*CNS questions*

1. Which of the following medical treatments should the nurse anticipate administering to a client with
increased intracranial pressure due to brain hemorrhage, except?

A. acetaminophen (Tylenol)

B. dexamethasone (Decadron)

C. mannitol (Osmitrol)

D. phenytoin (Dilantin)

E. nitroglycerin (Nitrostat)

2. A client who had a stroke is seen bumping into things on the side and is having difficulty picking up
the beginning of the next line of what he is reading. The client is experiencing which of the following
conditions?

A. Visual neglect

B. Astigmatism

C. Blepharitis

D. Homonymous Hemianopsia
3. A client is admitted to the emergency room with a spinal cord injury. The client is complaining of
lightheadedness, flushed skin above the level of the injury, and headache. The client’s blood pressure is
160/90 mm Hg. Which of the following is a priority action for the nurse to take?

A. Loosen tight clothing or accessories

B. Assess for any bladder distention

C. Raise the head of the bed

D. Administer antihypertensive

4. A client is admitted with a diagnosis of Sturge-Weber syndrome. Which of the following information
would you expect to find in this client?

A. It is a dysfunction of the trigeminal nerve causing a severe sharp pain in the nose, lips, gums, or
across the cheeks.

B. It is a non-progressive neurological disorder of the seventh cranial nerve causing paralysis of one of
the sides of the face.

C. It is a rare degenerative brain disorder characterized by sudden development of progressive

neurological and neuromuscular symptoms.

D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from
birth.

5. A female client has a neurological deficit involving the limbic system. Specific to this type of deficit,
the nurse would document which of the following information related to the client’s behavior.

A. Is disoriented to person, place, and time.

B. Affect is flat, with periods of emotional lability.

C. Cannot recall what was eaten for breakfast today.

D. Demonstrate inability to add and subtract; does not know who is the president.

6. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan
to do which of the following to ensure the client to ensure client safety?

A. Speak loudly to the client.

B. Test the temperature of the shower water.

C. Check the temperature of the food on the delivery tray.

D. Provide a clear path for ambulation without obstacles.

7. A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving
mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care
to help the client cope with this illness?

A. Giving the client full control over care decisions and restricting visitors.

B. Providing positive feedback and encouraging active range of motion.

C. Providing information, giving positive feedback and encouraging relaxation.

D. Providing intravenously administered sedatives, reducing distractions and limiting visitors.

8. A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse
inquires during the nursing admission interview if the client has a history of:
A. Seizures or trauma to the brain.

B. Meningitis during the last five (5 years).

C. Back injury or trauma to the spinal cord.

D. Respiratory or gastrointestinal infection during the previous month.

9. The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face
and preventing denervation. The nurse determines that the client needs additional information if the
client states that he or she will:

A. Wrinkle the forehead, blow out the cheeks, and whistle.

B. Massage the face with a gentle upward motion.

C. Perform facial exercises.

D. Exposure to cold and drafts.

10. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

A. Imbalanced nutrition: Less than body requirements

B. Ineffective airway clearance

C. Impaired urinary elimination

D. Risk for injury

11. When obtaining the health history from a male client with retinal detachment, the nurse expects the
client to report:

A. Light flashes and floaters in front of the eye.

B. A recent driving accident while changing lanes.

C. Headaches, nausea, and redness of the eyes.

D. Frequent episodes of double vision.

12. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the
emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be
the most dangerous for the client?

A. Give him a barbiturate.

B. Place him on mechanical ventilation.

C. Perform a lumbar puncture.

D. Elevate the head of his bed.

13. A female client admitted to an acute care facility after a car accident develops signs and symptoms
of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to
help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates
administering which drug endotracheally before suctioning?
A. phenytoin (Dilantin)

B. mannitol (Osmitrol)

C. lidocaine (Xylocaine)

D. furosemide (Lasix)

14. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the
nurse would anticipate that the client has problems with:

A. Body temperature control

B. Balance and equilibrium

C. Visual acuity

D. Thinking and reasoning

15. 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. Place a padded tongue blade at the bedside.

C. Set up oxygen and suction equipment.

D. Pad the side rails before the patient arrives.

16. Which of the following pathologic processes is often associated with aseptic meningitis?
A. Ischemic infarction of cerebral tissue.

B. Childhood diseases of viral causation such as mumps.

C. Brain abscesses caused by a variety of pyogenic organisms.

D. Cerebral ventricular irritation from a traumatic brain injury

17. Meningitis occurs as an extension of a variety of bacterial infections due to which of the following
conditions?

A. Congenital anatomic abnormality of the meninges.

B. Lack of acquired resistance to the various etiologic organisms.

C. Occlusion or narrowing of the CSF pathway.

D. Natural affinity of the CNS to certain pathogens.

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

A. Positive Kernig’s sign

B. Negative Brudzinski’s sign

C. Positive homan’s sign

D. Negative Kernig’s sign

19. 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?
A. Abnormal flexion of the upper extremities and extension of the lower extremities.

B. Rigid extension and pronation of the arms and legs.

C. Rigid pronation of all extremities.

D. Flaccid paralysis of all extremities.

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?

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

B. Maintain enteric precautions.

C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

D. Maintain neutropenic precautions.

21. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained
for analysis. A nurse reviews the results of the CSF analysis and determines which of the following
results would verify the diagnosis?

A. Cloudy CSF, decreased protein, and decreased glucose.

B. Cloudy CSF, elevated protein, and decreased glucose.

C. Clear CSF, elevated protein, and decreased glucose.

D. Clear CSF, decreased pressure, and elevated protein.

22. 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.

A. Increased appetite

B. Vomiting

C. Polydipsia

D. Lethargy

E. Head tilt

F. Increased pulse

23. 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?

A. Bladder infection

B. Middle ear infection

C. Fractured clavicle

D. Septic arthritis

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

A. Hemorrhagic skin rash

B. Edema

C. Cyanosis
D. Dyspnea on exertion

25. 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?

A. Limiting conversation with the child.

B. Allowing the child to play in the bathtub.

C. Keeping extraneous noise to a minimum.

D. Performing treatments quickly.

26. 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?

A. Limiting conversation with the child.

B. Allowing the child to play in the bathtub.

C. Keeping extraneous noise to a minimum.

D. Performing treatments quickly

27. 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:

A. Tolerate the pain.

B. Decrease the perception of pain.

C. Escape the source of pain.

D. Divert attention from the source of pain.

28. 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:

A. A negative Kernig’s sign.

B. A positive Brudzinski’s sign.

C. Absence of nuchal rigidity.

D. A Glascow Coma Scale score of 15.

29. 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?

A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.

D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

30. 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:

A. A cerebral lesion
B. A temporal lesion

C. An intact brainstem

D. Brain death

31. A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is
based on an understanding that the cause is:

A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem.

B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia.

C. Primary genetic in origin, triggered by exposure to meningitis.

D. Primarily genetic in origin, triggered by exposure to neurotoxins.

32. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of
the following actions by the nurse would be least helpful to the client?

A. Speaking to the client at a slower rate.

B. Allowing plenty of time for the client to respond.

C. Completing the sentences that the client cannot finish.

D. Looking directly at the client during attempts at speech.

33. The nurse is assessing the adaptation of the female client to changes in functional status after a
brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:

A. Gets angry with family if they interrupt a task.

B. Experiences bouts of depression and irritability.

C. Has difficulty with using modified feeding utensils.

D. Consistently uses adaptive equipment in dressing self.

34. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the
nurse avoids doing which of the following?

A. Giving the client thin liquids.

B. Thickening liquids to the consistency of oatmeal.

C. Placing food on the unaffected side of the mouth.

D. Allowing plenty of time for chewing and swallowing.

35. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse
plans care knowing that this condition:

A. The client has complete bilateral paralysis of the arms and legs.

B. The client has weakness on the right side of the body, including the face and tongue.

C. The client has lost the ability to move the right arm but can walk independently.

D. The client has lost the ability to move the right arm but can walk independently.

36. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which
of the following actions by the nurse would be contraindicated?

A. Loosening restrictive clothing.

B. Restraining the client’s limbs.

C. Removing the pillow and raising padded side rails.

D. Positioning the client to the side, if possible, with the head flexed forward.

37. A male 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?

A. Strict adherence to a bowel retraining program.

B. Keeping the linen wrinkle-free under the client.

C. Preventing unnecessary pressure on the lower limbs.

D. Limiting bladder catheterization to once every 12 hours.

38. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse
assesses that this is cerebrospinal fluid if the fluid:

A. Is clear and tests negative for glucose.

B. Is grossly bloody in appearance and has a pH of 6.

C. Clumps together on the dressing and has a pH of 7.

D. Separates into concentric rings and tests positive for glucose.

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

A. Head midline
B. Head turned to the side

C. Neck in neutral position

D. Head of bed elevated 30 to 45 degrees

40. A male client is having a lumbar puncture performed. The nurse would plan to place the client in
which position?

A. Side-lying, with a pillow under the hip.

B. Prone, with a pillow under the abdomen.

C. Prone, in slight-Trendelenburg’s position.

D. Side-lying, with the legs, pulled up and head bent down onto the chest.

41. A female client admitted to the hospital with a neurological problem asks the nurse whether
magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this
diagnostic procedure based on the client’s history of:

A. Hypertension

B. Heart failure

C. Prosthetic valve replacement

D. Chronic obstructive pulmonary disorder

42. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use
which of the following to test the client’s peripheral response to pain?
A. Sternal rub

B. Nail bed pressure

C. Pressure on the orbital rim

D. Squeezing of the sternocleidomastoid muscle

43. Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse
rushes to the victim and determines the need to open the airway in this victim by using which method?

A. Flexed position

B. Head tilt-chin lift

C. Jaw-thrust maneuver

D. Modified head tilt-chin lift

44. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory
goal is to:

A. Prevent respiratory alkalosis.

B. Lower arterial pH.

C. Promote carbon dioxide elimination.

D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.

45. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so
frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?
A. Anxiety

B. Powerlessness

C. Ineffective denial

D. Risk for disuse syndrome

46. A female client is admitted in a disoriented and restless state after sustaining a concussion during a
car accident. Which nursing diagnosis takes highest priority for this client’s plan of care?

A. Disturbed sensory perception (visual)

B. Self-care deficit: Dressing/grooming

C. Impaired verbal communication

D. Risk for injury

47. During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse
should make sure to:

A. Use the pointed end of the reflex hammer when striking the Achilles' tendon.

B. Support the joint where the tendon is being tested.

C. Tap the tendon slowly and softly.

D. Hold the reflex hammer tightly.

48. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What
should the nurse do when preparing the client for this test?
A. Immobilize the neck before the client is moved onto a stretcher.

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

C. Place a cap on the client’s head.

D. Administer a sedative as ordered.

49. The nurse is working on a surgical floor. The nurse must log roll a male client following a:

A. Laminectomy.

B. Thoracotomy.

C. Hemorrhoidectomy.

D. Cystectomy.

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

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

B. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any
sensory loss.”

C. “It must be hard to accept the permanency of your paralysis.”

D. “You’ll first regain use of your legs and then your arms.”

51. A male client is having tonic-clonic seizures. What should the nurse do first?
A. Elevate the head of the bed.

B. Restrain the client’s arms and legs.

C. Place a tongue blade in the client’s mouth.

D. Take measures to prevent injury.

52. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce
fatigue, the nurse should tell the client to:

A. Take a hot bath.

B. Rest in an air-conditioned room.

C. Increase the dose of muscle relaxants.

D. Avoid naps during the day.

53. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular
accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia.
Which history finding is a risk factor for CVA?

A. Caucasian race

B. Female sex

C. Obesity

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

A. Cranial nerves I and II.

B. Cranial nerves III and V.

C. Cranial nerves VI and VIII.

D. Cranial nerves IX and X.

55. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe
headache. Which action should the nurse perform?

A. Sit with the client for a few minutes.

B. Administer an analgesic.

C. Inform the nurse manager.

D. Call the physician immediately.

56. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following
symptoms would the nurse expect to find?

A. Vision changes

B. Absent deep tendon reflexes

C. Tremors at rest

D. Flaccid muscles
57. A female client who was trapped inside a car for hours after a head-on collision is rushed to the
emergency department with multiple injuries. During the neurologic examination, the client responds to
painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

A. Diencephalon

B. Medulla

C. Midbrain

D. Cortex

58. A male client is color blind. The nurse understands that this client has a problem with:

A. Rods.

B. Cones.

C. Lens.

D. Aqueous humor.

59. While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis.
Which of the following statements about neuromuscular blocking agents is true for a client with this
condition?

A. The client may be less sensitive to the effects of a neuromuscular blocking agent.

B. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.

C. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.

D. Pancuronium and succinylcholine both require cautious administration.

60. A female client who was found unconscious at home is brought to the hospital by a rescue squad. In
the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by:

A. Introducing ice water into the external auditory canal.

B. Touching the cornea with a wisp of cotton.

C. Turning the client’s head suddenly while holding the eyelids open.

D. Shining a bright light into the pupil.

61. 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?

A. Reposition the client to avoid neck flexion.

B. Administer 1 g Mannitol IV as ordered.

C. Increase the ventilator’s respiratory rate to 20 breaths/minute.

D. Administer 100 mg of pentobarbital IV as ordered.

62. 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?

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

B. Rapid Dilantin administration can cause cardiac arrhythmias.

C. Dilantin should be mixed in dextrose in water before administration.

D. Dilantin should be administered through an IV catheter in the client’s hand.

63. 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?

A. Evaluate urine specific gravity.

B. Anticipate treatment for renal failure.

C. Provide emollients to the skin to prevent breakdown.

D. Slow down the IV fluids and notify the physician.

64. 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?

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

B. Emergent; the client is poorly oxygenated.

C. Normal

D. Significant; the client has alveolar hypoventilation.

65. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage,
which may be shown by which of the following signs?

A. Bloody drainage from the ears

B. Frequent swallowing

C. Guaiac-positive stools

D. Hematuria
66. After a hypophysectomy, vasopressin is given IM for which of the following reasons?

A. To treat growth failure.

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

C. To reduce cerebral edema and lower intracranial pressure.

D. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

67. 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?

A. Assess full ROM to determine extent of injuries.

B. Call for an immediate chest x-ray.

C. Immobilize the client’s head and neck.

D. Open the airway with the head-tilt-chin-lift maneuver.

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

A. Aphasia

B. Hemiparesis

C. Paraplegia

D. Tetraplegia
69. 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?

A. Bladder distension

B. Neurological deficit

C. Pulse ox readings

D. The client’s feelings about the injury

70. 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?

A. Autonomic dysreflexia

B. Hemorrhagic shock

C. Neurogenic shock

D. Pulmonary embolism

71. 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?

A. acetazolamide (Diamox)

B. furosemide (Lasix)

C. methylprednisolone (Solu-Medrol)

D. sodium bicarbonate
72. 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?

A. Place the client flat in bed.

B. Assess patency of the indwelling urinary catheter.

C. Give one SL nitroglycerin tablet.

D. Raise the head of the bed immediately to 90 degrees.

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

A. To hasten wound healing.

B. To immobilize the cervical spine.

C. To prevent autonomic dysreflexia.

D. To hold bony fra

74. Which of the following interventions describes an appropriate bladder program for a client in
rehabilitation for spinal cord injury?

A. Insert an indwelling urinary catheter to straight drainage.

B. Schedule intermittent catheterization every 2 to 4 hours.

C. Perform a straight catheterization every 8 hours while awake.

D. Perform Crede’s maneuver to the lower abdomen before the client voids.
75. A client who 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?

A. Laceration of the middle meningeal artery.

B. Rupture of the carotid artery.

C. Thromboembolism from a carotid artery.

D. Venous bleeding from the arachnoid space.

76. 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?

A. Position the client flat in bed.

B. Check the fluid for dextrose with a dipstick.

C. Suction the nose to maintain airway patency.

D. Insert nasal and ear packing with sterile gauze.

77. When discharging a client from the ER after

head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following
statements best describes a lucid interval?

A. An interval when the client’s speech is garbled.

B. An interval when the client is alert but can’t recall recent events.

C. An interval when the client is oriented but then becomes somnolent.

D. An interval when the client has a “warning” symptom, such as an odor or visual disturbance.

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

A. A client with a brain injury.

B. A client with a herniated nucleus pulposus.

C. A client with a high cervical spine injury.

D. A client with a stroke.

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

A. Absence of pain sensation in chest

B. Spasticity

C. Spontaneous respirations

D. Urinary continence

80. A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following
conditions can cause autonomic dysreflexia?

A. Headache

B. Lumbar spinal cord injury

C. Neurogenic shock
D. Noxious stimuli

81. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse
should perform which of the following interventions?

A. Elevate the client’s legs.

B. Put the client flat in bed.

C. Put the client in Trendelenburg's position.

D. Put the client in the high-Fowler’s position.

82. 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?

A. Autonomic dysreflexia

B. Hypervolemia

C. Neurogenic shock

D. Sepsis

83. 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?A. Absent corneal reflex.

A. Absent corneal reflex.

B. Decerebrate posturing.
C. Movement of only the right or left half of the body.

D. The need for mechanical ventilation.

84. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which
of the following symptoms would also be anticipated?

A. Decreased urine output or oliguria

B. Hypertension and bradycardia

C. Respiratory depression

D. Symptoms of shock

85. A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the
following instructions should be given?

A. “Clean the meatus from back to front.”

B. “Measure the quantity of urine.”

C. “Gently rotate the catheter during removal.”

D. “Clean the meatus with soap and water.”

86. 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?

A. “Watch him for a keyhole pupil the next 24 hours.”

B. “Expect profuse vomiting for 24 hours after the injury.”

C. “Wake him every hour and assess his orientation to person, time, and place.”

D. “Notify the physician immediately if he has a headache.”

87. Which neurotransmitter is responsible for many of the functions of the frontal lobe?

A. Dopamine

B. GABA

C. Histamine

D. Norepinephrine

88. 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?

A. Extent of intracranial bleeding.

B. Sites of brain injury.

C. Activity of the brain.

D. Percent of functional brain tissue.

89. 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?

A. Subdural hematoma
B. Subarachnoid hemorrhage

C. Epidural hematoma

D. Contusion

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

A. Quadriplegia with gross arm movement and diaphragmatic breathing.

B. Quadriplegia and loss of respiratory function.

C. Paraplegia with intercostal muscle loss.

D. Loss of bowel and bladder control.

91. 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?

A. By inserting a nasopharyngeal airway.

B. By inserting an oropharyngeal airway.

C. By performing a jaw thrust maneuver.

D. By performing the head-tilt, chin-lift maneuver.

92. 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.
A. Elevate the HOB to 90 degrees.

B. Loosen constrictive clothing.

C. Use a fan to reduce diaphoresis.

D. Assess for bladder distention and bowel impaction.

E. Administer antihypertensive medication.

F. Place the client in a supine position with legs elevated.

93. 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:

A. desmopressin (DDAVP, Stimate)

B. Dexamethasone (Decadron)

B. Dexamethasone (Decadron) C. ethacrynic acid (Edecrin)

D. mannitol (Osmitrol)

94. 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:

A. Skull fracture

B. Concussion

C. Subdural hematoma

D. Epidural hematoma
95. 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:

A. A flattened abdomen.

B. Hematest positive nasogastric tube drainage.

C. Hyperactive bowel sounds.

D. A history of diarrhea.

96. 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?

A. Strict adherence to a bowel retraining program.

B. Limiting bladder catheterization to once every 12 hours.

C. Keeping the linen wrinkle-free under the client.

D. Preventing unnecessary pressure on the lower limbs.

97. 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?

A. Monitoring vital signs before and during position changes.

B. Using vasopressor medications as prescribed.

C. Moving the client quickly as one unit.

D. Applying Teds or compression stockings.

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

A. Keeping the client on a stretcher.

B. Logrolling the client on a firm mattress.

C. Logrolling the client on a soft mattress.

D. Placing the client on a Stryker frame.

99. 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?

A. Positive reflexes

B. Hyperreflexia

C. Inability to elicit a Babinski’s reflex.

D. Reflex emptying of the bladder.

100. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After
checking the client’s vital signs. SATA---(Arrange your answers in the correct order).

A. Administer an antihypertensive medication.

B. Raise the head of the bed.

C. Check for bladder distention.

D. Loosen tight clothing on the client.

E. Contact the physician.

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

A. Unequal pupil size

B. Decreasing systolic blood pressure

C. Tachycardia

D. Decreasing body temperature

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

A. Slow, irregular respirations

B. Rapid, shallow respirations

C. Asymmetric chest expansion

D. Nasal flaring

103. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

A. Give the client a warming blanket.

B. Administer low-dose barbiturate.

C. Encourage the client to hyperventilate.

D. Restrict fluids.
104. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in
the client’s condition?

A. Widening pulse pressure

B. Decrease in the pulse rate

C. Dilated, fixed pupil

D. Decrease in LOC

105. 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?

A. Place her in a jacket restraint.

B. Wrap her hands in soft “mitten” restraints.

C. Tuck her arms and hands under the draw sheet.

D. Apply a wrist restraint to each arm.

106. Which of the following describes decerebrate posturing?

A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers.

B. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of
the feet.

C. Supination of arms, dorsiflexion of feet.

D. Back arched; rigid extension of all four extremities.

107. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent
intracranial occipital bleeding. Which action would be most appropriate?

A. Count the rate to be sure the ventilations are deep enough to be sufficient.

B. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow
Coma score.

C. Call the physician to adjust the ventilator settings.

D. Check deep tendon reflexes to determine the best motor response.

108. 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?

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

B. Elevating the head of the bed to 30 degrees.

C. Logrolling or turning as a unit when turning.

D. Keeping the head in a neutral position.

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

A. Decerebrate posturing

B. Dilated nonreactive pupils

C. Deep tendon reflexes

D. Absent corneal reflex

110. 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?

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 the patient about the need for good oral hygiene.

D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.