Neuro Week 6 Study Guide Questions

Question 1

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

A. Extension of the arms
B. External rotation of the lower extremities
C. Pronation of the hands
D. Plantar flexion of the legs

Answer 1

D. Plantar flexion of the legs

Rationale: Plantar flexion of the legs is correct because decorticate posturing includes internal rotation and flexion of the arms and wrists, with the legs extended and feet plantar flexed.

Question 2

The nurse is caring for a client with increased intracranial pressure secondary to a brain tumor. Which position should the nurse place the client in to help decrease intracranial​ pressure?

A. High Fowler​
B. Semi-Fowler
C. Left lateral recumbent
D. Fowler

Answer 2

B. Semi-Fowler

Rationale: The client with increased intracranial pressure should be placed in the​ semi-Fowler position​ (30 degrees​ elevation) to decrease pressure.

Question 3

A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply)

A. Violent headache
B. Neck pain and stiffness
C. Slurred speech
D. Projectile vomiting
E. Rapid Loss of Consciousness

Answer 3

A. Violent headache
C. Slurred speech
D. Projectile vomiting
E. Rapid Loss of Consciousness

Question 4

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm/Hg. Which assessment should the nurse recognize as a late sign of ICP? (SATA)

A. Tachypnea
B. Hyperthermia
C. Bradycardia
D. Nonreactive dilated pupils
E. Widened pulse pressure

Answer 4

C. Bradycardia
D. Nonreactive dilated pupils
E. Widened pulse pressure (hypertension)

Question 5

A nurse is receving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the followinf is an appropriate conclusion based on this data?

A. The client can follow simple motor commands.
B. The client is unable to make vocal sounds.
C. The client is unconscious.
D. The client opens his eyes when spoken to.

Answer 5

D. The client opens his eyes when spoken to.

Rationale: Patients with a GCS of 9-12 are typically drowsy or obtunded, they can open eyes and localise painful stimuli upon assessment. GCS of 13-15 are a lot minor and usually conscious.

Question 6

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

A. The client needs total nursing care.
B. The client is alert and oriented.
C. The client is in a deep coma.
D. Indicates stable neurologic status.

Answer 6

A. The client needs total nursing care.

Rationale: A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.

Question 7

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

a. Place suction equipment at the client’s bedside.
b. Apply an eye patch to the client’s right eye.
c. Avoid the use of warm water to wash the client’s face.
d. Provide ROM exercises to the client’s neck and shoulders

Answer 7

a. Place suction equipment at the client’s bedside.

Cranial nerve 9 is glossopharangeal nerve which functions the tongue can help with the act of swallowing.
Cranial nerve 10 is vagus nerve which controls the muscles of the larynx that is used for speech and functions the parasympathetic nervous system controlling digestion, heart rate, etc.
Therefore if these two nerves are affected it can impair the ability to swallow and breathe which is priority.

Question 8

A nurse is performing a neurological assessment for a client that who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

A. Instruct the client to look up and down without moving his head.
B. Observe the client’s ability to smile and frown.
C. Have the client stand with eyes his closed and touch his nose.
D. Ask the client to shrug his shoulders against passive resistance.

Answer 8

A. Instruct the client to look up and down without moving his head.

Rationale: The nurse should observe the client’s extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).

Question 9

A nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?

A) The client turns his head against resistance.
B) The client’s tongue is in a midline position.
C) The client’s pupils constrict in response to light.
D) The client has a symmetrical smile.

Answer 9

D) The client has a symmetrical smile.

Rationale: Patient should be able to smile and look for symmetry of the face

Question 10

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?

A. Localization of pain
B. Decorticate posturing
C. Decerebrate posturing
D. Flexion withdrawal

Answer 10

B. Decorticate posturing

Question 11

NGN fill in the blank

Patient eyes open to sound
Verbal response is inappropriate words
Patient can localize pain

Answer 11

GCS = 11

First is eyes open to sound that is 3
Saying inappropriate words is 3
Patient able to localize pain is 5

Question 12

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

A. Neck in neutral position
B. Head mildline
C. Head turned to the side
D. Head of bed elevated 30 to 45 degrees

Answer 12

C. Head turned to the side

Rationale: Important to keep the neck midline and in neutral position. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

Question 13

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mmHg. Which of the following actions should the nurse take?

a)Adjust the head of the bed
b)Flex the patients hip
c)Hyperextend the patients neck
d)Provide warming measures

Answer 13

a) Adjust the head of the bed

Question 14

NGN

Answer 14

Diagnosis: Cushing triad (widened pulse pressure, bradycardia, irregular respirations -cheyene stokes)

Actions to take: Dilated pupils, bradycardia
Parameters of monitor: hypotension, increased RR

Question 15

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse closely monitor the client for increased intracranial pressure as indicated by which of the following findings?

A. Elevated temperature
B. Pupils reactive to light
C. Widened pulse pressure
D. Nuchal rigidity

Answer 15

C. Widened pulse pressure

Rationale: a widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting and decreased LOC

Question 16

Hygiene care for pt and ICP is starting to go up what are you going to do?

Answer 16

Stop and let ICP go back to baseline

Question 17

A patient does not respond to verbal stimuli, so the nurse applies painful stimulus and notes the patient’s reaction. The patient clenches his teeth, and his arms are extended, adducted, and hyper-pronated. The nurse recognizes this as:

A. a positive Babinski sign.
B. decorticate posturing.
C. decerebrate posturing.
D. localization of pain.

Answer 17

C. Decerebrate posturing

Decerebrate posturing or abnormal extension is evidenced by clenching of the teeth with arms stiffly extended, adducted, and hyperpronated and the legs stiffly extended with plantar flexion of the feet. A positive Babinski sign is evidenced by sustained extensor response of the big toe. Decorticate posturing or abnormal flexion is evidenced by abnormal flexion of the arms, wrists, and fingers. Localization occurs when the extremity opposite the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.

Question 18

The nurse is admitting a patient with a head injury. Which parameters will the nurse evaluate as part of the patient’s neurologic assessment? Select all that apply.

a. Level of consciousness
b. Respiratory function
c. Urinary output
d. Vital signs
e. Pupillary function

Answer 18

a. Level of consciousness
b. Respiratory function
d. Vital signs
e. Pupillary function

Question 19

A nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take? (SATA)

A. provide oral fluids (maintain this)
B. monitor for nausea (antiemetics can be given)
C. maintain fetal position
D. check LOC
E. check sensation in the toes (checking sensation in lower extremities)

Answer 19

A, B, D, E

Everything but maintain fetal position

Question 20

The nurse is assisting with a lumbar puncture and notes that the cerebrospinal fluid (CSF) is a smoky color. The nurse notes that this indicates the presence of:

A. infection.
B. red blood cells (RBCs).
C. elevated protein count.
D. increased pressure.

Answer 20

B. red blood cells (RBCs).

Question 21

Which information is most important for the nurse to communicate to the primary care provider (PCP) about a client who is scheduled for CT angiography?

A. Allergy to penicillin
B. History of bacterial meningitis
C. Poor skin turgor and dry mucous membranes
D. The client’s dose of metformin (Glucophage) held today

Answer 21

C. Poor skin turgor and dry mucous membranes

The most important information for the nurse to communicate to the PCP about a client scheduled for a CT angiography is the client with poor skin turgor and dry mucous membranes. This assessment indicates dehydration which places the client at risk for contrast induced nephropathy.Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported as part of the client hand-off to Radiology (SAFETY).

Question 22

Mannitol

Answer 22

Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces.
Decreases a patients ICP

gold standard for ICP

Question 23

A nurse is caring for a patient post lumbar puncture. Which of the following should we report to provider?

Answer 23

Patient is vomiting

Rationale: Nausea and vomiting may occur with increased ICP. The classic three symptoms of increased ICP in a conscious client are nausea, headache, and diplopia (double vision). Vomiting should be investigated immediately.

Question 24

The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient’s oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex?

a. The patient’s eyes move in the same direction the head is turned.
b. The patient’s eyes move in the opposite direction to the movement of the patient’s head.
c. The patient’s eyes rove and move in opposite directions from each other.
d. The patient’s eyes move up and down and then back and forth.

Answer 24

b. The patient’s eyes move in the opposite direction to the movement of the patient’s head.

Rationale: To assess the oculocephalic reflex, the nurse holds the patient’s eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in which the head is turned, doll’s eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not intact, the reflex is absent.

Question 25

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse
identify as an indication of increased intracranial pressure (ICP)?

A. Tachycardia
B. Amnesia
C. Hypotension
D. Restlessness

Answer 25

D. Restlessness

Question 26

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

A. Use log rolling to reposition the client.
B. Place a warming blanket on the client.
C. Instruct the client to cough and deep breathe.
D. Place the client in a supine position.

Answer 26

A. Use log rolling to reposition the client.

Using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.

Question 27

Eye Opening (GCS score)

Answer 27

4- Eyes open spontaneously
3- Eyes open to sound
2- Eyes open to pain or pressure
1- None

Question 28

Verbal response (GCS score)

Answer 28

5- Oriented
4- Confused
3- inappropriate words
2- Incomprehensible sounds
1- None

Question 29

Motor response (GCS score)

Answer 29

6- Obeys commands
5- localizes pain
4- Withdraws from pain
3- Flexion to pain
2- Extension to pain
1- None

Question 30

Glasgow coma score meaning

Answer 30

A GCS score 13 or higher = mild brain injury
Score of 9-12 = moderate brain injury; can be confused and anxious but still conscious. May have some motor/ sense problems.
Score of 8 or less = severe brain injury; needs intubation and total care

Question 31

Normal MAP, ICP and CPP levels

Answer 31

MAP: 70-150 mmHg (<60 ischemia of brain = high ICP)
ICP: 5-15 mmHg
CPP: 70-105 mmHg

Question 32

(Another similar to number 3) A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

A. Pupillary changes
B. Disorientation
C. Headache
D. Slurred speech
E. Neck pain and stiffness

Answer 32

A. Pupillary changes
B. Disorientation
C. Headache
D. Slurred speech

Question 33

(Similar to question 12)
A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

A. Flex the client’s hip.
B. Hyperextend the client’s neck.
C. Provide warming measures for the client.
D. Adjust the client’s head of bed.

Answer 33

D. Adjust the client’s head of bed.

Question 34

(Similar to question 12) After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action would the nurse take first?

a. Document the increase in intracranial pressure.
b. Ensure that the patient‘s neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.

Answer 34

b. Ensure that the patient‘s neck is in neutral position.

Question 35

A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?

A. Chlorpromazine
B. Dobutamine
C. Mannitol
D. Propranolol

Answer 35

C. Mannitol

Question 36

A nurse is planning to administer mannitol to a client who has heart failure and pulmonary edema. Which of the following actions should the nurse take before giving the medication?

A. Check the urine output.
B. Check the blood pressure.
C. Check the blood glucose.
D. Check the oxygen saturation.

Answer 36

A. Check the urine output.

Mannitol is an osmotic diuretic that increases urine output and decreases intracranial pressure and intraocular pressure. The nurse should check the urine output before giving the medication to ensure adequate renal function and prevent fluid overload and electrolyte imbalance. The normal urine output is 0.5 to 1 mL/kg/hr.

Question 37

If a patient has a GCS of 11, what should the nurse ask the patient?

Answer 37

Ask to see if they can follow command

Question 38

Central venous pressure range

Answer 38

2-8 mm Hg (involves the right side of the heart)
- amount of blood in the ventricles before contraction
Low ? = dehydrated
High= fluid overload

Question 39

What is benefit of starting enteral nutrition within 48 hours

Answer 39

Early initiation of enteral feeding is considered beneficial as it helps to stimulate the gut mucosa and maintain its barrier function, which can reduce the risk of bacterial translocation and subsequent infections.

Question 40

vasogenic cerebral edema increases intracranial pressure by
a. shifting fluid in the gray matter
b. altering the endothelial lining of cerebral capillaries
c. leaking molecules from the intracellular to the capillaries
d. altering the osmotic gradient flow into the intravascular component

Answer 40

b. altering the endothelial lining of cerebral capillaries

It involves interruption of blood brain barrier

This can occur in : Clients who have experienced a stroke, have a brain tumor, or in cases of high-altitude illness.

Question 41

What procedure is used to drain the accumulation of cerebrospinal fluid in traumatic brain injury?

Answer 41

Ventriculostomy