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1. What is the priority nursing diagnosis for a patient experiencing a migraine

headache dd?

a. Acute pain related to biologic and chemical factors

b. Anxiety related to change in or threat to health status
c. Hopelessness related to deteriorating physiological condition
d. Risk for Side effects related to medical therapy

2. You are creating a teaching plan for a patient with newly diagnosed
migraine headaches. Which key items should be included in the teaching
plan? (Choose all that apply).

a. Avoid foods that contain tyramine, such as alcohol and aged cheese.
b. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
c. Abortive therapy is aimed at eliminating the pain during the aura.
d. A potential side effect of medications is rebound headache.
e. Complementary therapies such as relaxation may be helpful.
f. Continue taking estrogen as prescribed by your physician.

3. The patient with migraine headaches has a seizure. After the seizure,
which action can you delegate to the nursing assistant?

a. Document the seizure.

b. Perform neurologic checks.
c. Take the patients vital signs.
d. Restrain the patient for protection.

4. You are preparing to admit a patient with a seizure disorder. Which of the
following actions can you delegate to LPN/LVN?

a. Complete admission assessment.

b. Set up oxygen and suction equipment.
c. Place a padded tongue blade at bedside.
d. Pad the side rails before patient arrives.

5. A nursing student is teaching a patient and family about epilepsy prior to

the patients discharge. For which statement should you intervene?

a. You should avoid consumption of all forms of alcohol.

b. Wear you medical alert bracelet at all times.
c. Protect your loved ones airway during a seizure.
d. Its OK to take over-the-counter medications.

6. A patient with Parkinsons disease has a nursing diagnosis of Impaired

Physical Mobility related to neuromuscular impairment. You observe a
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nursing assistant performing all of these actions. For which action must you
intervene?

a. The NA assists the patient to ambulate to the bathroom and back to bed.
b. The NA reminds the patient not to look at his feet when he is walking.
c. The NA performs the patients complete bath and oral care.
d. The NA sets up the patients tray and encourages patient to feed himself.

7. The nurse is preparing to discharge a patient with chronic low back pain.
Which statement by the patient indicates that additional teaching is
necessary?

a. I will avoid exercise because the pain gets worse.

b. I will use heat or ice to help control the pain.
c. I will not wear high-heeled shoes at home or work.
d. I will purchase a firm mattress to replace my old one.

8. A patient with a spinal cord injury (SCI) complains about a severe

throbbing headache that suddenly started a short time ago. Assessment of
the patient reveals increased blood pressure (168/94) and decreased heart
rate (48/minute), diaphoresis, and flushing of the face and neck. What action
should you take first?

a. Administer the ordered acetaminophen (Tylenol).

b. Check the Foley tubing for kinks or obstruction.
c. Adjust the temperature in the patients room.
d. Notify the physician about the change in status.

9. Which patient should you, as charge nurse, assign to a new graduate RN

who is orienting to the neurologic unit?

a. A 28-year-old newly admitted patient with spinal cord injury

b. A 67-year-old patient with stroke 3 days ago and left-sided weakness
c. An 85-year-old dementia patient to be transferred to long-term care today
d. A 54-year-old patient with Parkinsons who needs assistance with bathing

10. A patient with a spinal cord injury at level C3-4 is being cared for in the
ED. What is the priority assessment?

a. Determine the level at which the patient has intact sensation.

b. Assess the level at which the patient has retained mobility.
c. Check blood pressure and pulse for signs of spinal shock.
d. Monitor respiratory effort and oxygen saturation level.
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11. You are pulled from the ED to the neurologic floor. Which action should
you delegate to the nursing assistant when providing nursing care for a
patient with SCI?

a. Assess patients respiratory status every 4 hours.

b. Take patients vital signs and record every 4 hours.
c. Monitor nutritional status including calorie counts.
d. Have patient turn, cough, and deep breathe every 3 hours.

12. You are helping the patient with an SCI to establish a bladder-retraining
program. What strategies may stimulate the patient to void? (Choose all that
apply).

a. Stroke the patients inner thigh.

b. Pull on the patients pubic hair.
c. Initiate intermittent straight catheterization.
d. Pour warm water over the perineum.
e. Tap the bladder to stimulate detrusor muscle.

13. The patient with a cervical SCI has been placed in fixed skeletal traction
with a halo fixation device. When caring for this patient the nurse may
delegate which action (s) to the LPN/LVN? (Choose all that apply).

a. Check the patients skin for pressure form device.

b. Assess the patients neurologic status for changes.
c. Observe the halo insertion sites for signs of infection.
d. Clean the halo insertion sites with hydrogen peroxide.

14. You are preparing a nursing care plan for the patient with SCI including
the nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The
patient tells you, I dont know why were doing all this. My lifes over. What
additional nursing diagnosis takes priority based on this statement?

a. Risk for Injury related to altered mobility

b. Imbalanced Nutrition, Less Than Body Requirements
c. Impaired Adjustment to Spinal Cord Injury
d. Poor Body Image related to immobilization

15. Which patient should be assigned to the traveling nurse, new to

neurologic nursing care, who has been on the neurologic unit for 1 week?

a. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)

b. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
c. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory
distress
d. A 25-year-old patient admitted with CA level spinal cord injury (SCI)
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16. The patient with multiple sclerosis tells the nursing assistant that after
physical therapy she is too tired to take a bath. What is your priority nursing
diagnosis at this time?

a. Fatigue related to disease state

b. Activity Intolerance due to generalized weakness
c. Impaired Physical Mobility related to neuromuscular impairment
d. Self-care Deficit related to fatigue and neuromuscular weakness

17. The LPN/LVN, under your supervision, is providing nursing care for a
patient with GBS. What observation would you instruct the LPN/LVN to report
immediately?

a. Complaints of numbness and tingling

b. Facial weakness and difficulty speaking
c. Rapid heart rate of 102 beats per minute
d. Shallow respirations and decreased breath sounds

18. The nursing assistant reports to you, the RN, that the patient with
myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate
of 120/minute, rise in blood pressure (158/94), and was incontinent off urine
and stool. What is your best first action at this time?

a. Administer an acetaminophen suppository.

b. Notify the physician immediately.
c. Recheck vital signs in 1 hour.
d. Reschedule patients physical therapy.

19. You are providing care for a patient with an acute hemorrhage stroke.
The patients husband has been reading a lot about strokes and asks why his
wife did not receive alteplase. What is your best response?

a. Your wife was not admitted within the time frame that alteplase is usually
given.
b. This drug is used primarily for patients who experience an acute heart
attack.
c. Alteplase dissolves clots and may cause more bleeding into your wifes
brain.
d. Your wife had gallbladder surgery just 6 months ago and this prevents the
use of alteplase.

20. You are supervising a senior nursing student who is caring for a patient
with a right hemisphere stroke. Which action by the student nurse requires
that you intervene?
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a. The student instructs the patient to sit up straight, resulting in the

patients puzzled expression.
b. The student moves the patients tray to the right side of her over-bed tray.
c. The student assists the patient with passive range-of-motion (ROM)
exercises.
d. The student combs the left side of the patients hair when the patient
combs only the right side.

21. Which action (s) should you delegate to the experienced nursing
assistant when caring for a patient with a thrombotic stroke with residual
left-sided weakness? (Choose all that apply).

a. Assist patient to reposition every 2 hours.

b. Reapply pneumatic compression boots.
c. Remind patient to perform active ROM.
d. Check extremities for redness and edema.

22.The patient who had a stroke needs to be fed. What instruction should
you give to the nursing assistant who will feed the patient?

a. Position the patient sitting up in bed before you feed her.

b. Check the patients gag and swallowing reflexes.
c. Feed the patient quickly because there are three more waiting.
d. Suction the patients secretions between bites of food.

23. You have just admitted a patient with bacterial meningitis to the medical-
surgical unit. The patient complains of a severe headache with photophobia
and has a temperature of 102.60 F orally. Which collaborative intervention
must be accomplished first?

a. Administer codeine 15 mg orally for the patients headache.

b. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
c. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
d. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.

24. You are mentoring a student nurse in the intensive care unit (ICU) while
caring for a patient with meningococcal meningitis. Which action by the
student requires that you intervene immediately?

a. The student enters the room without putting on a mask and gown.
b. The student instructs the family that visits are restricted to 10 minutes.
c. The student gives the patient a warm blanket when he says he feels cold.
d. The student checks the patients pupil response to light every 30 minutes.

25. A 23-year-old patient with a recent history of encephalitis is admitted to

the medical unit with new onset generalized tonic-clonic seizures. Which
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nursing activities included in the patients care will be best to delegate to an

LPN/LVN whom you are supervising? (Choose all that apply).

a. Document the onset time, nature of seizure activity, and postictal

behaviors for all seizures.
b. Administer phenytoin (Dilantin) 200 mg PO daily.
c. Teach patient about the need for good oral hygiene.
d. Develop a discharge plan, including physician visits and referral to the
Epilepsy Foundation.

26.While working in the ICU, you are assigned to care for a patient with a
seizure disorder. Which of these nursing actions will you implement first if
the patient has a seizure?

a. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.

b. Administer lorazepam (Ativan) 1 mg IV.
c. Turn the patient to the side and protect airway.
d. Assess level of consciousness during and immediately after the seizure.

27. A patient recently started on phenytoin (Dilantin) to control simple

complex seizures is seen in the outpatient clinic. Which information obtained
during his chart review and assessment will be of greatest concern?

a. The gums appear enlarged and inflamed.

b. The white blood cell count is 2300/mm3.
c. Patient occasionally forgets to take the phenytoin until after lunch.
d. Patient wants to renew his drivers license in the next month.

28. After receiving a change-of-shift report at 7:00 AM, which of these

patients will you assess first?

a. A 23-year-old with a migraine headache who is complaining of severe

nausea associated with retching
b. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs
preoperative teaching
c. A 59-year-old with Parkinsons disease who will need a swallowing
assessment before breakfast
d. A 63-year-old with multiple sclerosis who has an oral temperature of
101.80 F and flank pain

29. All of these nursing activities are included in the care plan for a 78-year-
old man with Parkinsons disease who has been referred to your home health
agency. Which ones will you delegate to a nursing assistant (NA)? (Choose all
that apply).

a. Check for orthostatic changes in pulse and bloods pressure.

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b. Monitor for improvement in tremor after levodopa (L-dopa) is given.

c. Remind the patient to allow adequate time for meals.
d. Monitor for abnormal involuntary jerky movements of extremities.
e. Assist the patient with prescribed strengthening exercises.
f. Adapt the patients preferred activities to his level of function.

30. As the manager in a long-term-care (LTC) facility, you are in charge of

developing a standard plan of care for residents with Alzheimers disease.
Which of these nursing tasks is best to delegate to the LPN team leaders
working in the facility?

a. Check for improvement in resident memory after medication therapy is

initiated.
b. Use the Mini-Mental State Examination to assess residents every 6
months.
c. Assist residents to toilet every 2 hours to decrease risk for urinary
intolerance.
d. Develop individualized activity plans after consulting with residents and
family.

31. A patient who has been admitted to the medical unit with new-onset
angina also has a diagnosis of Alzheimers disease. Her husband tells you
that he rarely gets a good nights sleep because he needs to be sure she
does not wander during the night. He insists on checking each of the
medications you give her to be sure they are the same as the ones she takes
at home. Based on this information, which nursing diagnosis is most
appropriate for this patient?

a. Decreased Cardiac Output related to poor myocardial contractility

b. Caregiver Role Strain related to continuous need for providing care
c. Ineffective Therapeutic Regimen Management related to poor patient
memory
d. Risk for Falls related to patient wandering behavior during the night

32. You are caring for a patient with a recurrent glioblastoma who is receiving
dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of
right arm weakness and headache. Which assessment information concerns
you the most?

a. The patient does not recognize family members.

b. The blood glucose level is 234 mg/dL.
c. The patient complains of a continued headache.
d. The daily weight has increased 1 kg.

33. A 70-year-old alcoholic patient with acute lethargy, confusion, and

incontinence is admitted to the hospital ED. His wife tells you that he fell
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down the stairs about a month ago, but he didnt have a scratch afterward.
She feels that he has become gradually less active and sleepier over the last
10 days or so. Which of the following collaborative interventions will you
implement first?

a. Place on the hospital alcohol withdrawal protocol.

b. Transfer to radiology for a CT scan.
c. Insert a retention catheter to straight drainage.
d. Give phenytoin (Dilantin) 100 mg PO.

34. Which of these patients in the neurologic ICU will be best to assign to an
RN who has floated from the medical unit?

a. A 26-year-old patient with a basilar skull structure who has clear drainage
coming out of the nose
b. A 42-year-old patient admitted several hours ago with a headache and
diagnosed with a ruptured berry aneurysm.
c. A 46-year-old patient who was admitted 48 hours ago with bacterial
meningitis and has an antibiotic dose due
d. A 65-year-old patient with a astrocytoma who has just returned to the unit
after having a craniotomy

Answers and Rationales

Here are the answers and rationale for this exam. Counter check your
answers to those below and tell us your scores. If you have any disputes or
need more clarification to a certain question, please direct them to the
comments section.

1. Answer: A The priority for interdisciplinary care for the patient

experiencing a migraine headache is pain management. All of the other
nursing diagnoses are accurate, but none of them is as urgent as the issue of
pain, which is often incapacitating. Focus: Prioritization

2. Answers: A, B, C, D & E Medications such as estrogen supplements may

actually trigger a migraine headache attack. All of the other statements are
accurate. Focus: Prioritization

3. Answer: C Taking vital signs is within the education and scope of practice
for a nursing assistant. The nurse should perform neurologic checks and
document the seizure. Patients with seizures should not be restrained;
however, the nurse may guide the patients movements as necessary. Focus:
Delegation/supervision

4. Answer: B The LPN/LVN can set up the equipment for oxygen and
suctioning. The RN should perform the complete initial assessment. Padded
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side rails are controversial in terms of whether they actually provide safety
and ay embarrass the patient and family. Tongue blades should not be at the
bedside and should never be inserted into the patients mouth after a seizure
begins. Focus: Delegation/supervision.

5. Answer: D A patient with a seizure disorder should not take over-the-

counter medications without consulting with the physician first. The other
three statements are appropriate teaching points for patients with seizures
disorders and their families. Focus: Delegation/supervision

6. Answer: C The nursing assistant should assist the patient with morning
care as needed, but the goal is to keep this patient as independent and
mobile as possible. Assisting the patient to ambulate, reminding the patient
not to look at his feet (to prevent falls), and encouraging the patient to feed
himself are all appropriate to goal of maintaining independence. Focus:
Delegation/supervision

7. Answer: A Exercises are used to strengthen the back, relieve pressure on

compressed nerves and protect the back from re-injury. Ice, heat, and firm
mattresses are appropriate interventions for back pain. People with chronic
back pain should avoid wearing high-heeled shoes at all times. Focus:
Prioritization

8. Answer: B These signs and symptoms are characteristic of autonomic

dysreflexia, a neurologic emergency that must be promptly treated to
prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli,
most often a distended bladder or constipation, so checking for poor catheter
drainage, bladder distention, or fecal impaction is the first action that should
be taken. Adjusting the room temperature may be helpful, since too cool a
temperature in the room may contribute to the problem. Tylenol will not
decrease the autonomic dysreflexia that is causing the patients headache.
Notification of the physician may be necessary if nursing actions do not
resolve symptoms. Focus: Prioritization

9. Answer: B The new graduate RN who is oriented to the unit should be

assigned stable, non-complex patients, such as the patient with stroke. The
patient with Parkinsons disease needs assistance with bathing, which is best
delegated to the nursing assistant. The patient being transferred to the
nursing home and the newly admitted SCI should be assigned to experienced
nurses. Focus: Assignment

10. Answer: D The first priority for the patient with an SCI is assessing
respiratory patterns and ensuring an adequate airway. The patient with a
high cervical injury is at risk for respiratory compromise because the spinal
nerves (C3 5) innervate the phrenic nerve, which controls the diaphragm.
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The other assessments are also necessary, but not as high priority. Focus:
Prioritization

11. Answer: B The nursing assistants training and education include taking
and recording patients vital signs. The nursing assistant may assist with
turning and repositioning the patient and may remind the patient to cough
and deep breathe but does not teach the patient how to perform these
actions. Assessing and monitoring patients require additional education and
are appropriate to the scope of practice for professional nurses. Focus:
Delegation/supervision

12. Answers: A, B, D & E- All of the strategies, except straight

catheterization, may stimulate voiding in patients with SCI. Intermittent
bladder catheterization can be used to empty the patients bladder, but it
will not stimulate voiding. Focus: Prioritization

13. Answers: A, C & D Checking and observing for signs of pressure or

infection are within the scope of practice of the LPN/LVN. The LPN/LVN also
has the appropriate skills for cleaning the halo insertion sites with hydrogen
peroxide. Neurologic examination requires additional education and skill
appropriate to the professional RN. Focus: Delegation/supervision

14. Answer: C The patients statement indicates impairment of adjustment

to the limitations of the injury and indicates the need for additional
counseling, teaching, and support. The other three nursing diagnoses may
be appropriate to the patient with SCI, but they are not related to the
patients statement. Focus: Prioritization

15. Answer: B The traveling is relatively new to neurologic nursing and

should be assigned patients whose conditions are stable and not complex.
The newly diagnosed patient will need to be transferred to the ICU. The
patient with C4 SCI is at risk for respiratory arrest. All three of these patients
should be assigned to nurses experienced in neurologic nursing care. Focus:
Assignment

16. Answer: D At this time, based on the patients statement, the priority is
Self-Care Deficit related to fatigue after physical therapy. The other three
nursing diagnoses are appropriate to a patient with MS, but they are not
related to the patients statement. Focus: Prioritization

17. Answer: D The priority interventions for the patient with GBS are aimed
at maintaining adequate respiratory function. These patients are risk for
respiratory failure, which is urgent. The other findings are important and
should be reported to the nurse, but they are not life-threatening. Focus:
Prioritization, delegation/supervision
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18. Answer: B The changes that the nursing assistant is reporting are
characteristics of myasthenia crisis, which often follows some type of
infection. The patient is at risk for inadequate respiratory function. In
addition to notifying the physician, the nurse should carefully monitor the
patients respiratory status. The patient may need incubation and
mechanical ventilation. The nurse would notify the physician before giving
the suppository because there may be orders for cultures before giving
acetaminophen. This patients vital signs need to be re-checked sooner than
1 hour. Rescheduling the physical therapy can be delegated to the unit clerk
and is not urgent. Focus: Prioritization

19. Answer: C Alteplase is a clot buster. With patient who has experienced
hemorrhagic stroke, there is already bleeding into the brain. A drug like
alteplase can worsen the bleeding. The other statements are also accurate
about use of alteplase, but they are not pertinent to this patients diagnosis.
Focus: Prioritization

20. Answer: A Patients with right cerebral hemisphere stroke often present
with neglect syndrome. They lean to the left and when asked, respond that
they believe they are sitting up straight. They often neglect the left side of
their bodies and ignore food on the left side of their food trays. The nurse
would need to remind the student of this phenomenon and discuss the
appropriate interventions. Focus: Delegation/supervision

21. Answer: A, B and C The experienced nursing assistant would know how
to reposition the patient and how to reapply compression boots, and would
remind the patient to perform activities he has been taught to perform.
Assessing for redness and swelling (signs of deep venous thrombosis {DVT})
requires additional education and still appropriate to the professional nurse.
Focus: Delegation/supervision

22. Answer: A Positioning the patient in a sitting position decreases the risk
of aspiration. The nursing assistant is not trained to assess gag or swallowing
reflexes. The patient should not be rushed during feeding. A patient who
needs to be suctioned between bites of food is not handling secretions and is
at risk for aspiration. This patient should be assessed further before feeding.
Focus: Delegation/supervision

23. Answer: B Untreated bacterial meningitis has a mortality are

approaching 100%, so rapid antibiotic treatment is essential. The other
interventions will help reduce CNS stimulation and irritation, and should be
implemented as soon as possible. Focus: Prioritization

24. Answer: A Meningococcal meningitis is spread through contact with

respiratory secretions so use of a mask and gown is required to prevent
spread of the infection to staff members or other patients. The other actions
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may not be appropriate but they do not require intervention as rapidly. The
presence of a family member at the bedside may decrease patient confusion
and agitation. Patients with hyperthermia frequently complain of feeling
chilled, but warming the patient is not an appropriate intervention. Checking
the pupil response to light is appropriate, but it is not needed every 30
minutes and is uncomfortable for a patient with photophobia. Focus:
Prioritization

25. Answer: B Administration of medications is included in LPN education

and scope of practice. Collection of data about the seizure activity may be
accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN
would know to call the supervising RN immediately if a patient started to
seize. Documentation of the seizure, patient teaching, and planning of care
are complex activities that require RN level education and scope of practice.
Focus: Delegation

26. Answer: C The priority action during a generalized tonic-clonic seizure is

to protect the airway. Administration of lorazepam should be the next action,
since it will act rapidly to control the seizure. Although oxygen may be useful
during the postictal phase, the hypoxemia during tonic-clonic seizures is
caused by apnea. Checking the level of consciousness is not appropriate
during the seizure, because generalized tonic-clonic seizures are associated
with a loss of consciousness. Focus: Prioritization

27. Answer: B Leukopenia is a serious adverse effect of phenytoin and

would require discontinuation of the medication. The other data indicate a
need for further assessment and/or patient teaching, but will not require a
change in medical treatment for the seizures. Focus: Prioritization

28. Answer: D Urinary tract infections are a frequent complication in patient

with multiple sclerosis because of the effect on bladder function. The
elevated temperature and decreased breath sounds suggest that this patient
may have pyelonephritis. The physician should be notified immediately so
that antibiotic therapy can be started quickly. The other patients should be
assessed soon, but do not have needs as urgent and this patient. Focus:
Prioritization

29. Answer: S A, C and E NA education and scope of practice includes

taking pulse and blood pressure measurements. In addition, NAs can
reinforce previous teaching or skills taught by the RN or other disciplines,
such as speech or physical therapists. Evaluation of patient response to
medication and development and individualizing the plan of care require RN-
level education and scope of practice. Focus: Delegation

30. Answer: A LPN education and team leader responsibilities include

checking for the therapeutic and adverse effects of medications. Changes in
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the residents memory would be communicated to the RN supervisor, who is

responsible for overseeing the plan of care for each resident. Assessment for
changes on the Mini-Mental State Examination and developing the plan of
care are RN responsibilities. Assisting residents with personal care and
hygiene would be delegated to nursing assistants working the LTC facility.
Focus: Delegation

31. Answer: B The husbands statement about lack of sleep and anxiety
over whether the patient is receiving the correct medications are behaviors
that support this diagnosis. There is no evidence that the patients cardiac
output is decreased. The husbands statements about how he monitors the
patient and his concern with medication administration indicate that the Risk
for Ineffective Therapeutic Regimen Management and falls are not priorities
at this time. Focus: Prioritization

32. Answer: A The inability to recognize a family member is a new

neurologic deficit for this patient, and indicates a possible increase in
intracranial pressure (ICP). This change should be communicated to the
physician immediately so that treatment can be initiated. The continued
headache also indicates that the ICP may be elevated, but it is not a new
problem. The glucose elevation and weight gain are common adverse effects
of dexamethasone that may require treatment, but they are not
emergencies. Focus: Prioritization

33. Answer: B The patients history and assessment data indicate that he
may have a chronic subdural hematoma. The priority goal is to obtain a rapid
diagnosis and send the patient to surgery to have the hematoma evacuated.
The other interventions also should be implemented as soon as possible, but
the initial nursing activities should be directed toward treatment of any
intracranial lesion. Focus: Prioritization

34. Answer: C This patient is the most stable of the patients listed. An RN
from the medical unit would be familiar with administration of IV antibiotics.
The other patients require assessments and care from RNs more experienced
in caring for patients with neurologic diagnoses. Focus: Assignment.

1. Regular oral hygiene is an essential intervention for the client who has had
a stroke. Which of the following nursing measures is inappropriate when
providing oral hygiene?

1. Placing the client on the back with a small pillow under the head.
2. Keeping portable suctioning equipment at the bedside.
3. Opening the clients mouth with a padded tongue blade.
4. Cleaning the clients mouth and teeth with a toothbrush.
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2. A 78-year-old client is admitted to the emergency department with

numbness and weakness of the left arm and slurred speech. Which nursing
intervention is a priority?

1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for A STAT computer tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.

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?

1. Current medications.
2. Complete physical and history.
3. Time of onset of current stroke.
4. Upcoming surgical procedures.

4. During the first 24 hours after thrombolytic therapy for ischemic stroke,
the primary goal is to control the clients:

1. Pulse
2. Respirations
3. Blood pressure
4. Temperature

5. What is a priority nursing assessment in the first 24 hours after admission

of the client with a thrombotic stroke?

1. Cholesterol level
2. Pupil size and pupillary response
3. Bowel sounds
4. Echocardiogram

6. What is the expected outcome of thrombolytic drug therapy?

1. Increased vascular permeability.

2. Vasoconstriction.
3. Dissolved emboli.
4. Prevention of hemorrhage

7. 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?
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1. An oral anticoagulant medication.

2. A beta-blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication.

8. Which client would the nurse identify as being most at risk for
experiencing a CVA?

1. A 55-year-old African American male.

2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female.

9. Which assessment data would indicate to the nurse that the client would
be at risk for a hemorrhagic stroke?

1. A blood glucose level of 480 mg/dl.

2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mmHg.
4. The presence of bronchogenic carcinoma.

10. The nurse and unlicensed assistive personnel (UAP) are caring for a client
with right-sided paralysis. Which action by the UAP requires the nurse to
intervene?

1. The assistant places a gait belt around the clients waist prior to
ambulating.
2. The assistant places the client on the back with the clients head to the
side.
3. The assistant places her hand under the clients right axilla to help
him/her move up in bed.
4. The assistant praises the client for attempting to perform ADLs
independently.

Answers and Rationale

1. Answer: 1. 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.

Option B: It may be necessary to suction, so having suction equipment at the

bedside is necessary.
Option C: Padded tongue blades are safe to use.
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Option D: A toothbrush is appropriate to use.

2. Answer: 3. 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. This would make (1) not the priority since if a
stroke was determined to be hemorrhagic, rt-PA is contraindicated.

Option A: rt-PA is contraindicated.

Options B and D: Discuss the precipitating factors for teaching would not be
a priority and slurred speech would as indicate interference for teaching.
Referring the client for speech therapy would be an intervention after the
CVA emergency treatment is administered according to protocol.
3. Answer: 3. Time of onset of current stroke.

The time of onset of a stroke to t-PA administration is critical. Administration

within 3 hours has better outcomes.

Option A: Current medications are relevant, but the onset of current stroke
takes priority.
Option B: A complete history is not possible in emergency care.
Option D: Upcoming surgical procedures will need to be delay if t-PA is
administered.
4. Answer: 3. 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 physician and is specific to the
clients ischemic tissue needs and risks of bleeding from treatment. Other
vital signs are monitored, but the priority is blood pressure.

5. Answer: 2. Pupil size and pupillary response

It is crucial to monitor the pupil size and pupillary response to indicate

changes around the cranial nerves.

Option A: Cholesterol level is an assessment to be addressed for long-term

healthy lifestyle rehabilitation.
Option C: Bowel sounds need to be assessed because an ileus or constipation
can develop, but is not a priority in the first 24 hours.
Option D: An echocardiogram is not needed for the client with a thrombotic
stroke.
6. Answer: 3. Dissolved emboli.
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Thrombolytic therapy is used to dissolve emboli and reestablish cerebral

perfusion.

7. Answer: 1. An oral anticoagulant medication.

Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant

would be anticipated to prevent thrombi formation; and oral (warfarin
[Coumadin]) at discharge versus intravenous.

Option B: Beta blockers slow the heart rate and lower the blood pressure.
Option C: Anti-hyperuricemic medication is given to clients with gout.
Option D: Thrombolytic medication might have been given at initial
presentation but would not be a drug prescribed at discharge.
8. Answer: 1. A 55-year-old African American male.

African Americans have twice the rate of CVAs as Caucasians; males are
more likely to have strokes than females except in advanced years.

Option B: Orientals have a lower risk, possibly due to their high omega-3
fatty acids.
Option D: Pregnancy is a minimal risk factor for CVA.
9. Answer: 3. 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.

Option A: High blood glucose levels could predispose a patient to ischemic

stroke, but not hemorrhagic.
Option B: Bruit in the carotid artery would predispose a client to an embolic
or ischemic stroke.
Option D: Cancer is not a precursor to stroke.
10. Answer: 3. The assistant places her hand under the clients right axilla to
help him/her move up in bed.

This action is inappropriate and would require intervention by the nurse

because pulling on a flaccid shoulder joint could cause shoulder dislocation;
as always use a lift sheet for the client and nurse safety.

Options A, B, and D: All the other actions are appropriate.

. An 18-year-old client is admitted with a closed head injury sustained in a

MVA. His intracranial pressure (ICP) shows an upward trend. Which
intervention should the nurse perform first?

1. Reposition the client to avoid neck flexion

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2. Administer 1 g Mannitol IV as ordered

3. Increase the ventilators respiratory rate to 20 breaths/minute
4. Administer 100 mg of pentobarbital IV as ordered.

2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading

dose of Dilantin IV. Which consideration is most important when
administering this dose?

1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.

2. Rapid Dilantin administration can cause cardiac arrhythmias.
3. Dilantin should be mixed in dextrose in water before administration.
4. Dilantin should be administered through an IV catheter in the clients
hand.

3. A client with head trauma develops a urine output of 300 ml/hr, dry skin,
and dry mucous membranes. Which of the following nursing interventions is
the most appropriate to perform initially?

1. Evaluate urine specific gravity

2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow down the IV fluids and notify the physician

4. When evaluating an ABG from a client with a subdural hematoma, the

nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best
describes this result?

1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure

(ICP).
2. Emergent; the client is poorly oxygenated.
3. Normal
4. Significant; the client has alveolar hypoventilation.

5. A client who had a transsphenoidal hypophysectomy should be watched

carefully for hemorrhage, which may be shown by which of the following
signs?

1. Bloody drainage from the ears

2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria

6. After a hypophysectomy, vasopressin is given IM for which of the following

reasons?

1. To treat growth failure

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2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)

3. To reduce cerebral edema and lower intracranial pressure
4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

7. A client comes into the ER after hitting his head in an MVA. Hes alert and
oriented. Which of the following nursing interventions should be done first?

1. Assess full ROM to determine extent of injuries

2. Call for an immediate chest x-ray
3. Immobilize the clients head and neck
4. Open the airway with the head-tilt-chin-lift maneuver

8. A client with a C6 spinal injury would most likely have which of the
following symptoms?

1. Aphasia
2. Hemiparesis
3. Paraplegia
4. Tetraplegia

9. A 30-year-old was admitted to the progressive care unit with a C5 fracture

from a motorcycle accident. Which of the following assessments would take
priority?

1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The clients feelings about the injury

10. While in the ER, a client with C8 tetraplegia develops a blood pressure of
80/40, pulse 48, and RR of 18. The nurse suspects which of the following
conditions?

1. Autonomic dysreflexia
2. Hemorrhagic shock
3. Neurogenic shock
4. Pulmonary embolism

11. A client is admitted with a spinal cord injury at the level of T12. He has
limited movement of his upper extremities. Which of the following
medications would be used to control edema of the spinal cord?

1. Acetazolamide (Diamox)
2. Furosemide (Lasix)
3. Methylprednisolone (Solu-Medrol)
4. Sodium bicarbonate
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12. A 22-year-old client with quadriplegia is apprehensive and flushed, with a

blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following
nursing interventions should be done first?

1. Place the client flat in bed

2. Assess patency of the indwelling urinary catheter
3. Give one SL nitroglycerin tablet
4. Raise the head of the bed immediately to 90 degrees

13. A client with a cervical spine injury has Gardner-Wells tongs inserted for
which of the following reasons?

1. To hasten wound healing

2. To immobilize the cervical spine
3. To prevent autonomic dysreflexia
4. To hold bony fragments of the skull together

14. Which of the following interventions describes an appropriate bladder

program for a client in rehabilitation for spinal cord injury?

1. Insert an indwelling urinary catheter to straight drainage

2. Schedule intermittent catheterization every 2 to 4 hours
3. Perform a straight catheterization every 8 hours while awake
4. Perform Credes maneuver to the lower abdomen before the client voids.

15. A client is admitted to the ER for head trauma is diagnosed with an

epidural hematoma. The underlying cause of epidural hematoma is usually
related to which of the following conditions?

1. Laceration of the middle meningeal artery

2. Rupture of the carotid artery
3. Thromboembolism from a carotid artery
4. Venous bleeding from the arachnoid space

16. A 23-year-old client has been hit on the head with a baseball bat. The
nurse notes clear fluid draining from his ears and nose. Which of the
following nursing interventions should be done first?

1. Position the client flat in bed

2. Check the fluid for dextrose with a dipstick
3. Suction the nose to maintain airway patency
4. Insert nasal and ear packing with sterile gauze
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17. When discharging a client from the ER after a head trauma, the nurse
teaches the guardian to observe for a lucid interval. Which of the following
statements best described a lucid interval?

1. An interval when the clients speech is garbled

2. An interval when the client is alert but cant recall recent events
3. An interval when the client is oriented but then becomes somnolent
4. An interval when the client has a warning symptom, such as an odor or
visual disturbance.

18. Which of the following clients on the rehab unit is most likely to develop
autonomic dysreflexia?

1. A client with a brain injury

2. A client with a herniated nucleus pulposus
3. A client with a high cervical spine injury
4. A client with a stroke

19. Which of the following conditions indicates that spinal shock is resolving
in a client with C7 quadriplegia?

1. Absence of pain sensation in chest

2. Spasticity
3. Spontaneous respirations
4. Urinary continence

20. A nurse assesses a client who has episodes of autonomic dysreflexia.

Which of the following conditions can cause autonomic dysreflexia?

1. Headache
2. Lumbar spinal cord injury
3. Neurogenic shock
4. Noxious stimuli

21. During an episode of autonomic dysreflexia in which the client becomes

hypertensive, the nurse should perform which of the following interventions?

1. Elevate the clients legs

2. Put the client flat in bed
3. Put the client in the Trendelenburgs position
4. Put the client in the high-Fowlers position

22. A client with a T1 spinal cord injury arrives at the emergency department
with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower
extremities. Which of the following conditions would most likely be
suspected?
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1. Autonomic dysreflexia
2. Hypervolemia
3. Neurogenic shock
4. Sepsis

23. A client has a cervical spine injury at the level of C5. Which of the
following conditions would the nurse anticipate during the acute phase?

1. Absent corneal reflex

2. Decerebrate posturing
3. Movement of only the right or left half of the body
4. The need for mechanical ventilation

24. A client with C7 quadriplegia is flushed and anxious and complains of a

pounding headache. Which of the following symptoms would also be
anticipated?

1. Decreased urine output or oliguria

2. Hypertension and bradycardia
3. Respiratory depression
4. Symptoms of shock

25. A 40-year-old paraplegic must perform intermittent catheterization of the

bladder. Which of the following instructions should be given?

1. Clean the meatus from back to front.

2. Measure the quantity of urine.
3. Gently rotate the catheter during removal.
4. Clean the meatus with soap and water.

26. An 18-year-old client was hit in the head with a baseball during practice.
When discharging him to the care of his mother, the nurse gives which of the
following instructions?

1. Watch him for keyhole pupil the next 24 hours.

2. Expect profuse vomiting for 24 hours after the injury.
3. Wake him every hour and assess his orientation to person, time, and
place.
4. Notify the physician immediately if he has a headache.

27. Which neurotransmitter is responsible for may of the functions of the

frontal lobe?

1. Dopamine
2. GABA
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3. Histamine
4. Norepinephrine

28. The nurse is discussing the purpose of an electroencephalogram (EEG)

with the family of a client with massive cerebral hemorrhage and loss of
consciousness. It would be most accurate for the nurse to tell family
members that the test measures which of the following conditions?

1. Extent of intracranial bleeding

2. Sites of brain injury
3. Activity of the brain
4. Percent of functional brain tissue

29. A client arrives at the ER after slipping on a patch of ice and hitting her
head. A CT scan of the head shows a collection of blood between the skull
and dura mater. Which type of head injury does this finding suggest?

1. Subdural hematoma
2. Subarachnoid hemorrhage
3. Epidural hematoma
4. Contusion

30. After falling 20, a 36-year-old man sustains a C6 fracture with spinal cord
transaction. Which other findings should the nurse expect?

1. Quadriplegia with gross arm movement and diaphragmatic breathing

2. Quadriplegia and loss of respiratory function
3. Paraplegia with intercostal muscle loss
4. Loss of bowel and bladder control

31. A 20-year-old client who fell approximately 30 is unresponsive and

breathless. A cervical spine injury is suspected. How should the first-
responder open the clients airway for rescue breathing?

1. By inserting a nasopharyngeal airway

2. By inserting a oropharyngeal airway
3. By performing a jaw-thrust maneuver
4. By performing the head-tilt, chin-lift maneuver

32. The nurse is caring for a client with a T5 complete spinal cord injury.
Upon assessment, the nurse notes flushed skin, diaphoresis above the T5,
and a blood pressure of 162/96. The client reports a severe, pounding
headache. Which of the following nursing interventions would be appropriate
for this client? Select all that apply.

1. Elevate the HOB to 90 degrees

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2. Loosen constrictive clothing

3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel impaction
5. Administer antihypertensive medication
6. Place the client in a supine position with legs elevated

33. The client with a head injury has been urinating copious amounts of
dilute urine through the Foley catheter. The clients urine output for the
previous shift was 3000 ml. The nurse implements a new physician order to
administer:

1. Desmopressin (DDAVP, Stimate)

2. Dexamethasone (Decadron)
3. Ethacrynic acid (Edecrin)
4. Mannitol (Osmitrol)

34. The nurse is caring for the client in the ER following a head injury. The
client momentarily lost consciousness at the time of the injury and then
regained it. The client now has lost consciousness again. The nurse takes
quick action, knowing this is compatible with:

1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma

35. The nurse is caring for a client who suffered a spinal cord injury 48 hours
ago. The nurse monitors for GI complications by assessing for:

1. A flattened abdomen
2. Hematest positive nasogastric tube drainage
3. Hyperactive bowel sounds
4. A history of diarrhea

36. A client with a spinal cord injury is prone to experiencing autonomic

dysreflexia. The nurse would avoid which of the following measures to
minimize the risk of recurrence?

1. Strict adherence to a bowel retraining program

2. Limiting bladder catheterization to once every 12 hours
3. Keeping the linen wrinkle-free under the client
4. Preventing unnecessary pressure on the lower limbs

37. The nurse is planning care for the client in spinal shock. Which of the
following actions would be least helpful in minimizing the effects of
vasodilation below the level of the injury?
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1. Monitoring vital signs before and during position changes

2. Using vasopressor medications as prescribed
3. Moving the client quickly as one unit
4. Applying Teds or compression stockings.

38. The nurse is caring for a client admitted with spinal cord injury. The nurse
minimizes the risk of compounding the injury most effectively by:

1. Keeping the client on a stretcher

2. Logrolling the client on a firm mattress
3. Logrolling the client on a soft mattress
4. Placing the client on a Stryker frame

39. The nurse is evaluating neurological signs of the male client in spinal
shock following spinal cord injury. Which of the following observations by the
nurse indicates that spinal shock persists?

1. Positive reflexes
2. Hyperreflexia
3. Inability to elicit a Babinskis reflex
4. Reflex emptying of the bladder

40. A client with a spinal cord injury suddenly experiences an episode of

autonomic dysreflexia. After checking the clients vital signs, list in order of
priority, the nurses actions (Number 1 being the first priority and number 5
being the last priority).

1. Check for bladder distention

2. Raise the head of the bed
3. Contact the physician
4. Loosen tight clothing on the client
5. Administer an antihypertensive medication

41. A client is at risk for increased ICP. Which of the following would be a
priority for the nurse to monitor?

1. Unequal pupil size

2. Decreasing systolic blood pressure
3. Tachycardia
4. Decreasing body temperature

42. Which of the following respiratory patterns indicate increasing ICP in the
brain stem?

1. Slow, irregular respirations

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2. Rapid, shallow respirations

3. Asymmetric chest expansion
4. Nasal flaring

43. Which of the following nursing interventions is appropriate for a client

with an ICP of 20 mm Hg?

1. Give the client a warming blanket

2. Administer low-dose barbiturate
3. Encourage the client to hyperventilate
4. Restrict fluids

44. A client has signs of increased ICP. Which of the following is an early
indicator of deterioration in the clients condition?

1. Widening pulse pressure

2. Decrease in the pulse rate
3. Dilated, fixed pupil
4. Decrease in LOC

45. A client who is regaining consciousness after a craniotomy becomes

restless and attempts to pull out her IV line. Which nursing intervention
protects the client without increasing her ICP?

1. Place her in a jacket restraint

2. Wrap her hands in soft mitten restraints
3. Tuck her arms and hands under the draw sheet
4. Apply a wrist restraint to each arm

46. Which of the following describes decerebrate posturing?

1. Internal rotation and adduction of arms with flexion of elbows, wrists, and
fingers
2. Back hunched over, rigid flexion of all four extremities with supination of
arms and plantar flexion of the feet
3. Supination of arms, dorsiflexion of feet
4. Back arched; rigid extension of all four extremities.

47. A client receiving vent-assisted mode ventilation begins to experience

cluster breathing after recent intracranial occipital bleeding. Which action
would be most appropriate?

1. Count the rate to be sure the ventilations are deep enough to be sufficient
2. Call the physician while another nurse checks the vital signs and
ascertains the patients Glasgow Coma score.
3. Call the physician to adjust the ventilator settings.
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4. Check deep tendon reflexes to determine the best motor response

48. In planning the care for a client who has had a posterior fossa
(infratentorial) craniotomy, which of the following is contraindicated when
positioning the client?

1. Keeping the client flat on one side or the other

2. Elevating the head of the bed to 30 degrees
3. Log rolling or turning as a unit when turning
4. Keeping the head in neutral position

49. A client has been pronounced brain dead. Which findings would the nurse
assess? Check all that apply.

1. Decerebrate posturing
2. Dilated nonreactive pupils
3. Deep tendon reflexes
4. Absent corneal reflex

50. A 23-year-old patient with a recent history of encephalitis is admitted to

the medical unit with new onset generalized tonic-clonic seizures. Which
nursing activities included in the patients care will be best to delegate to an
LPN/LVN whom you are supervising?

1. Document the onset time, nature of seizure activity, and postictal

behaviors for all seizures.
2. Administer phenytoin (Dilantin) 200 mg PO daily.
3. Teach patient about the need for good oral hygiene.
4. Develop a discharge plan, including physician visits and referral to the
Epilepsy Foundation.

Answers and Rationale

1. Answer: 1. Reposition the client to avoid neck flexion

The nurse should first attempt nursing interventions, such as repositioning

the client to avoid neck flexion, which increases venous return and lowers
ICP.

Options B, C, and D: If nursing measures prove ineffective notify the

physician, who may prescribe mannitol, pentobarbital, or hyperventilation
therapy.
2. Answer: 2. Rapid Dilantin administration can cause cardiac arrhythmias.

Dilantin IV shouldnt be given at a rate exceeding 50 mg/minute. Rapid

administration can depress the myocardium, causing arrhythmias.
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Option A: Therapeutic drug levels range from 10 to 20 mg/ml.

Option C: Dilantin shouldnt be mixed in solution for administration. However,
because its compatible with normal saline solution, it can be injected
through an IV line containing normal saline.
Option D: When given through an IV catheter hand, Dilantin may cause
purple glove syndrome.
3. Answer: 1. Evaluate urine specific gravity

Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure
of the pituitary to produce the anti-diuretic hormone. This may occur with
increased intracranial pressure and head trauma; the nurse evaluates for low
urine specific gravity, increased serum osmolarity, and dehydration.

Option B: Theres no evidence that the client is experiencing renal failure.

Option C: Providing emollients to prevent skin breakdown is important, but
doesnt need to be performed immediately.
Option D: Slowing the rate of IV fluid would contribute to dehydration when
polyuria is present.
4. Answer: 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP).

A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties;

therefore, lowering PaCO2 through hyperventilation will lower ICP caused by
dilated cerebral vessels.

Option B: Oxygenation is evaluated through PaO2 and oxygen saturation.

Option D: Alveolar hypoventilation would be reflected in an increased PaCO2.
5. Answer: 2. Frequent swallowing

Frequent swallowing after brain surgery may indicate fluid or blood leaking
from the sinuses into the oropharynx.

Option A: Blood or fluid draining from the ear may indicate a basilar skull
fracture.
6. Answer: 4. To replace antidiuretic hormone (ADH) normally secreted by the
pituitary.

After hypophysectomy or removal of the pituitary gland, the body cant

synthesize ADH.

Option A: Somatropin or growth hormone, not Vasopressin is used to treat

growth failure.
Option B: SIADH results from excessive ADH secretion.
Option C: Mannitol or corticosteroids are used to decrease cerebral edema.
7. Answer: 3. Immobilize the clients head and neck
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All clients with a head injury are treated as if a cervical spine injury is present
until x-rays confirm their absence. The airway doesnt need to be opened
since the client appears alert and not in respiratory distress.

Option A: ROM would be contraindicated at this time.

Option B: There is no indication that the client needs a chest x-ray.
Option D: In addition, the head-tilt-chin-lift maneuver wouldnt be used until
the cervical spine injury is ruled out.
8. Answer: 4. Tetraplegia

Tetraplegia occurs as a result of cervical spine injuries.

Option C: Paraplegia occurs as a result of injury to the thoracic cord and

below.
9. Answer: 3. Pulse ox readings

After a spinal cord injury, ascending cord edema may cause a higher level of
injury. The diaphragm is innervated at the level of C4, so assessment of
adequate oxygenation and ventilation is necessary.

Options A, B, and D: Although the other options would be necessary at a

later time, observation for respiratory failure is the priority.
10. Answer: 3. Neurogenic shock

Symptoms of neurogenic shock include hypotension, bradycardia, and warm,

dry skin due to the loss of adrenergic stimulation below the level of the
lesion.

Option A: Hypertension, bradycardia, flushing, and sweating of the skin are

seen with autonomic dysreflexia.
Option B: Hemorrhagic shock presents with anxiety, tachycardia, and
hypotension; this wouldnt be suspected without an injury.
Option D: Pulmonary embolism presents with chest pain, hypotension,
hypoxemia, tachycardia, and hemoptysis; this may be a later complication of
spinal cord injury due to immobility.
11. Answer: 3. Methylprednisolone (Solu-Medrol)

High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce
cord swelling and limit neurological deficit. The other drugs arent indicated
in this circumstance.

12. Answer: 4. Raise the head of the bed immediately to 90 degrees

Anxiety, flushing above the level of the lesion, piloerection, hypertension,

and bradycardia are symptoms of autonomic dysreflexia, typically caused by
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such noxious stimuli such as a full bladder, fecal impaction, or decubitus

ulcer.

Option A: Putting the client flat will cause the blood pressure to increase
even more.
Option B: The indwelling urinary catheter should be assessed immediately
after the HOB is raised.
Option C: Nitroglycerin is given to reduce chest pain and reduce preload; it
isnt used for hypertension or dysreflexia.
13. Answer: 2. To immobilize the cervical spine

Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until

surgical stabilization is accomplished.

14. Answer: 2. Schedule intermittent catheterization every 2 to 4 hours

Intermittent catheterization should begin every 2 to 4 hours early in the

treatment. When residual volume is less than 400 ml, the schedule may
advance to every 4 to 6 hours.

Options A and C: Indwelling catheters may predispose the client to infection

and are removed as soon as possible.
Option D: Credes maneuver is not used on people with spinal cord injury.
15. Answer: 1. Laceration of the middle meningeal artery

Epidural hematoma or extradural hematoma is usually caused by laceration

of the middle meningeal artery.

Options B and C: An embolic stroke is a thromboembolism from a carotid

artery that ruptures.
Option D: Venous bleeding from the arachnoid space is usually observed with
a subdural hematoma.
16. Answer: 2. Check the fluid for dextrose with a dipstick

Clear fluid from the nose or ear can be determined to be cerebral spinal fluid
or mucous by the presence of dextrose.

Option A: Placing the client flat in bed may increase ICP and promote
pulmonary aspiration.
Option C: The nose wouldnt be suctioned because of the risk for suctioning
brain tissue through the sinuses.
Option D: Nothing is inserted into the ears or nose of a client with a skull
fracture because of the risk of infection.
17. Answer: 3. An interval when the client is oriented but then becomes
somnolent
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A lucid interval is described as a brief period of unconsciousness followed by

alertness; after several hours, the client again loses consciousness.

Option A: Garbled speech is known as dysarthria.

Option B: An interval in which the client is alert but cant recall recent events
is known as amnesia.
Option D: Warning symptoms or auras typically occur before seizures.
18. Answer: 3. A client with a high cervical spine injury

Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients

with spinal cord injuries about the level of T10. The other clients arent prone
to dysreflexia.

19. Answer: 2. Spasticity

Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or

neurogenic shock is characterized by hypotension, bradycardia, dry skin,
flaccid paralysis, or the absence of reflexes below the level of injury.

Option A: The absence of pain sensation in the chest doesnt apply to spinal
shock.
Option C: Spinal shock descends from the injury, and respiratory difficulties
occur at C4 and above.
20. Answer: 4. Noxious stimuli

Noxious stimuli, such as a full bladder, fecal impaction, or a decubitus ulcer,

may cause autonomic dysreflexia.

Option A: A headache is a symptom of autonomic dysreflexia, not a cause.

Option B: Autonomic dysreflexia is most commonly seen with injuries at T10
or above.
Option C: Neurogenic shock isnt a cause of dysreflexia.
21. Answer: 4. Put the client in the high-Fowlers position

Putting the client in the high-Fowlers position will decrease cerebral blood
flow, decreasing hypertension.

Options A, B, and C: Elevating the clients legs, putting the client flat in bed,
or putting the bed in the Trendelenburgs position places the client in
positions that improve cerebral blood flow, worsening hypertension.
22. Answer: 3. Neurogenic shock

Loss of sympathetic control and unopposed vagal stimulation below the level
of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis,
and warm, dry skin in the client in neurogenic shock.
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Option A: Autonomic dysreflexia occurs after neurogenic shock abates.

Option B: Hypervolemia is indicated by rapid and bounding pulse and edema.
Option D: Signs of sepsis would include elevated temperature, increased
heart rate, and increased respiratory rate.
23. Answer: 4. The need for mechanical ventilation

The diaphragm is stimulated by nerves at the level of C4. Initially, this client
may need mechanical ventilation due to cord edema. This may resolve in
time.

Options A, B, and C: Absent corneal reflexes, decerebrate posturing, and

hemiplegia occur with brain injuries, not spinal cord injuries.

24. Answer: 2. Hypertension and bradycardia

Hypertension, bradycardia, anxiety, blurred vision, and flushing above the

lesion occur with autonomic dysreflexia due to uninhibited sympathetic
nervous system discharge. The other options are incorrect.

25. Answer: 4. Clean the meatus with soap and water.

Intermittent catheterization may be performed chronically with clean

technique, using soap and water to clean the urinary meatus.

Option A: The meatus is always cleaned from front to back in a woman, or in

expanding circles working outward from the meatus in a man.
Option B: It isnt necessary to measure the urine.
Option C: The catheter doesnt need to be rotated during removal.
26. Answer: 3. Wake him every hour and assess his orientation to person,
time, and place.

Changes in LOC may indicate expanding lesions such as subdural hematoma;

orientation and LOC are frequently assessed for 24 hours.

Option A: A keyhole pupil is found after iridectomy.

Option B: Profuse or projectile vomiting is a symptom of increased ICP and
should be reported immediately.
Option D: A slight headache may last for several days after concussion;
severe or worsening headaches should be reported.
27. Answer: 1. Dopamine

The frontal lobe primarily functions to regulate thinking, planning, and affect.
Dopamine is known to circulate widely throughout this lobe, which is why its
such an important neurotransmitter in schizophrenia.

28. Answer: 3. Activity of the brain

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An EEG measures the electrical activity of the brain.

Options A and B: Extent of intracranial bleeding and location of the injury site
would be determined by CT or MRI.
Option D: Percent of functional brain tissue would be determined by a series
of tests.
29. Answer: 3. Epidural hematoma

An epidural hematoma occurs when blood collects between the skull and the
dura mater.

Option A: In a subdural hematoma, venous blood collects between the dura

mater and the arachnoid mater.
Option B: In a subarachnoid hemorrhage, blood collects between the pia
mater and arachnoid membrane.
Option D: A contusion is a bruise on the brains surface.
30. Answer: 1. Quadriplegia with gross arm movement and diaphragmatic
breathing

A client with a spinal cord injury at levels C5 to C6 has quadriplegia with

gross arm movement and diaphragmatic breathing.

Option B: Injury levels C1 to C4 leads to quadriplegia with total loss of

respiratory function.
Option C: Paraplegia with intercostal muscle loss occurs with injuries at T1 to
L2.
Option D: Injuries below L2 cause paraplegia and loss of bowel and bladder
control.
31. Answer: 3. By performing a jaw-thrust maneuver

If the client has a suspected cervical spine injury, a jaw-thrust maneuver

should be used to open the airway.

Options A and B: If the tongue or relaxed throat muscles are obstructing the
airway, a nasopharyngeal or oropharyngeal airway can be inserted; however,
the client must have spontaneous respirations when the airway is open.
Option D: The head-tilt, chin-lift maneuver requires neck hyperextension,
which can worsen the cervical spine injury.
32. Answer: 1, 2, 4, 5.

The client has signs and symptoms of autonomic dysreflexia. The potentially
life-threatening condition is caused by an uninhibited response from the
sympathetic nervous system resulting from a lack of control over the
autonomic nervous system. The nurse should immediately elevate the HOB
to 90 degrees and place extremities dependently to decrease venous return
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to the heart and increase venous return from the brain. Because tactile
stimuli can trigger autonomic dysreflexia, any constrictive clothing should be
loosened. The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening complication
of autonomic dysreflexia because it can cause stroke, MI, or seizures. If
removing the triggering event doesnt reduce the clients blood pressure, IV
antihypertensives should be administered.

Option C: A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
33. Answer: 1. Desmopressin (DDAVP, stimate)

A complication of a head injury is diabetes insipidus, which can occur with

insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior
pituitary gland. Urine output that exceeds 9 L per day generally requires
treatment with desmopressin.

Option B: Dexamethasone, a glucocorticoid, is administered to treat cerebral

edema. This medication may be ordered for the head injured patient.
Options C and D: Ethacrynic acid and mannitol are diuretics, which would be
contraindicated.
34. Answer: 4. Epidural hematoma

The changes in neurological signs from an epidural hematoma begin with a

loss of consciousness as arterial blood collects in the epidural space and
exerts pressure. The client regains consciousness as the cerebral spinal fluid
is reabsorbed rapidly to compensate for the rising intracranial pressure. As
the compensatory mechanisms fail, even small amounts of additional blood
can cause the intracranial pressure to rise rapidly, and the clients
neurological status deteriorates quickly.

35. Answer: 2. Hematest positive nasogastric tube drainage

Development of a stress ulcer can be detected by hematest positive NG tube

aspirate or stool.

Options A and C: After spinal cord injury, the client can develop paralytic
ileus, which is characterized by the absence of bowel sounds and abdominal
distention.
Option D: A history of diarrhea is irrelevant.
36. Answer: 2. Limiting bladder catheterization to once every 12 hours

The most frequent cause of autonomic dysreflexia is a distended bladder.

Straight catheterization should be done every 4 to 6 hours, and Foley
catheters should be checked frequently to prevent kinks in the tubing.
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Option A: Constipation and fecal impaction are other causes, so maintaining

bowel regularity is important.
Options C and D: Other causes include stimulation of the skin from tactile,
thermal, or painful stimuli. The nurse administers care to minimize risk in
these areas.
37. Answer: 3. Moving the client quickly as one unit

Reflex vasodilation below the level of the spinal cord injury places the client
at risk for orthostatic hypotension, which may be profound.

Option A: Measures to minimize this include measuring vital signs before and
during position changes, use of a tilt-table with early mobilization, and
changing the clients position slowly.
Option B: Vasopressor medications are administered per protocol.
Option D: Venous pooling can be reduced by using Teds (compression
stockings) or pneumatic boots.
38. Answer: 4. Placing the client on a Stryker frame

Spinal immobilization is necessary after spinal cord injury to prevent further

damage and insult to the spinal cord. Whenever possible, the client is placed
on a Stryker frame, which allows the nurse to turn the client to prevent
complications of immobility, while maintaining alignment of the spine. If a
Stryker frame is not available, a firm mattress with a bed board should be
used.

39. Answer: 3. Inability to elicit a Babinskis reflex

Resolution of spinal shock is occurring when there is a return of reflexes

(especially flexors to noxious cutaneous stimuli), a state of hyperreflexia
rather than flaccidity, reflex emptying of the bladder, and a positive
Babinskis reflex.

40. Answer: 2, 4, 1, 3, 5.

Autonomic dysreflexia is characterized by severe hypertension, bradycardia,

severe headache, nasal stuffiness, and flushing. The cause is a noxious
stimulus, most often a distended bladder or constipation. Autonomic
dysreflexia is a neurological emergency and must be treated promptly to
prevent a hypertensive stroke. Immediate nursing actions are to sit the client
up in bed in a high-Fowlers position and remove the noxious stimulus. The
nurse should loosen any tight clothing and then check for bladder distention.
If the client has a foley catheter, the nurse should check for kinks in the
tubing. The nurse also would check for a fecal impaction and disimpact if
necessary. The physician is contacted especially if these actions do not
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relieve the signs and symptoms. Antihypertensive medications may be

prescribed by the physician to minimize cerebral hypertension.

41. Answer: 1. Unequal pupil size

Increasing ICP causes unequal pupils as a result of pressure on the third

cranial nerve.

Option B: Increasing ICP causes an increase in the systolic pressure, which

reflects the additional pressure needed to perfuse the brain.
Option C: It increases the pressure on the vagus nerve, which produces
bradycardia.
Option D: It causes an increase in body temperature from hypothalamic
damage.
42. Answer: 1. Slow, irregular respirations

Neural control of respiration takes place in the brain stem. Deterioration and
pressure produce irregular respiratory patterns.

Options B, C, and D: Rapid, shallow respirations, asymmetric chest

movements, and nasal flaring are more characteristic of respiratory distress
or hypoxia.
43. Answer: 3. Encourage the client to hyperventilate

Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction,

which reduces CSF and blood volume, two important factors for reducing a
sustained ICP of 20 mm Hg.

Option A: A cooling blanket is used to control the elevation of temperature

because a fever increases the metabolic rate, which in turn increases ICP.
Option B: High doses of barbiturates may be used to reduce the increased
cellular metabolic demands.
Option D: Fluid volume and inotropic drugs are used to maintain cerebral
perfusion by supporting the cardiac output and keeping the cerebral
perfusion pressure greater than 80 mm Hg.
44. Answer: 4. Decrease in LOC

A decrease in the clients LOC is an early indicator of deterioration of the

clients neurological status. Changes in LOC, such as restlessness and
irritability, may be subtle.

Options A, B, and C: Widening of the pulse pressure, decrease in the pulse

rate, and dilated, fixed pupils occur later if the increased ICP is not treated.
45. Answer: 2. Wrap her hands in soft mitten restraints
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It is best for the client to wear mitts which help prevent the client from
pulling on the IV without causing additional agitation.

Options A, C, and D: Using a jacket or wrist restraint or tucking the clients

arms and hands under the draw sheet restrict movement and add to feelings
of being confined, all of which would increase her agitation and increase ICP.
46. Answer: 4. Back arched; rigid extension of all four extremities.

Decerebrate posturing occurs in patients with damage to the upper brain

stem, midbrain, or pons and is demonstrated clinically by the arching of the
back, rigid extension of the extremities, pronation of the arms, and plantar
flexion of the feet.

Option A: Internal rotation and adduction of arms with flexion of the elbows,
wrists, and fingers described decorticate posturing, which indicates damage
to corticospinal tracts and cerebral hemispheres.
47. Answer: 2. Call the physician while another nurse checks the vital signs
and ascertains the patients Glasgow Coma score.

Cluster breathing consists of clusters of irregular breaths followed by periods

of apnea on an irregular basis. A lesion in the upper medulla or lower pons is
usually the cause of cluster breathing. Because the client had a bleed in the
occipital lobe, which is superior and posterior to the pons and medulla,
clinical manifestations that indicate a new lesion are monitored very closely
in case another bleed ensues. The physician is notified immediately so that
treatment can begin before respirations cease. Another nurse needs to
assess vital signs and score the client according to the GCS, but time is also
of the essence. Checking deep tendon reflexes is one part of the GCS
analysis.

48. Answer: 2. Elevating the head of the bed to 30 degrees

Elevating the HOB to 30 degrees is contraindicated for infratentorial

craniotomies because it could cause herniation of the brain down onto the
brainstem and spinal cord, resulting in sudden death. Elevation of the head
of the bed to 30 degrees with the head turned to the side opposite of the
incision, if not contraindicated by the ICP; is used for supratentorial
craniotomies.

49. Answers: 2, 3, 4.

A client who is brain dead typically demonstrates nonreactive dilated pupils

and nonreactive or absent corneal and gag reflexes. The client may still have
spinal reflexes such as deep tendon and Babinski reflexes in brain death.
Decerebrate or decorticate posturing would not be seen.
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50. Answer: 2. Administer phenytoin (Dilantin) 200 mg PO daily.

Administration of medications is included in LPN education and scope of

practice. Collection of data about the seizure activity may be accomplished
by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know
to call the supervising RN immediately if a patient started to seize.

Options A, C, and D: Documentation of the seizure, patient teaching, and

planning of care are complex activities that require RN level education and
scope of practice.

. 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?

1. Vomiting continues
2. Intracranial pressure (ICP) is increased
3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebrospinal fluid (CSF)

2. 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?

1. To reduce intraocular pressure

2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to decrease ICP
4. To draw water into the vascular system to increase blood pressure

3. A client with subdural hematoma was given mannitol to decrease

intracranial pressure (ICP). Which of the following results would best show
the mannitol was effective?

1. Urine output increases

2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. BUN and creatinine levels return to normal

4. Which of the following values is considered normal for ICP?

1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
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4. 120/80 mm Hg

5. Which of the following symptoms may occur with a phenytoin level of 32

mg/dl?

1. Ataxia and confusion

2. Sodium depletion
3. Tonic-clonic seizure
4. Urinary incontinence

6. Which of the following signs and symptoms of increased ICP after head
trauma would appear first?

1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure

7. Problems with memory and learning would relate to which of the following
lobes?

1. Frontal
2. Occipital
3. Parietal
4. Temporal

8. While cooking, your client couldnt feel the temperature of a hot oven.
Which lobe could be dysfunctional?

1. Frontal
2. Occipital
3. Parietal
4. Temporal

9. The nurse is assessing the motor function of an unconscious client. The

nurse would plan to use which of the following to test the clients peripheral
response to pain?

1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure

10. The client is having a lumbar puncture performed. The nurse would plan
to place the client in which position for the procedure?
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1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
3. Prone, in a slight Trendelenburgs position
4. Prone, with a pillow under the abdomen.

11. 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:

1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. Brain death

12. 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?

1. Increasing temperature, increasing pulse, increasing respirations,

decreasing blood pressure.
2. Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure.
3. Decreasing temperature, decreasing pulse, increasing respirations,
decreasing blood pressure.
4. Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure.

13. 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:

1. A positive Brudzinskis sign

2. A negative Kernigs sign
3. Absence of nuchal rigidity
4. A Glascow Coma Scale score of 15

14. 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:

1. Tolerate the pain

2. Decrease the perception of pain
3. Escape the source of pain
4. Divert attention from the source of pain.
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15. During the acute stage of meningitis, a 3-year-old child is restless and
irritable. Which of the following would be most appropriate to institute?

1. Limiting conversation with the child

2. Keeping extraneous noise to a minimum
3. Allowing the child to play in the bathtub
4. Performing treatments quickly

16. Which of the following would lead the nurse to suspect that a child with
meningitis has developed disseminated intravascular coagulation?

1. Hemorrhagic skin rash

2. Edema
3. Cyanosis
4. Dyspnea on exertion

17. When interviewing the parents of a 2-year-old child, a history of which of

the following illnesses would lead the nurse to suspect pneumococcal
meningitis?

1. Bladder infection
2. Middle ear infection
3. Fractured clavicle
4. Septic arthritis

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.

1. Head tilt
2. Vomiting
3. Polydipsia
4. Lethargy
5. Increased appetite
6. Increased pulse

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 that which of the following results would verify
the diagnosis?

1. Cloudy CSF, decreased protein, and decreased glucose

2. Cloudy CSF, elevated protein, and decreased glucose
3. Clear CSF, elevated protein, and decreased glucose
4. Clear CSF, decreased pressure, and elevated protein
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20. A nurse is planning care for a child with acute bacterial meningitis. Based
on the mode of transmission of this infection, which of the following would be
included in the plan of care?

1. No precautions are required as long as antibiotics have been started

2. Maintain enteric precautions
3. Maintain respiratory isolation precautions for at least 24 hours after the
initiation of antibiotics
4. Maintain neutropenic precautions

21. 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?

1. Abnormal flexion of the upper extremities and extension of the lower

extremities
2. Rigid extension and pronation of the arms and legs
3. Rigid pronation of all extremities
4. Flaccid paralysis of all extremities

22. Which of the following assessment data indicated nuchal rigidity?

1. Positive Kernigs sign

2. Negative Brudzinskis sign
3. Positive homans sign
4. Negative Kernigs sign

23. Meningitis occurs as an extension of a variety of bacterial infections due

to which of the following conditions?

1. Congenital anatomic abnormality of the meninges

2. Lack of acquired resistance to the various etiologic organisms
3. Occlusion or narrowing of the CSF pathway
4. Natural affinity of the CNS to certain pathogens

24. Which of the following pathologic processes is often associated with

aseptic meningitis?

1. Ischemic infarction of cerebral tissue

2. Childhood diseases of viral causation such as mumps
3. Brain abscesses caused by a variety of pyogenic organisms
4. Cerebral ventricular irritation from a traumatic brain injury
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25. You are preparing to admit a patient with a seizure disorder. Which of the
following actions can you delegate to LPN/LVN?

1. Complete admission assessment.

2. Set up oxygen and suction equipment.
3. Place a padded tongue blade at bedside.
4. Pad the side rails before patient arrives.

Answers and Rationale

1. Answer: 2. 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.

Option A: Vomiting may be caused by reasons other than increased ICP;

therefore, LP isnt strictly contraindicated.
Option C: An LP may be performed on clients needing mechanical ventilation.
Option D: Blood in the CSF is diagnostic for subarachnoid hemorrhage and
was obtained before signs and symptoms of ICP.
2. Answer: 3. 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.

3. Answer: 1. Urine output increases

Mannitol promotes osmotic diuresis by increasing the pressure gradient in

the renal tubes.

Option B: Fixed and dilated pupils are symptoms of increased ICP or cranial
nerve damage.
Options C and D: No information is given about abnormal BUN and creatinine
levels or that mannitol is being given for renal dysfunction or blood pressure
maintenance.
4. Answer: 1. 0 to 15 mm Hg

Normal ICP is 0-15 mm Hg.

5. Answer: 1. 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.
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Options B, C, and D: Phenytoin doesnt cause hyponatremia, seizure, or

urinary incontinence. Incontinence may occur during or after a seizure.

6. Answer: 3. Restlessness and confusion

The earliest symptom of elevated ICP is a change in mental status.

Option A and D: Bradycardia, widened pulse pressure, and bradypnea occur

later.
Option B: The client may void large amounts of very dilute urine if theres
damage to the posterior pituitary.
7. Answer: 4. Temporal

The temporal lobe functions to regulate memory and learning problems

because of the integration of the hippocampus.

Option A: The frontal lobe primarily functions to regulate thinking, planning,

and judgment.
Option B: The occipital lobe functions regulate vision.
Option C: The parietal lobe primarily functions with sensory function.
8. Answer: 3. Parietal

The parietal lobe regulates sensory function, which would include the ability
to sense hot or cold objects.

Option A: The frontal lobe regulates thinking, planning, and judgment.

Option B: The occipital lobe is primarily responsible for vision function.
Option D: The temporal lobe regulates memory.
9. Answer: 4. Nail bed pressure

Motor testing on the unconscious client can be done only by testing response
to painful stimuli. Nail Bed pressure tests a basic peripheral response.
Cerebral responses to pain are testing using

Options A, B, and C: Cerebral responses to pain are testing using sternal rub,
placing upward pressure on the orbital rim, or squeezing the clavicle or
sternocleidomastoid muscle.
10. Answer: 1. 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.

11. Answer: 3. An intact brainstem

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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.

12. Answer: 2. 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.

13. Answer: 1. A positive Brudzinskis sign

Signs of meningeal irritation compatible with meningitis include nuchal

rigidity, positive Brudzinskis sign, and positive Kernigs sign. Brudzinskis
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.

Option B: Kernigs sign is positive when the client feels pain and spasm of the
hamstring muscles when the knee and thigh are extended from a flexed-right
angle position.
Option C: Nuchal rigidity is characterized by a stiff neck and soreness, which
is especially noticeable when the neck is fixed.
Option D: A Glasgow Coma Scale of 15 is a perfect score and indicates the
client is awake and alert with no neurological deficits.
14. Answer: 3. Escape the source of pain

The clients innate responses to pain are directed initially toward escaping
from the source of pain.

Options A, B, and D: Variations in individuals tolerance and perception of

pain are apparent only in conscious clients, and only conscious clients are
able to employ distraction to help relieve pain.

15. Answer: 2. Keeping extraneous noise to a minimum

A child in the acute stage of meningitis is irritable and hypersensitive to loud

noise and light. Therefore, extraneous noise should be minimized and bright
lights avoided as much as possible.
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Option A: There is no need to limit conversations with the child. However, the
nurse should speak in a calm, gentle, reassuring voice.
Option C: The child needs gentle and calm bathing. Because of the acuteness
of the infection, sponge baths would be more appropriate than tub baths.
Option D: Although treatments need to be completed as quickly as possible
to prevent overstressing the child, any treatments should be performed
carefully and at a pace that avoids sudden movements to prevent startling
the child and subsequently increasing intracranial pressure.
16. Answer: 1. Hemorrhagic skin rash

DIC is characterized by skin petechiae and a purpuric skin rash caused by

spontaneous bleeding into the tissues. An abnormal coagulation
phenomenon causes the condition.

17. Answer: 2. Middle ear infection

Organisms that cause bacterial meningitis, such as pneumococci or

meningococci, are commonly spread in the body by vascular dissemination
from a middle ear infection. The meningitis may also be a direct extension
from the paranasal and mastoid sinuses. The causative organism is a
pneumococcus. A chronically draining ear is frequently also found.

18. Answer: 1, 2, 4.

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.

19. Answer: 2. 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. Answer: 3. Maintain respiratory isolation precautions for at least 24 hours

after the initiation of antibiotics

A major priority of nursing care for a child suspected of having meningitis is

to administer the prescribed antibiotic as soon as it is ordered. The child is
also placed on respiratory isolation for at least 24 hours while culture results
are obtained and the antibiotic is having an effect.

21. Answer: 2. Rigid extension and pronation of the arms and legs
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Decerebrate posturing is characterized by the rigid extension and pronation

of the arms and legs.

22. Answer: 1. Positive Kernigs sign

A positive Kernigs sign indicated nuchal rigidity, caused by an irritative

lesion of the subarachnoid space. Brudzinskis sign is also indicative of the
condition.

23. Answer: 2. Lack of acquired resistance to the various etiologic organisms

Extension of a variety of bacterial infections is a major causative factor of

meningitis and occurs as a result of a lack of acquired resistance to the
etiologic organisms. Preexisting CNS anomalies are factors that contribute to
susceptibility.

24. Answer: 2. Childhood diseases of viral causation such as mumps

Aseptic meningitis is caused principally by viruses and is often associated

with other diseases such as measles, mumps, herpes, and leukemia.

Options A and C: Incidences of brain abscess are high in bacterial meningitis,

and ischemic infarction of cerebral tissue can occur with tubercular
meningitis.
Option D: Traumatic brain injury could lead to bacterial (not viral) meningitis.
25. Answer: 2. Set up oxygen and suction equipment.

The LPN/LVN can set up the equipment for oxygen and suctioning. Focus:
Delegation/supervision.

Option A: The RN should perform the complete initial assessment.

Option C: Tongue blades should not be at the bedside and should never be
inserted into the patients mouth after a seizure begins.
Option D: Padded side rails are controversial in terms of whether they
actually provide safety and ay embarrass the patient and family.