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 client’s mouth with a padded tongue blade.
4. Cleaning the client’s mouth and teeth with a toothbrush.

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.

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

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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?

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.

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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 client’s waist prior to ambulating.
2. The assistant places the client on the back with the client’s head to the side.
3. The assistant places her hand under the client’s right axilla to help him/her move up in
bed.
4. The assistant praises the client for attempting to perform ADL’s 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.
 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.

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 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 client’s 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 constipationcan 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.

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 CVA’s as Caucasians; males are more likely to
have strokes than females except in advanced years.

 Option B: Oriental’s 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 client’s 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.

1. 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

2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilator’s 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 client’s 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

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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

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.

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7. A client comes into the ER after hitting his head in an MVA. He’s 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 client’s 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 fracturefrom a

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

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

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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
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

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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 Crede’s 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

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 client’s speech is garbled

2. An interval when the client is alert but can’t 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 client’s legs

2. Put the client flat in bed
3. Put the client in the Trendelenburg’s position
4. Put the client in the high-Fowler’s 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?

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
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
client’s 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

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 client’s 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?
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 Babinski’s 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 client’s vital signs, list in order of priority, the
nurse’s 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

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 client’s 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
patient’s Glasgow Coma score.
3. Call the physician to adjust the ventilator settings.
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 patient’s 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 EpilepsyFoundation.

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 shouldn’t be given at a rate exceeding 50 mg/minute. Rapid administration

can depress the myocardium, causing arrhythmias.

 Option A: Therapeutic drug levels range from 10 to 20 mg/ml.

 Option C: Dilantin shouldn’t be mixed in solution for administration. However,
because it’s 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: There’s no evidence that the client is experiencing renal failure.

 Option C: Providing emollients to prevent skin breakdown is important, but
doesn’t 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 can’t 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 client’s head and neck

All clients with a head injury are treated as if a cervical spine injury is present until x-
rays confirm their absence. The airway doesn’t 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 wouldn’t 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 wouldn’t 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 aren’t 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 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
isn’t 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 infectionand are removed as soon as possible.
 Option D: Crede’s 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 wouldn’t 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

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 can’t 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 aren’t 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 doesn’t 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 isn’t a cause of dysreflexia.

21. Answer: 4. Put the client in the high-Fowler’s position

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

 Options A, B, and C: Elevating the client’s legs, putting the client flat in bed, or
putting the bed in the Trendelenburg’s 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.

 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 isn’t necessary to measure the urine.
 Option C: The catheter doesn’t 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 it’s such an important
neurotransmitter in schizophrenia.

28. Answer: 3. Activity of the brain

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 brain’s 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 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 doesn’t reduce the client’s blood
pressure, IV antihypertensives should be administered.

 Option C: A fan shouldn’t 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 client’s neurological status deteriorates quickly.

35. Answer: 2. Hematest positive nasogastric tube drainage

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

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.

 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 client’s 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 Babinski’s 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 Babinski’s 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-Fowler’s 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 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 client’s LOC is an early indicator of deterioration of the client’s

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

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 client’s

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 patient’s 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.

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.

1. 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

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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
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

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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 couldn’t 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 client’s peripheral response
to pain?

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

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10. The client is having a lumbar puncture performed. The nurse would plan to
place the client in which position for the procedure?

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 Trendelenburg’s 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.

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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 Brudzinski’s sign

2. A negative Kernig’s 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.

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

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 Kernig’s sign

2. Negative Brudzinski’s sign
3. Positive homan’s sign
4. Negative Kernig’s 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
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 isn’t 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.

Options B, C, and D: Phenytoin doesn’t 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 there’s
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

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 Brudzinski’s sign

Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive
Brudzinski’s sign, and positive Kernig’s sign. Brudzinski’s sign is positive when the
client flexes the hips and knees in response to the nurse gently flexing the head and neck
onto the chest.

 Option B: Kernig’s 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 client’s 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.

 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

Decerebrate posturing is characterized by the rigid extension and pronation of the arms
and legs.

22. Answer: 1. Positive Kernig’s sign

A positive Kernig’s sign indicated nuchal rigidity, caused by an irritative lesion of the
subarachnoid space. Brudzinski’s sign is also indicative of the condition.
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 patient’s 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.