only an ischemic stroke can use
rt-PA. Demonstrates structural abnormalities, edema, hematomas, ischemia, and
infarctions. Demonstrates structural abnormalities, edema, hematomas, ischemia,
and infarctions.
3. A client arrives in the emergency department with an ischemic stroke and receives
tissue plasminogen activator (t-PA) administration. Which is the priority nursing
assessment?
Correct Answer: A. Time of onset of current stroke
The time of onset of a stroke to t-PA administration is critical.
hours has better outcomes. Tissue plasminogen activator (tPA) is classified as a
serine protease (enzymes that cleave peptide bonds in proteins). It is thus one of the
essential components of the dissolution of blood clots. Its primary function includes
catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in
dissolving blood clots.
4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary
goal is to control the client’s:
Correct Answer: C. Blood pressure
Controlling the blood pressure is critical because an intracerebral hemorrhage is the
major adverse effect of thrombolytic therapy. Blood pressure should be maintained
according to the physician and is specific to the client’s ischemic tissue needs and
risks of bleeding from treatment. Other vital signs are monitored, but the priority is
blood pressure.
5. What is a priority nursing assessment in the first 24 hours after admission of the client
with a thrombotic stroke?
Correct Answer: B. Pupil size and pupillary response
It is crucial to monitor the pupil size and pupillary response to indicate changes
around the cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial
nerve and are useful in determining whether the brain stem is intact. Pupil size and
equality is determined by a balance between parasympathetic and sympathetic
innervation. Response to light reflects the combined function of the optic (II) and
oculomotor (III) cranial nerves.
6. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack
(TIA). Which medication would the nurse anticipate being ordered for the client on
discharge?
Correct Answer: D. An oral anticoagulant medication.
Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be
anticipated to prevent thrombus formation; and oral (warfarin [Coumadin]) at
 discharge versus intravenous. Oral anticoagulation is indicated for patients with atrial
fibrillation or other cardioembolic sources of TIA.
7. Which assessment data would indicate to the nurse that the client would be at risk for
a hemorrhagic stroke?
Correct Answer: C. A blood pressure of 220/120 mmHg.
Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured
blood vessel in the cranium. Hypertension is the most common cause of hemorrhagic
stroke. Long standing hypertension produces degeneration of media, breakage of the
elastic lamina, and fragmentation of smooth muscles of arteries.
8. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of
severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar
puncture (LP) would be contraindicated in this client in which of the following
circumstances?
Correct Answer: B. Intracranial pressure (ICP) is increased.
Sudden removal of CSF results in pressures lower in the lumbar area than the brain
and favors herniation of the brain; therefore, LP is contraindicated with increased ICP.
A head computed tomogram (CT) should be obtained before performing a lumbar
puncture if there is a concern for increased intracranial pressure. Signs and
symptoms of possible increased intracranial pressure include altered mental status,
focal neurological deficits, new-onset seizure, papilledema, immunocompromised
state, malignancy, history of focal CNS disease (stroke, focal infection, tumor),
concern for mass CNS lesion and age greater than 60 years old.
9. A client with a subdural hematoma becomes restless and confused, with dilation of
the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
Correct Answer: C. To promote osmotic diuresis to decrease ICP.
Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid
from intracellular to intravascular spaces. Although mannitol is used for all the
reasons described, the reduction of ICP in this client is a concern. The mannitol
causes the cells in the brain to dehydrate mildly. The water inside the brain cells
(intracellular water) leaves the cells and enters the bloodstream as the mannitol
draws it out of the cells and into the bloodstream. Once in the bloodstream, the extra
water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys
filter the mannitol into the urine.
10. Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?
Correct Answer: A. Ataxia and confusion
A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates
toxicity. Symptoms of toxicity include confusion and ataxia. The neurotoxic effects are
concentration dependent and can range from mild nystagmus to ataxia, slurred
speech, vomiting, lethargy and eventually coma and death. Paradoxically, at very high
concentrations, phenytoin can lead to seizures.
11. Problems with memory and learning would relate to which of the following lobes?
Correct Answer: D. Temporal
The temporal lobe functions to regulate memory and learning problems because of
the integration of the hippocampus. The hippocampus is responsible for creating
declarative memories–those that can be consciously thought of and verbalized.
Declarative memory can be episodic and semantic. Episodic memory is the ability to
remember a specific occasion in the past in its specific time and place. Meanwhile,
semantic memory is the ability to recall general facts about the world.
12. While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe
could be dysfunctional?
Correct Answer: C. Parietal
The parietal lobe regulates sensory function, which would include the ability to sense
hot or cold objects. The anterior parietal lobe contains the primary sensory cortex
(SI), located in the postcentral gyrus (Broadman area BA 3, 1, 2). SI receives the
majority of the sensory inputs that are coming from the thalamus, and it’s responsible
for interpreting the simple somatosensory signals like (touch, position, vibration,
pressure, pain, temperature).
 13. The client is having a lumbar puncture performed. The nurse would plan to place the
client in which position for the procedure?
Correct Answer: A. Side-lying, with legs pulled up and head bent down onto the
chest
The client undergoing lumbar puncture is positioned lying on the side, with
the legs pulled up to the abdomen, and with the head bent down onto the chest. This
position helps to open the spaces between the vertebrae. The positioning of the
patient in either a lateral recumbent position or sitting position may be used. The
lateral recumbent position is preferred as it will allow an accurate measurement of
opening pressure, and it also reduces the risk of post-lumbar puncture headache.
14. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious
client. Cold water is injected into the left auditory canal. The client exhibits eye
conjugate movements toward the left followed by a rapid nystagmus toward the right.
The nurse understands that this indicates the client has
Correct Answer: C. An intact brainstem
Caloric testing provides information about differentiating between cerebellar
and brainstem lesions. After determining patency of the ear canal, cold or warm water
is injected in the auditory canal. A normal response that indicates intact function of
cranial nerves III, IV, and VIII is conjugate eye movements toward the side being
irrigated, followed by rapid nystagmus to the opposite side. Absent or disconjugate
eye movements indicate brainstem damage.
15. The nurse is caring for the client with increased intracranial pressure. The nurse
would note which of the following trends in vital signs if the ICP is rising?
Correct Answer: B. Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure.
A change in vital signs may be a late sign of increased intracranial pressure.
Trends include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may arise. Cushing triad is a clinical
syndrome consisting of hypertension, bradycardia and irregular respiration and is a
sign of impending brain herniation. This occurs when the ICP is too high the elevation
of blood pressure is a reflex mechanism to maintain CPP.
16. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The
nurse would suspect the client is developing meningitis as a complication of surgery if
the client exhibits:
Correct Answer: B. A positive Brudzinski’s sign
Signs of meningeal irritation compatible with meningitis include nuchal rigidity,
positive Brudzinski’s sign, and positive Kernig’s sign. Brudzinski’s sign is positive
when the client flexes the hips and knees in response to the nurse gently flexing the
head and neck onto the chest. Brudzinski’s sign is characterized by reflexive flexion
of the knees and hips following passive neck flexion. To elicit this sign, the examiner
places one hand on the patient’s chest and the other hand behind the patient’s neck.
The examiner then passively flexes the neck forward and assesses whether the
knees and hips flex.
17. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse
responds based on the knowledge that the human body typically and automatically
responds to pain first with attempts to:
Correct Answer: C. Escape the source of pain.
The client’s innate responses to pain are directed initially toward escaping from the
source of pain. For example, in sudden strong pain like that generated by pricking the
finger, a reflex response occurs within the spinal cord. Motor neurons are activated
and the muscles of the arm contract, moving the hand away from the sharp object.
This occurs in a fraction of a second — before the signal has been relayed on to the
brain — so the client will have pulled his arm away before even becoming conscious
of the pain.
18. The nurse is assessing a child diagnosed with a brain tumor. Which of the following
signs and symptoms would the nurse expect the child to demonstrate? Select all that
apply.
Correct Answer: B, D & E
Vomiting, Lethargy, Head tilt
 Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain
tumor. Clinical manifestations are the result of location and size of the tumor. Tumors
that develop in the brain are called primary tumors. Tumors that spread to the brain
after forming in a different part of the body are called secondary tumors or metastatic
tumors. This article focuses on primary tumors. There are more than 100 types of
primary brain and spinal cord tumors.
19. A lumbar puncture is performed on a child suspected of having bacterial meningitis.
CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and
determines which of the following results would verify the diagnosis?
Correct Answer: B. Cloudy CSF, elevated protein, and decreased glucose.
A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the
case of bacterial meningitis, findings usually include an elevated pressure, turbid or
cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.
20. A nurse is reviewing the record of a child with increased ICP and notes that the child
has exhibited signs of decerebrate posturing. On assessment of the child, the nurse
would expect to note which of the following if this type of posturing was present?
Correct Answer: B. Rigid extension and pronation of the arms and legs.
Decerebrate posturing is characterized by the rigid extension and pronation
of the arms and legs. Synonymous terms for decerebrate posturing include abnormal
extension, decerebrate rigidity, extensor posturing, or decerebrate response.
Decerebrate posturing can be seen in patients with large bilateral forebrain lesions
with progression caudally into the diencephalon and midbrain. It can also be caused
by a posterior fossa lesion compressing the midbrain or rostral pons.
21. Which of the following assessment data indicated nuchal rigidity?
` Correct Answer: A. Positive Kernig’s sign
A positive Kernig’s sign indicated nuchal rigidity, caused by an irritative
lesion of the subarachnoid space. Brudzinski’s sign is also indicative of the condition.
To elicit the Kernig sign, clinicians typically perform the exam with the patient lying
supine with the thighs flexed on the abdomen, and the knees flexed. The examiner
then passively extends the legs. In the presence of meningeal inflammation, the
patient will resist leg extension or describe pain in the lower back or posterior thighs,
which indicates a positive sign.
22. You are preparing to admit a patient with a seizure disorder. Which of the following
actions can you delegate to LPN/LVN?
Correct Answer: C. Set up oxygen and suction equipment.
The LPN/LVN can set up the equipment for oxygen and suctioning.
Supportive care with attention to airway, breathing, and circulation issues are vital.
Clear communication between team members is essential since patients’ clinical
status may abruptly change. Most patients will have a single, brief, uncomplicated
event and return to full consciousness. Detection of any underlying cause of the
seizure or seizures is important, so that appropriate therapy or counseling is
available.
23. If a male client experienced a cerebrovascular accident (CVA) that damaged the
hypothalamus, the nurse would anticipate that the client has problems with:
Correct Answer: A. Body temperature control
The body’s thermostat is located in the hypothalamus; therefore, injury to
that area can cause problems of body temperature control. The spinothalamic tract is
the sensory pathway for pain, temperature and crude touch that originates in the
spinal cord and feeds into the ventral posterolateral nucleus of the thalamus for
further processing, while the ventral posteromedial nucleus receives sensory
information from the trigeminal nerve about the face.
24. A female client admitted to an acute care facility after a car accident develops signs
and symptoms of increased intracranial pressure (ICP). The client is intubated and
placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP
caused by suctioning, the nurse anticipates administering which drug endotracheally
before suctioning?
Correct Answer: C. lidocaine (Xylocaine)
Administering lidocaine via an endotracheal tube may minimize elevations in
ICP caused by suctioning. Lidocaine use, both intravenous (IV) and laryngotracheal
(LT), has been reported to blunt the ICP elevations during intubation. Though one
 would assume that the ICP mediated effects of lidocaine stem from its local
anesthetic effect, there are other proposed mechanisms of ICP reduction via the IV
route. Lidocaine injected IV has been shown in models to induce cerebral
vasoconstriction leading to a decrease in cerebral blood volume and thus ICP.
Furthermore, IV lidocaine leads to sodium channel inhibition and thus a reduction in
cerebral activity and metabolic demands, as well as excitotoxicity, leading to a
potential ICP reduction effect.
25. After striking his head on a tree while falling from a ladder, a young man age 18 is
admitted to the emergency department. He’s unconscious and his pupils are
nonreactive. Which intervention would be the most dangerous for the client?
Correct Answer: C. Perform a lumbar puncture.
The client’s history and assessment suggest that he may have increased
intracranial pressure (ICP). If this is the case, lumbar puncture shouldn’t be done
because it can quickly decompress the central nervous system and, thereby, cause
additional damage. A head computed tomogram (CT) should be obtained before
performing a lumbar puncture if there is a concern for increased intracranial pressure.
Signs and symptoms of possible increased intracranial pressure include altered
mental status, focal neurological deficits, new-onset seizure, papilledema,
immunocompromised state, malignancy, history of focal CNS disease (stroke, focal
infection, tumor), concern for mass CNS lesion and age greater than 60 years old.
26. The nurse has given the male client with Bell’s palsy instructions on preserving
muscle tone in the face and preventing denervation. The nurse determines that the
client needs additional information if the client states that he or she will:
Correct Answer: D. Exposure to cold and drafts.
Exposure to cold or drafts is avoided. Local application of heat to the face
may improve blood flow and provide comfort. Facial pain is controlled with analgesic
agents or heat applied to the involved side of the face.
27. A female client is admitted to the hospital with a diagnosis of Guillain-Barre
syndrome. The nurse inquires during the nursing admission interview if the client has
a history of:
Correct Answer: D. Respiratory or gastrointestinal infection during the previous
month.
Guillain-Barré syndrome is a clinical syndrome of unknown origin that
involves cranial and peripheral nerves. Many clients report a history of respiratory or
gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits.
Occasionally, the syndrome can be triggered by vaccination or surgery.
28. A female client with Guillain-Barre syndrome has ascending paralysis and is intubated
and receiving mechanical ventilation. Which of the following strategies would the
nurse incorporate in the plan of care to help the client cope with this illness?
Correct Answer: C. Providing information, giving positive feedback, and
encouraging relaxation.
The client with Guillain-Barré syndrome experiences fear and anxiety from
the ascending paralysis and sudden onset of the disorder. The nurse can alleviate
these fears by providing accurate information about the client’s condition, giving
expert care and positive feedback to the client, and encouraging relaxation and
distraction. The family can become involved with selected care activities and provide
diversion for the client as well.
29. A male client has an impairment of cranial nerve II. Specific to this impairment, the
nurse would plan to do which of the following to ensure the client to ensure client
safety?
Correct Answer: D. Provide a clear path for ambulation without obstacles.
Cranial nerve II is the optic nerve, which governs vision. The nurse can
provide safety for the visually impaired client by clearing the path of obstacles when
ambulating. Compromise of the optic nerve results in visual field defects and/or visual
loss. The type of visual field defect depends on which region of the optic pathway is
disrupted.
30. A female client has a neurological deficit involving the limbic system. Specific to this
type of deficit, the nurse would document which of the following information related to
the client’s behavior.
Correct Answer: B. Affect is flat, with periods of emotional lability.
The limbic system is responsible for feelings (affect) and emotions. While the
limbic system was initially suggested to be the sole neurological system involved in
regulating emotion, it is now considered only one part of the brain to regulate visceral,
autonomic processes. In general, the limbic system assists in various processes
relating to cognition; including spatial memory, learning, motivation, emotional
processing, and social processing.
31. A client who had a stroke is seen bumping into things on the side and is having
difficulty picking up the beginning of the next line of what he is reading. The client is
experiencing which of the following conditions?
Correct Answer: D. Homonymous Hemianopsia
Homonymous Hemianopsia is the loss of half of the visual field. It is usually
caused by a stroke, brain tumor, and trauma. A client with hemianopia may bump into
things on the side of the visual field defect and often lose their place in reading due to
the visual field loss.
32. Which of the following medical treatments should the nurse anticipate administering
to a client with increased intracranial pressure due to brain hemorrhage, except?
Correct Answer: E. nitroglycerin (Nitrostat)
Decreasing blood pressure is essential to prevent exacerbation of
intracerebral bleeding. However, BP medication such as nitroglycerin is avoided due
to its vasodilating effects that increase cerebral blood volume and thus increases
intracranial pressure.
33. Which of the following symptoms would you expect to a client with a phenytoin level
of 35 mg/dL?
Correct Answer: A. Ataxia
A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 35 mg/dl signifies
toxicity. Symptoms of this level of concentration include ataxia, tremor, slurred
speech, nausea, and vomiting.
34. . Select the main structures below that play a role with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater
The answers are A, C, and D. Inside the skull are three structures that can alter
intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.
35. The Monro-Kellie hypothesis explains the compensatory relationship among the
structures in the skull that play a role with intracranial pressure. Which of the following
are NOT compensatory mechanisms performed by the body to decrease intracranial
pressure naturally? Select all that apply:
A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
D. Leaking proteins into the brain barrier
The answers are B and D. These are NOT compensatory mechanisms, but actions
that will actually increase intracranial pressure. Vasoconstriction (not dilation)
decreases blood flow and helps lower ICP. Leaking of protein actually leads to more
swelling of the brain tissue. Remember water is attracted to protein (oncotic
pressure).
36. A patient is being treated for increased intracranial pressure. Which activities below 39. 6. Which patient below is at MOST risk for increased intracranial pressure?
should the patient avoid performing?
A. Coughing A. A patient who is experiencing severe hypotension.
B. Sneezing B. A patient who is admitted with a traumatic brain injury.
C. Talking C. A patient who recently experienced a myocardial infarction.
D. Valsalva maneuver D. A patient post-op from eye surgery.
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees The answer is B. Remember head trauma, cerebral hemorrhage, hematoma,
hydrocephalus, tumor, encephalitis etc. can all increase ICP.
The answers are A, B, D, and E. These activities can increase ICP.
40. A patient with increased ICP has the following vital signs: blood pressure 99/60, HR
37. A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient 65, Temperature 101.6 ‘F, respirations 14, oxygen saturation of 95%. ICP reading is
has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? 21 mmHg. Based on these findings you would?

A. cause vasoconstriction and decrease the ICP A. Administered PRN dose of a vasopressor
B. promote diuresis and decrease the ICP B. Administer 2 L of oxygen
C. cause vasodilation and increase the ICP C. Remove extra blankets and give the patient a cool bath
D. cause vasodilation and decrease the ICP D. Perform suctioning

The answer is C. An elevated carbon dioxide level (52 is high…normal 35-45) in the
blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP
5 to 15 mmHg). Therefore, many patients with severe ICP may need to be
mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to
vasoconstriction and decrease ICP (with constriction there is less blood volume and
flow going to the brain and this helps decrease pressure)….remember Monro-Kellie
hypothesis.
38. You’re providing education to a group of nursing students about ICP. You explain that
when cerebral perfusion pressure falls too low the brain is not properly perfused and
brain tissue dies. A student asks, “What is a normal cerebral perfusion pressure
level?” Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg
The answer is B. This is a normal CPP. Option A represents a normal intracranial
pressure.
The answer is C. It is important to monitor the patient for hyperthermia (a fever). A
fever increases ICP and cerebral blood volume, and metabolic needs of the patient.
The nurse can administer antipyretics per MD order, remove extra blankets, decrease
room temperature, give a cool bath or use a cooling system. Remember it is
important to prevent shivering (this also increases metabolic needs and ICP).
41. A patient has a ventriculostomy. Which finding would you immediately report to the
doctor?
A. Temperature 98.4 ‘F
B. CPP 70 mmHg
C. ICP 24 mmHg
D. PaCO2 35
The answer is C. A ventriculostomy is a catheter inserted in the area of the lateral
ventricle to assess ICP. It will help drain CSF during increased pressure readings and
measure ICP. The nurse must monitor for ICP levels greater than 20 mmHg and
report it to the doctor.
42. External ventricular drains monitor ICP and are inserted where? The answer is C. Mental status changes are the earliest indicator a patient is
experiencing increased ICP. All the other signs and symptoms listed happen later.
A. Subarachnoid space
B. Lateral Ventricle 46. Select all the signs and symptoms that occur with increased ICP:
C. Epidural space
D. Right Ventricle A. Decorticate posturing
B. Tachycardia
The answer is B. External ventricular drains (also called ventriculostomy) are C. Decrease in pulse pressure
inserted in the lateral ventricle. D. Cheyne-stokes
E. Hemiplegia
43. Which of the following is contraindicated in a patient with increased ICP? F. Decerebrate posturing

A. Lumbar puncture The answers are A, D, E, and F. Option B is wrong because bradycardia (not
B. Midline position of the head tachycardia) happens in the late stage along with an INCREASE (not decrease) in
C. Hyperosmotic diuretics pulse pressure.
D. Barbiturates medications
47. You’re maintaining an external ventricular drain. The ICP readings should be?
The answer is A. LPs are avoided in patients with ICP because they can lead to
possible brain herniation. A. 5 to 15 mmHg
B. 20 to 35 mmHg
44. You’re collecting vital signs on a patient with ICP. The patient has a Glascoma Scale C. 60 to 100 mmHg
rating of 4. How will you assess the patient’s temperature? D. 5 to 25 mmHg

A. Rectal The answer is A. Normal ICP should be 5 to 15 mmHg.

B. Oral
C. Axillary 48. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the
following:
The answer is A. This GCS rating demonstrates the patient is unconscious. If a
patient is unconscious the nurse should take the patient’s temperature either via the A. BP 150/112, HR 110, RR 8
rectal, tympanic, or temporal method. Oral and axillary are not reliable. B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
45. A patient who experienced a cerebral hemorrhage is at risk for developing increased D. BP 80/40, HR 49, RR 12
ICP. Which sign and symptom below is the EARLIEST indicator the patient is having
this complication? The answer is C. These vital signs represent Cushing’s triad. There is an increase in
the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and
A. Bradycardia bradypnea.
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size
49. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the The answer is D. Avoid flexing the hips because this can increase intra-abdominal/thoracic
patient’s cerebral perfusion pressure, and how do you interpret this as the nurse? pressure, which will increase ICP.

A. 90 mmHg, normal 53. During the eye assessment of a patient with increased ICP, you need to assess the
B. 62 mmHg, abnormal oculocephalic reflex. If the patient has brain stem damage what response will you
C. 36 mmHg, abnormal find?
D. 56 mmHg, normal
A. The eyes will roll down as the head is moved side to side.
The answer is A. CPP is calculated by the following formula: CPP=MAP-ICP. The B. The eyes will move in the opposite direction as the head is moved side to side
patient’s CPP is 90 and this is normal. A normal CPP is 60-100 mmHg. C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to
50. According to question 16, the patient’s blood pressure is 130/88. What is the patient’s side.
mean arterial pressure (MAP)?
The answer is D. This is known as a negative doll’s eye and represents brain stem
A. 42 damage. It is a very bad sign.
B. 74
C. 102 54. A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT
D. 88 about this medication?

The answer is C. MAP is calculated by taking the DBP (88) and multiplying it by 2. A. Mannitol will remove water from the brain and place it in the blood to be removed
This equals 176. Then take this number and add the SBP (130). This equals 306. from the body.
Then take this number and divide by 3, which equal 102. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
C. When a patient receives Mannitol the nurse must monitor the patient for both fluid
51. During the assessment of a patient with increased ICP, you note that the patient’s volume overload and depletion.
arms are extended straight out and toes pointed downward. You will document this D. Mannitol is not for patients who are experiencing anuria.
as:
The answer is B. All the other options are correct. Mannitol will PREVENT (not cause)
A. Decorticate posturing water and electrolytes (specifically sodium and chloride) from being
B. Decerebrate posturing reabsorbed….hence it will leave the body as urine.
C. Flaccid posturing
55. What assessment finding requires immediate intervention if found while a patient is
The answer is B. receiving Mannitol?

52. While positioning a patient in bed with increased ICP, is it important to avoid? A. An ICP of 10 mmHg
B. Crackles throughout lung fields
A. Midline positioning of the head C. BP 110/72
B. Placing the HOB at 30-35 degrees D. Patient complains of dry mouth and thirst
C. Preventing flexion of the neck
D. Flexion of the hips
 The answer is B. Mannitol can cause fluid volume overload that leads to heart failure
and pulmonary edema. Crackles in the lung fields represent pulmonary edema and
require immediate intervention. Option A is a normal ICP reading and shows the
mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur
with this medication because remember we are trying to dehydrate the brain to keep
edema and intracranial pressure decreased.
56. The nurse is performing a mental status examination on a male client diagnosed with
a subdural hematoma. This test assesses which of the following?
Correct Answer: C. Cerebral function
The mental status examination assesses functions governed by the
cerebrum. Some of these are orientation, attention span, judgment, and abstract
reasoning. Cerebrum is the largest part of the brain and is composed of right and left
hemispheres. It performs higher functions like interpreting touch, vision, and hearing,
as well as speech, reasoning, emotions, learning, and fine control of movement.
57. Shortly after admission to an acute care facility, a male client with a seizure disorder
develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat.
How soon can the nurse administer the second dose of diazepam, if needed and
prescribed?
Correct Answer: B. In 10 to 15 minutes
When used to treat status epilepticus, diazepam may be given every 10 to
15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the
regimen in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in
24 hours. It is crucial to monitor respiratory and cardiovascular status, blood pressure,
heart rate, and symptoms of anxiety in patients taking diazepam.
58. A female client complains of periorbital aching, tearing, blurred vision, and
photophobia in her right eye. Ophthalmologic examination reveals a small, irregular,
nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part
of the client’s therapeutic regimen, the physician prescribes atropine sulfate
(Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate
belongs to which drug classification?
Correct Answer: D. Cholinergic blocker
Atropine sulfate is a cholinergic blocker. It isn’t a parasympathomimetic agent, a
sympatholytic agent, or an adrenergic blocker. Atropine is an antimuscarinic that
works through competitive inhibition of postganglionic acetylcholine receptors and
direct vagolytic action, which leads to parasympathetic inhibition of the acetylcholine
receptors in smooth muscle.
59. Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days
ago. Which of the following findings should the nurse consider abnormal?
Correct Answer: C. Urine retention or incontinence.
Urine retention or incontinence may indicate cauda equina syndrome, which requires
immediate surgery. Cauda equina syndrome (CES) results from compression and
disruption of the function of these nerves and can be inclusive of the conus medullaris
or distal to it, and most often occurs when damage occurs to the L3-L5 nerve roots.
60. A female client who’s paralyzed on the left side has been receiving physical therapy
and attending teaching sessions about safety. Which behavior indicates that the client
accurately understands safety measures related to paralysis?
Correct Answer: B. The client uses a mirror to inspect the skin.
Using a mirror enables the client to inspect all areas of the skin for signs of
breakdown without the help of staff or family members. Inspect skin daily. Observe for
pressure areas, and provide meticulous skincare. Teach the patient to inspect skin
surfaces and to use a mirror to look at hard-to-see-areas. Altered circulation, loss of
sensation, and paralysis potentiate pressure sore formation. This is a lifelong
consideration.
61. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine
(Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase
agent, the nurse reviews the client’s history. Which preexisting condition would
contraindicate the use of pyridostigmine?
 Correct Answer: C. Intestinal obstruction
Anticholinesterase agents such as pyridostigmine are contraindicated in a client with
a mechanical obstruction of the intestines or urinary tract, peritonitis, or
hypersensitivity to anticholinesterase agents. Pyridostigmine bromide is preferred
over neostigmine because of its longer duration of action. In those with bromide
intolerance that leads to gastrointestinal effects, ambenonium chloride can be used.
Patients with MuSK MG respond poorly to these drugs and hence may require higher
doses.
62. A male client is admitted with a cervical spine injury sustained during a diving
accident. When planning this client’s care, the nurse should assign the highest priority
to which nursing diagnosis?
Correct Answer: B. Ineffective breathing pattern
Because a cervical spine injury can cause respiratory distress, the nurse should take
immediate action to maintain a patent airway and provide adequate oxygenation.
Maintain patent airway: keep head in neutral position, elevate head of bed slightly if
tolerated, use airway adjuncts as indicated. Patients with high cervical injury and
impaired gag and cough reflexes require assistance in preventing aspiration and
maintaining patient airway.
63. A male client has a history of painful, continuous muscle spasms. He has taken
several skeletal muscle relaxants without experiencing relief. His physician prescribes
diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve
painful muscle spasms, Diazepam also is recommended for:
Correct Answer: D. Treatment of spasticity associated with spinal cord lesions.
In addition to relieving painful muscle spasms, Diazepam also is recommended for
treatment of spasticity associated with spinal cord lesions. Diazepam’s use is limited
by its central nervous system effects and the tolerance that develops with prolonged
use. It is a fast-acting, long-lasting benzodiazepine commonly used in the treatment
of anxiety disorders, as well as alcohol detoxification, acute recurrent seizures,
severe muscle spasm, and spasticity associated with neurologic disorders.
64. A female client who was found unconscious at home is brought to the hospital by a
rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic
(doll’s eye) response by:
Correct Answer: C. Turning the client’s head suddenly while holding the eyelids
open.
To elicit the oculocephalic response, which detects cranial nerve compression, the
nurse turns the client’s head suddenly while holding the eyelids open. Normally, the
eyes move from side to side when the head is turned; in an abnormal response, the
eyes remain fixed. The oculocephalic reflex (doll’s eyes reflex) is an application of the
vestibular-ocular reflex (VOR) used for neurologic examination of cranial nerves 3, 6,
and 8, the reflex arc including brainstem nuclei, and overall gross brainstem function.
65. A female client who was trapped inside a car for hours after a head-on collision is
rushed to the emergency department with multiple injuries. During the neurologic
examination, the client responds to painful stimuli with decerebrate posturing. This
finding indicates damage to which part of the brain?
Correct Answer: C. Midbrain
Decerebrate posturing, characterized by abnormal extension in response to painful
stimuli, indicates damage to the midbrain. Decerebrate posturing can be seen in
patients with large bilateral forebrain lesions with progression caudally into the
diencephalon and midbrain. It can also be caused by a posterior fossa lesion
compressing the midbrain or rostral pons.
66. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which
of the following symptoms would the nurse expect to find?
Correct Answer: A. Vision changes
Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of
multiple sclerosis. Multiple sclerosis (MS) is a chronic autoimmune disease of the
central nervous system (CNS) characterized by inflammation, demyelination, gliosis,
and neuronal loss. Neurological symptoms vary and can include vision impairment,
numbness and tingling, focal weakness, bladder and bowel incontinence, and
cognitive dysfunction. Symptoms vary depending on lesion location.
67. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports 70. For a male client with suspected increased intracranial pressure (ICP), a most
a severe headache. Which action should the nurse perform? appropriate respiratory goal is to:

Correct Answer: D. Call the physician immediately. Correct Answer: C. Promote carbon dioxide elimination.

A headache may be an indication that an aneurysm is leaking. The nurse should
notify the physician immediately. Unruptured cerebral aneurysms are asymptomatic
and are therefore unable to be detected based on history and physical exam alone.
However, when ruptured, they commonly present with a sudden onset, severe
headache. This is classically described as a “thunderclap headache” or “worst
headache of my life.” In 30% of patients, the pain is lateralized to the side of the
aneurysm.
The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is
because an acid environment in the brain causes cerebral vessels to dilate and
therefore increases ICP. Hypercarbia lowers serum pH and can increase cerebral
blood flow contributing to rising ICP, hence hyperventilation to lower pCO2 to around
30 mm Hg can be transiently used.
71.

68. During recovery from a cerebrovascular accident (CVA), a female client is given
nothing by mouth, to help prevent aspiration. To determine when the client is ready for
a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This
assessment evaluates:

Correct Answer: D. Cranial nerves IX and X.

Swallowing is a motor function of cranial nerves IX and X. Cranial nerve IX

(glossopharyngeal nerve), is responsible for motor (SVE) innervation of the
stylopharyngeus and the pharyngeal constrictor muscles by the nucleus ambiguus.
Damage to the recurrent laryngeal branch of the vagus nerve can result in vocal
hoarseness or acute dyspnea with bilateral avulsion.

69. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory
muscles and requires mechanical ventilation. When the client asks the nurse about
the paralysis, how should the nurse respond?

Correct Answer: A. “You may have difficulty believing this, but the paralysis
caused by this disease is temporary.”

The nurse should inform the client that the paralysis that accompanies Guillain-Barré
syndrome is only temporary. Return of motor function begins proximally and extends
distally in the legs. Guillain-Barre syndrome (GBS) patients describe a fulminant
course of symptoms that usually include ascending weakness and non-length
dependent sensory symptoms. By definition, the nadir is usually reached within 4
weeks. Symmetric involvement is a key feature of GBS.