Icp, Sci, Cva Q&a

Stroke NCLEX All
Study online at https://quizlet.com/_5lvk8u
1. In promoting health maintenance for prevention of C: Individuals

strokes, the nurse understands that the highest risk with hypertension
for the most common type of stroke is present in and diabetes- The
a. African Americans highest risk fac-
b. women who smoke tors for throm-
c.individuals with hypertension and diabetes botic stroke are
d. those who are obese with high dietary fat intake hypertension and
diabetes. African
Americans have
a higher risk
for stroke than
do white persons
but probably be-
cause they have a
greater incidence
of hypertension.
Factors such as
obesity, diet high in
saturated fats and
cholesterol, ciga-
rette smoking, and
excessive alcohol
use are also risk
factors but carry
less risk than hy-
pertension.
2. A thrombus that develops in a cerebral artery does not C: Circulation

always cause a loss of neurologic function because through the circle
a. the body can dissolve the atherosclerotic plaques of Willis may pro-
as they form vide blood sup-
b. some tissues of the brain do not require constant ply to the affected
blood supply to prevent damage area of the brain.
c. circulation through the circle of Willis may provide The communica-
blood supply to the affected area of the brain tion between cere-
d. neurologic deficits occur only when major arteries bral arteries in
are occluded by thrombus formation around an ather- the circle of Will-
osclerotic plaque ing provides a col-
lateral circulation,
1 / 37
Stroke NCLEX All
which may main-
tain circulation to
an area of the
brain if its orig-
inal blood sup-
ply is obstructed.
ALl areas of the
brain require con-
stant blood sup-
ply, and athero-
sclerotic plaques
are not readily re-
versed. Neurolog-
ic deficits can re-
sult from ischemia
cause by many
factors.
3. A patient comes to the emergency department im- D: The patient

mediately after experiencing numbness of the face has probably ex-
and an inability to speak, but while the patient awaits perienced a tran-
examination, the symptoms disappear and the patient sient ischemic at-
request discharge. The nurse stresses that it is impor- tack (TIA), which
tant for the patient to be evaluated primarily because is a sign of pro-
a. the patient has probably experienced an asympto- gressive cerebral
matic lacunar stroke vascular disease-
b. the symptoms are likely to return and progress to A TIA is a tem-
worsening neurologic deficit in the next 24 hours porary focal loss
c. neurologic deficits that are transient occur most of neurologic func-
often as a result of small hemorrhages that clot off tion caused by is-
d. the patient has probably experienced a transient chemia of an area
ischemic attack (TIA), which is a sign of progressive of the brain, usu-
cerebral vascular disease ally lasting only
about 3 hours.
TIAs may be
due to microem-
boli from heart dis-
ease or carotid or
cerebral thrombi
2 / 37
Stroke NCLEX All
and are a warning
of progressive dis-
ease. Evaluation is
necessary to de-
termine the cause
of the neurologic
deficit and provide
prophylactic treat-
ment if possible.
4. The neurologic functions that are affected by a stroke C: The brain area
are primarily related to perfused by the
a. the amount of tissue area involved affected artery-
b. the rapidity of onset of symptoms clinical manifesta-
c. the brain area perfused by the affected artery tion of altered
d. the presence or absence of collateral circulation neurologic func-
tion differ, de-
pending primari-
ly on the specif-
ic cerebral artery
involved and the
area of the brain
that is perfused by
the artery. The de-
gree of impairment
depends on rapid-
ity of onset, the
size of the lesion,
and the presence
of collateral circu-
lation.
5. A patient is admitted to the hospital with a left hemi- A: CT scan- A CT

plegia. To determine the size and location and to as- scan is the most
certain whether a stroke is ischemic or hemorrhagic, commonly used di-
the nurse anticipates that the health care provider will agnostic test to de-
request a termine the size
a. CT scan and location of the
b. lumbar puncture lesion and to differ-
3 / 37
Stroke NCLEX All
c. cerebral arteriogram entiate a thrombot-
d. positron emission tomography (PET) ic stroke from a he-
morrhagic stroke.
Positron emission
tomography (PET)
will show the meta-
bolic activity of
the brain and
provide a depic-
tion of the ex-
tent of tissue dam-
age after a stroke.
Lumbar punctures
are not performed
routinely because
of the chance
of increased in-
tracranial pressure
causing hernia-
tion. Cerebral ar-
teriograms are in-
vasive and may
dislodge an em-
bolism or cause
further hemor-
rhage; they are
performed only
when no other
test can provide
the needed infor-
mation.
6. A carotid endarterectomy is being considered as a C: Involves re-

treatment for a patient who has had several TIAs. The moving an athero-
nurse explains to the patient that this surgery sclerotic plaque in
a. is used to restore blood to the brain following an the carotid artery
obstruction of a cerebral artery to prevent an
b. involves intracranial surgery to join a superficial impending stroke-
extracranial artery to an intracranial artery An endarterecto-
4 / 37
Stroke NCLEX All
c. involves removing an atherosclerotic plaque in the my is a re-
carotid artery to prevent an impending stroke moval of an ather-
d. is sued to open a stenosis in a carotid artery with osclerotic plaque,
a balloon and stent to restore cerebral circulation and plaque in the
carotid artery may
impair circulation
enough to cause
a stroke. A carotid
endarterectomy is
performed to pre-
vent a cere-
brovascular acci-
dent (CVA), as are
most other sur-
gical procedures.
An extacranial-in-
tracranial bypass
involves cranial
surgery to bypass
a sclerotic intacra-
nial artery. Per-
cutaneous translu-
minal angioplasty
uses a balloon to
compress stenot-
ic areas in the
carotid and verte-
brobasilar arteries
and often includes
inserting a stent
to hold the artery
open.
7. The incidence of ischemic stroke in patients with TIAs C: Daily low dose
and other risk factors is reduced with administration aspirin- the
of administration of
a. furosemide (Lasix) antiplatelet
b. lovastatin (Mevacor) agents, such as
aspirin,
5 / 37
Stroke NCLEX All
c. daily low dose aspirin dipyridamole
d. nimodipine (Nimotop) (Persantine), and
ticlopdipine
(Ticlid), reduces
the incidence of
stroke in those at
risk.
Anticoagulants
are also used for
prevention of
embolic strokes
but increase the
risk for
hemorrhage.
Diuretics are not
indicated for
stroke prevention
other than for their
role in controlling
BP, and
antilipemic agents
have bot been
found to have a
significant effect
on stroke
prevention. The
calcium channel
blocker
nimodipine is
used in patients
with subarachnoid
hemorrhage to
decrease the
effects of
vasospasm and
minimize tissue
damage.
P.S. I freaking love
6 / 37
Stroke NCLEX All
you and good luck
on the final!!
8. The priority intervention in the emergency department D: Maintenance of

for the patient with a stroke is respiratory func-
a. intravenous fluid replacement tion with a patent
b. administration of osmotic diuretics to reduce cere- airway and oxy-
bral edema gen administra-
c. initiation of hypothermia to decrease the oxygen tion- the first prior-
needs of the brain ity in acute man-
d. maintenance of respiratory function with a patent agement of the pa-
airway and oxygen administration tient with a stroke
is preservation of
life. Because the
patient with a
stroke may be un-
conscious or have
a reduced gag re-
flex, it is most im-
portant to main-
tain a patent air-
way for the pa-
tient and provide
oxygen if respira-
tory effort is im-
paired. IV fluid re-
placement, treat-
ment with osmotic
diuretics, and per-
haps hypothermia
may be used for
further treatment.
9. A diagnosis of a ruptured cerebral aneurysm has been B: Surgical clip-

made in a patient with manifestations of a stroke. The ping of they
nurse anticipates that treatment options that would be aneurysm- Surgi-
evaluated for the patient include cal management
a. hyperventilation therapy with clipping of an
b. surgical clipping of the aneurysm aneurysm to de-
7 / 37
Stroke NCLEX All
c. administration of hyperosmotic agents crease re bleeding
d. administration of thrombolytic therapy and vasospasm is
an option for a
stroke cause by
rupture of a cere-
bral aneurysm.
Placement of coils
into the lumens of
the aneurysm by
intercentional radi-
ologists is increas-
ing in popular-
ity. Hyperventila-
tion therapy would
increase vasodi-
lation and the
potential for he-
morrhage. Throm-
bolytic therapy
would be absolute-
ly contraindicated,
and if a vessel is
patent, osmotic di-
uretics may leak
into tissue, pulling
fluid out of the ves-
sel and increasing
edema.
10. During the acute phase of a stroke, the nurse as- A: Hypertension-
sesses the patient's vital signs and neurologic status The body re-
every 4 hours. A cardiovascular sign that the nurse sponds to the va-
would see as the body attempts to increase cerebral sopasm and a
blood flow is decreased circula-
a. hypertension tion to the brain
b. fluid overload that occurs with a
c. cardiac dysrhythmias stroke by increas-
d. S3 and S4 heart sounds ing the BP, fre-
quently resulting in
8 / 37
Stroke NCLEX All
hypertension. The
other options are
important cardio-
vascular factors to
assess, but they
do not result from
impaired cerebral
blood flow.
11. A nursing intervention is indicated for the patient with D: Having the pa-
hemiplegia is tient perform pas-
a. the use of a footboard to prevent plantar flexion sive ROM of
b. immobilization of the affected arm against the the affected limb
chest with a sling with the unaffected
c. positioning the patient in bed with each joint lower limb- active ROM
than the joint proximal to it should be initiat-
d. having the patient perform passive ROM of the ed on the unaffect-
affected limb with the unaffected limb ed side as soon
as possible, and
passive ROM of
the affected side
should be start-
ed on the first
day. Having the pa-
tient actively exer-
cise the unaffect-
ed side provides
the patient with ac-
tive and passive
ROM as needed.
Use of footboards
is controversial be-
cause they stim-
ulate plantar flex-
ion. The unaffect-
ed arm should
be supported,
but immobilization
may precipitate
9 / 37
Stroke NCLEX All
a painful shoul-
der-hand syn-
drome. The patient
should be posi-
tioned with each
joint higher than
the joint proximal
to it to prevent de-
pendent edema.
12. A newly admitted patient who has suffered a right A: Place objects
sided brain stroke has a nursing diagnosis of dis- on the right side
turbed visual sensory perception related to homony- within the pa-
mous hemianopsia. Early in the care of the patient, the tient's field of vi-
nurse should sion- the pres-
a. place objects on the right side within the patient's ence of homony-
field of vision mous hemianopia
b. approach the patient from the left side to encourage in a patient
the patient to turn the head with right-hemi-
c. place objects on the patient's left side to assess the sphere brain dam-
patient's ability to compensate age causes a loss
d. patch the affected eye to encourage the patient to of vision in the left
turn the head to scan the environment field. Early in the
care of the patient,
objects should be
placed on the right
side of the pa-
tient in the field
of vision, and the
nurse should ap-
proach the patient
from the right side.
Later in treatment,
patients should be
taught to turn the
head and scan
the environment
and should be
approached from
10 / 37
Stroke NCLEX All
the affected side
to encourage head
turning. Eye patch-
es are used if pa-
tients have diplop-
ia (double vision).
13. Four days following a stroke, a patient is to start oral A: check the pa-
fluids and feedings. Before feeding the patient, the tient's gag reflex-
nurse should first the first step in pro-
a. check the patient's gag reflex viding oral feed-
b. order a soft diet for the patient ings for a patient
c. raise the head of the bed to sitting position with a stroke is
d. evaluate the patient's ability to swallow small sips ensuring that the
of ice water patient has an in-
tact gag reflex be-
cause oral feed-
ings will not be
provided if gag re-
flex is impaired.
The nurse should
then evaluate the
patient's ability to
swallow ice chips
or ice water after
placing the patient
in an upright posi-
tion
14. An appropriate food for a patient with a stroke who C: scrambled

has mild dysphagia is eggs- soft foods
a. fruit juices that provide
b. pureed meat enough texture,
c. scrambled eggs flavor, and bulk
d. fortified milkshakes to stimulate swal-
lowing should be
used for the pa-
tient with dys-
phasia. Thin liq-
11 / 37
Stroke NCLEX All
uids are difficult
to swallow, and
patients may not
be able to control
them in the mouth.
Pureed foods are
often too bland
and to smooth,
and milk products
should be avoided
because they tend
to increase the vis-
cosity of mucus
and increase sali-
vation.
15. A patient's wife asks the nurse why her husband did D: The medica-
not receive the clot busting medication (tPA) she has tion you are talk-
been reading about. Her husband is diagnosed with a ing about dis-
hemorrhagic stroke. What should the nurse respond? solves clots and
a. He didn't arrive within the time frame for that ther- could cause more
apy bleeding in your
b. Not every is eligible for this drug. Has he had husband's head-
surgery lately? tPA dissolves clots
c. You should discuss the treatment of your husband and increases the
with your doctor risk for bleed-
d. The medication you are talking about dissolves ing. It is not
clots and could cause more bleeding in your hus- used with hemor-
band's head rhagic strokes. If
the patient had
a thrombotic/em-
bolic stroke the
time frame would
be important as
well as a history of
surgery. The nurse
should answer the
question as accu-
rately as possible
12 / 37
Stroke NCLEX All
and then encour-
age the individual
to talk with the pri-
mary care physi-
cian if he or she
has further ques-
tions.
16. To promote communication during rehabilitation of B: Talk about ADLs

the patient with aphasia, an appropriate nursing inter- that are familiar to
vention is to the patient- dur-
a. use gestures, pictures, and music to stimulate ing rehabilitation,
patient responses the patient with
b. talk about activities of daily living (ADLs) that are aphasia needs fre-
familiar to the patient quent, meaningful
c. structure statements so that patient does not have verbal stimulation
to respond verbally that has relevance
d. use flashcards with simple words and pictures to for him. Conversa-
promote language recall tion by the nurse
and family should
address ADLs that
are familiar to the
patient. Gestures,
pictures, and sim-
ple statements are
more appropriate
in the acute phase,
when patients may
be overwhelmed
with verbal stimuli.
Flashcards are of-
ten perceived by
the patient as
childish and mean-
ingless.
17. A patient with right hemisphere stroke has a nursing C: Teach the pa-
diagnosis of unilateral neglect related to sensory per- tient to care con-
ceptual deficits. During the patient's rehabilitation, it sciously for the af-
13 / 37
Stroke NCLEX All
is important for the nurse to fected side- uni-
a. avoid positioning the patient on the affected side lateral neglect, or
b. place all objects for care on the patient's unaffected neglect syndrome,
side occurs when the
c. teach the patient to care consciously for the affect- patient with a
ed side stroke is unaware
d. protect the affected side from injury with pillows of the affected
and supports side of the body,
which puts the pa-
tient at risk for
injury. During the
acute phase, the
affected side is
cared for by the
nurse with posi-
tioning and sup-
port, during reha-
bilitation the pa-
tient is taught to
care consciously
for and attend to
the affected side of
the body to protect
it from injury. Pa-
tients may be po-
sitioned on the af-
fected side for up
to 30 minutes.
18. A patient with a stroke has a right sided hemiplegia. C: Distract the
The nurse prepares family members to help control patient from in-
behavior changes seen with this type of stroke by appropriate emo-
teaching them to tional respons-
a. ignore undesirable behaviors manifested by the es- patients with
patient left-sided brain
b. provide directions to the patient verbally in small damage from
steps stroke often ex-
c. distract the patient from inappropriate emotional perience emotion-
responses al lability, inappro-
14 / 37
Stroke NCLEX All
d. supervise all activities before allowing the patient priate emotional
to pursue them independently responses, mood
swings, and un-
controlled tears or
laughter dispro-
portionate or out
of context with the
situation. The be-
havior is upsetting
and embarrassing
to both the patient
and the family, and
the patient should
be distracted to
minimize its pres-
ence. Patients with
right-brain dam-
age often have im-
pulsive, rapid be-
havior that super-
vision and direc-
tion.
19. The nurse can assist the patient and the family in D: Helping the pa-
coping with the long term effects of a stroke by tient and family un-
a. informing family members that the patient will need derstand the sig-
assistance with almost all ADLs nificance of resid-
b. explaining that the patient's prestroke behavior will ual stroke damage
return as improvement progresses to promote prob-
c. encouraging the patient and family members to lem solving and
seek assistance from family therapy or stroke support planning- the pa-
groups tient and family
d. helping the patient and family understand the sig- need accurate and
nificance of residual stroke damage to promote prob- complete informa-
lem solving and planning tion about the ef-
fects of the stroke
to problem solve
and make plans
for chronic care
15 / 37
Stroke NCLEX All
of the patient.
It is uncommon
for patients with
major strokes to
return complete-
ly to pre stroke
function, behav-
iors, and role, and
both the patient
and family will
mourn these loss-
es. The patient's
specific needs for
care must be iden-
tified, and re-
habilitation efforts
should be contin-
ued at home. Fam-
ily therapy and
support groups
may be helpful for
some patients and
families.
20. Which intervention should the nurse delegate to the C: Administer

LPN when caring for a patient following an acute ordered antihy-
stroke? pertensives and
a. assess the patient's neurologic status platelet inhibitors-
b. assess the patient's gag reflex before beginning medication admin-
feeding istration is within
c. administer ordered antihypertensives and platelet the scope of prac-
inhibitors tice for an LPN.
d. teach the patient's caregivers strategies to mini- Assessment and
mize unilateral neglect teaching are within
the scope of prac-
tice for the RN.
21. Characteristics of a thrombotic stroke Type most often

signaled by TIAs,
16 / 37
Stroke NCLEX All
commonly occurs
during or after
sleep, strong as-
sociation with hy-
pertension
22. Characteristics of embolic stroke Onset unrelated

to activity, quick
onset and res-
olution, associat-
ed with endocar-
dial disorders
23. Characteristics of intracerebral hemorrhage Rupture of ather-

osclerotic vessels,
carries the poorest
prognosis, creates
mass that com-
presses the brain
24. Characteristics of subarachnoid hemorrhage High initial mortal-

ity, symptoms of
meningeal irrita-
tion, caused by
rupture of intracra-
nial aneurysm,
associated with
sudden, severe
headache
25. Manifestations of left brain damage Aphasia, inabili-

ty to remember
words
26. Manifestations of right brain damage Left homonymous

hemianopsia, ag-
nosia, quick impul-
sive behavior, ne-
glect of the left
side of the body
17 / 37
Stroke NCLEX All
27. Which of the following is the best treatment for acute C: Alteplase
ischemic stroke?
a. heparin
b. LMWH
c. Alteplase
d. Eptifibatie
e. Warfarin
Which of the following is the best treatment for acute
ischemic stroke?
a. heparin
b. LMWH
c. Alteplase
d. Eptifibatie
e. Warfarin
28. 1st thing you do when you suspect a stroke Non-contrast CT

scan (determines
hemorrhagic vs is-
chemic)
29. Most common artery involved Internal Carotid

Artery
30. Permissive hypertension If you drop

blood pressure
then more green
tissue (ischemic)
turns red (infarct-
ed)
(only treat BP if
>200)
31. Treat for hemorrhagic stroke Lower BP
32. Problem with IV-TPA only 1-3% of pa-

tients arrive in time
to receive it
33. Arterial sources of stroke (3)

18 / 37
Stroke NCLEX All
1. Intracranial vas-
cular disease
2. Carotid vascular
disease
3. Aortic arch
34. Secondary prevention of stroke (3) 1. Anticoagulants

2. Antiplatelets
3. Surgery
35. Secondary prevention: Risk factor modification (4) 1. smoking cessa-

tion
2. diabetes control
3. aggressive cho-
lesterol lowering
4. hypertension
control
36. 4 major causes of hemorrhagic stroke 1)deep

hypertensive
intracerebral
hemorrhages,
2)ruptured
saccular
aneurysms,
3)arteriovenous
malforma-
tion,4)sponta-
neous lobar
hemorrhages
37.
38. After a patient experienced a brief episode of tinnitus, C. The patient's

diplopia, and dysarthria with no residual effects, the symptoms are
nurse anticipates teaching the patient about consistent with
a. cerebral aneurysm clipping. transient ischemic
b. heparin intravenous infusion. attack (TIA), and
c. oral low-dose aspirin therapy. drugs that inhib-
d. tissue plasminogen activator (tPA). it platelet aggrega-
19 / 37
Stroke NCLEX All
tion are prescribed
after a TIA to pre-
vent stroke. Con-
tinuous heparin in-
fusion is not rou-
tinely used af-
ter TIA or with
acute ischemic
stroke. The pa-
tient's symptoms
are not consis-
tent with a cerebral
aneurysm. tPA is
used only for acute
ischemic stroke,
not for TIA.
39. A 68-year-old patient is being admitted with a possible C. A sudden onset

stroke. Which information from the assessment indi- headache is typi-
cates that the nurse should consult with the health cal of a subarach-
care provider before giving the prescribed aspirin? noid hemorrhage,
a. The patient has dysphasia. and aspirin is con-
b. The patient has atrial fibrillation. traindicated. Atri-
c. The patient reports that symptoms began with a al fibrillation, dys-
severe headache. phasia, and tran-
d. The patient has a history of brief episodes of sient ischemic at-
right-sided hemiplegia. tack (TIA) are
not contraindica-
tions to aspirin
use, so the nurse
can administer the
aspirin.
40. A 73-year-old patient with a stroke experiences facial D. Right-sided

drooping on the right side and right-sided arm and leg paralysis indicates
paralysis. When admitting the patient, which clinical a left-brain stroke,
manifestation will the nurse expect to find? which will lead to
a. Impulsive behavior difficulty with com-
b. Right-sided neglect prehension and
20 / 37
Stroke NCLEX All
c. Hyperactive left-sided tendon reflexes use of language.
d. Difficulty comprehending instructions The left-side re-
flexes are like-
ly to be intact.
Impulsive behav-
ior and neglect are
more likely with a
right-side stroke.
41. During the change of shift report a nurse is told that a C. Visual distur-
patient has an occluded left posterior cerebral artery. bances are ex-
The nurse will anticipate that the patient may have pected with poste-
a. dysphasia. rior cerebral artery
b. confusion. occlusion. Aphasia
c. visual deficits. occurs with mid-
d. poor judgment. dle cerebral artery
involvement. Cog-
nitive deficits and
changes in judg-
ment are more
typical of anterior
cerebral artery oc-
clusion.
42. When teaching about clopidogrel (Plavix), the nurse D. Clopidogrel

will tell the patient with cerebral atherosclerosis (Plavix) inhibits
a. to monitor and record the blood pressure daily. platelet function
b. that Plavix will dissolve clots in the cerebral arter- and increases the
ies. risk for gastroin-
c. that Plavix will reduce cerebral artery plaque forma- testinal bleeding,
tion. so patients should
d. to call the health care provider if stools are bloody be advised to noti-
or tarry. fy the health care
provider about any
signs of bleed-
ing. The medica-
tion does not low-
er blood pressure,
decrease plaque
21 / 37
Stroke NCLEX All
formation, or dis-
solve clots.
43. A patient with carotid atherosclerosis asks the nurse A. In a carotid en-
to describe a carotid endarterectomy. Which response darterectomy, the
by the nurse is accurate? carotid artery is
a. "The obstructing plaque is surgically removed from incised and the
an artery in the neck." plaque is removed.
b. "The diseased portion of the artery in the brain is The response be-
replaced with a synthetic graft." ginning, "The dis-
c. "A wire is threaded through an artery in the leg eased portion of
to the clots in the carotid artery and the clots are the artery in the
removed." brain is replaced"
d. "A catheter with a deflated balloon is positioned at describes an ar-
the narrow area, and the balloon is inflated to flatten terial graft pro-
the plaque." cedure. The an-
swer beginning, "A
catheter with a de-
flated balloon is
positioned at the
narrow area" de-
scribes an angio-
plasty. The final re-
sponse beginning,
"A wire is thread-
ed through the
artery" describes
the mechanical
embolus removal
in cerebral is-
chemia (MERCI)
procedure.
44. A patient admitted with possible stroke has been D. Because ele-
aphasic for 3 hours and his current blood pressure vated BP may be
(BP) is 174/94 mm Hg. Which order by the health care a protective re-
provider should the nurse question? sponse to main-
a. Keep head of bed elevated at least 30 degrees. tain cerebral perfu-
b. Infuse normal saline intravenously at 75 mL/hr. sion, antihyperten-
22 / 37
Stroke NCLEX All
c. Administer tissue plasminogen activator (tPA) per sive therapy is rec-
protocol. ommended only
d. Administer a labetalol (Normodyne) drip to keep BP if mean arterial
less than 140/90 mm Hg. pressure (MAP) is
>130 mm Hg or
systolic pressure
is >220 mm Hg.
Fluid intake should
be 1500 to 2000
mL daily to main-
tain cerebral blood
flow. The head of
the bed should be
elevated to at least
30 degrees, un-
less the patient
has symptoms of
poor tissue perfu-
sion. tPA may be
administered if the
patient meets the
other criteria for
tPA use.
45. A 56-year-old patient arrives in the emergency depart- D. The patient's

ment with hemiparesis and dysarthria that started 2 history and clini-
hours previously, and health records show a history cal manifestations
of several transient ischemic attacks (TIAs). The nurse suggest an acute
anticipates preparing the patient for ischemic stroke
a. surgical endarterectomy. and a patient who
b. transluminal angioplasty. is seen within 4.5
c. intravenous heparin administration. hours of stroke on-
d. tissue plasminogen activator (tPA) infusion. set is likely to
receive tPA (af-
ter screening with
a CT scan). He-
parin administra-
tion in the emer-
gency phase is not
23 / 37
Stroke NCLEX All
indicated. Emer-
gent carotid trans-
luminal angioplas-
ty or endarterecto-
my is not indicated
for the patient who
is having an acute
ischemic stroke.
46. A female patient who had a stroke 24 hours ago has A. Communication
expressive aphasia. The nurse identifies the nursing will be facilitated
diagnosis of impaired verbal communication. An ap- and less frustrat-
propriate nursing intervention to help the patient com- ing to the pa-
municate is to tient when ques-
a. ask questions that the patient can answer with tions that require
"yes" or "no." a "yes" or "no" re-
b. develop a list of words that the patient can read and sponse are used.
practice reciting. When the lan-
c. have the patient practice her facial and tongue ex- guage areas of
ercises with a mirror. the brain are in-
d. prevent embarrassing the patient by answering for jured, the patient
her if she does not respond. might not be able
to read or recite
words, which will
frustrate the pa-
tient without im-
proving communi-
cation. Expressive
aphasia is caused
by damage to the
language areas of
the brain, not by
the areas that con-
trol the motor as-
pects of speech.
The nurse should
allow time for the
patient to respond.
24 / 37
Stroke NCLEX All
47. A 72-year-old patient who has a history of a transient C. Aspirin is or-
ischemic attack (TIA) has an order for aspirin 160 mg dered to prevent
daily. When the nurse is administering medications, stroke in patients
the patient says, "I don't need the aspirin today. I don't who have experi-
have a fever." Which action should the nurse take? enced TIAs. Doc-
a. Document that the aspirin was refused by the pa- umentation of the
tient. patient's refusal to
b. Tell the patient that the aspirin is used to prevent a take the medica-
fever. tion is an inade-
c. Explain that the aspirin is ordered to decrease quate response by
stroke risk. the nurse. There is
d. Call the health care provider to clarify the medica- no need to clari-
tion order. fy the order with
the health care
provider. The as-
pirin is not ordered
to prevent aches
and pains.
48. For a patient who had a right hemisphere stroke the A. The patient with
nurse establishes a nursing diagnosis of right-sided brain
a. risk for injury related to denial of deficits and impul- damage typically
siveness. denies any deficits
b. impaired physical mobility related to right-sided and has poor
hemiplegia. impulse control,
c. impaired verbal communication related to leading to risk for
speech-language deficits. injury when the pa-
d. ineffective coping related to depression and dis- tient attempts ac-
tress about disability. tivities such as
transferring from a
bed to a chair.
Right-sided brain
damage causes
left hemiplegia.
Left-sided brain
damage typically
causes language
deficits. Left-sided
brain damage is
25 / 37
Stroke NCLEX All
associated with
depression and
distress about the
disability.
49. A patient in the clinic reports a recent episode of dys- B. Following a tran-
phasia and left-sided weakness at home that resolved sient ischemic at-
after 2 hours. The nurse will anticipate teaching the tack (TIA), pa-
patient about tients typically are
a. alteplase (tPA). started on med-
b. aspirin (Ecotrin). ications such as
c. warfarin (Coumadin). aspirin to inhib-
d. nimodipine (Nimotop). it platelet func-
tion and decrease
stroke risk. tPA
is used for acute
ischemic stroke.
Coumadin is usu-
ally used for pa-
tients with atri-
al fibrillation. Ni-
modipine is used
to prevent cerebral
vasospasm after a
subarachnoid he-
morrhage.
50. When caring for a patient with a new right-sided C. During the
homonymous hemianopsia resulting from a stroke, acute period,
which intervention should the nurse include in the the nurse should
plan of care? place objects on
a. Apply an eye patch to the right eye. the patient's un-
b. Approach the patient from the right side. affected side. Be-
c. Place objects needed on the patient's left side. cause there is a
d. Teach the patient that the left visual deficit will visual defect in
resolve. the right half of
each eye, an eye
patch is not ap-
propriate. The pa-
26 / 37
Stroke NCLEX All
tient should be ap-
proached from the
left side. The visual
deficit may not re-
solve, although the
patient can learn
to compensate for
the defect.
51. A 58-year-old patient with a left-brain stroke sudden- D. Patients who

ly bursts into tears when family members visit. The have left-sided
nurse should brain stroke are
a. use a calm voice to ask the patient to stop the crying prone to emotion-
behavior. al outbursts that
b. explain to the family that depression is normal fol- are not necessar-
lowing a stroke. ily related to the
c. have the family members leave the patient alone for emotional state of
a few minutes. the patient. De-
d. teach the family that emotional outbursts are compression after a
mon after strokes. stroke is com-
mon, but the sud-
denness of the
patient's outburst
suggests that de-
pression is not the
major cause of the
behavior. The fam-
ily should stay with
the patient. The
crying is not within
the patient's con-
trol and asking the
patient to stop will
lead to embarrass-
ment.
52. The nurse identifies the nursing diagnosis of imbal- C. Because the
anced nutrition: less than body requirements relat- nursing diagno-
ed to impaired self-feeding ability for a left-handed sis indicates that
27 / 37
Stroke NCLEX All
patient with left-sided hemiplegia. Which intervention the patient's im-
should be included in the plan of care? balanced nutrition
a. Provide a wide variety of food choices. is related to the
b. Provide oral care before and after meals. left-sided hemiple-
c. Assist the patient to eat with the right hand. gia, the appropri-
d. Teach the patient the "chin-tuck" technique. ate interventions
will focus on teach-
ing the patient
to use the right
hand for self-feed-
ing. The other in-
terventions are ap-
propriate for pa-
tients with other
etiologies for the
imbalanced nutri-
tion.
53. Which stroke risk factor for a 48-year-old male patient C. Hypertension is
in the clinic is most important for the nurse to ad- the single most im-
dress? portant modifiable
a. The patient is 25 pounds above the ideal weight. risk factor. People
b. The patient drinks a glass of red wine with dinner who drink more
daily. than 1 (for women)
c. The patient's usual blood pressure (BP) is 170/94 or 2 (for men) alco-
mm Hg. holic beverages a
d. The patient works at a desk and relaxes by watching day may increase
television. risk for hyperten-
sion. Physical in-
activity and obe-
sity contribute to
stroke risk but not
as much as hyper-
tension.
54. A 40-year-old patient has a ruptured cerebral A. The patient

aneurysm and subarachnoid hemorrhage. Which in- with a subarach-
tervention will be included in the care plan? noid hemorrhage
a. Apply intermittent pneumatic compression stock- usually has mini-
28 / 37
Stroke NCLEX All
ings. mal activity to pre-
b. Assist to dangle on edge of bed and assess for vent cerebral va-
dizziness. sospasm or fur-
c. Encourage patient to cough and deep breathe every ther bleeding and
4 hours. is at risk for ve-
d. Insert an oropharyngeal airway to prevent airway nous thromboem-
obstruction. bolism (VTE). Ac-
tivities such as
coughing and sit-
ting up that might
increase intracra-
nial pressure (ICP)
or decrease cere-
bral blood flow are
avoided. Because
there is no in-
dication that the
patient is uncon-
scious, an oropha-
ryngeal airway is
inappropriate.
55. A patient in the emergency department with sud- D. The use of war-
den-onset right-sided weakness is diagnosed with an farin probably con-
intracerebral hemorrhage. Which information about tributed to the in-
the patient is most important to communicate to the tracerebral bleed-
health care provider? ing and remains a
a. The patient's speech is difficult to understand. risk factor for fur-
b. The patient's blood pressure is 144/90 mm Hg. ther bleeding. Ad-
c. The patient takes a diuretic because of a history of ministration of vita-
hypertension. min K is needed to
d. The patient has atrial fibrillation and takes warfarin reverse the effects
(Coumadin). of the warfarin, es-
pecially if the pa-
tient is to have
surgery to correct
the bleeding. The
history of hyper-
tension is a risk
29 / 37
Stroke NCLEX All
factor for the pa-
tient but has no im-
mediate effect on
the patient's care.
The BP of 144/90
indicates the need
for ongoing mon-
itoring but not
for any immediate
change in thera-
py. Slurred speech
is consistent with
a left-sided stroke,
and no change in
therapy is indicat-
ed.
56. A 47-year-old patient will attempt oral feedings for C. The patient
the first time since having a stroke. The nurse should should be as up-
assess the gag reflex and then right as possible
a. order a varied pureed diet. before attempting
b. assess the patient's appetite. feeding to make
c. assist the patient into a chair. swallowing easier
d. offer the patient a sip of juice. and decrease as-
piration risk. To
assess swallowing
ability, the nurse
should initially of-
fer water or ice
to the patient.
Pureed diets are
not recommended
because the tex-
ture is too smooth.
The patient may
have a poor ap-
petite, but the oral
feeding should be
30 / 37
Stroke NCLEX All
attempted regard-
less.
57. A patient with left-sided weakness that started 60 min- D. Rapid screening
utes earlier is admitted to the emergency department with a noncontrast
and diagnostic tests are ordered. Which test should CT scan is needed
be done first? before administra-
a. Complete blood count (CBC) tion of tissue plas-
b. Chest radiograph (Chest x-ray) minogen activator
c. 12-Lead electrocardiogram (ECG) (tPA), which must
d. Noncontrast computed tomography (CT) scan be given within 4.5
hours of the on-
set of clinical man-
ifestations of the
stroke. The soon-
er the tPA is giv-
en, the less brain
injury. The other di-
agnostic tests give
information about
possible causes of
the stroke and do
not need to be
completed as ur-
gently as the CT
scan.
58. A male patient who has right-sided weakness after C. The informa-
a stroke is making progress in learning to use the tion supports the
left hand for feeding and other activities. The nurse diagnosis of dis-
observes that when the patient's wife is visiting, she abled family cop-
feeds and dresses him. Which nursing diagnosis is ing because the
most appropriate for the patient? wife does not un-
a. Interrupted family processes related to effects of derstand the re-
illness of a family member habilitation pro-
b. Situational low self-esteem related to increasing gram. There are
dependence on spouse for care no data support-
c. Disabled family coping related to inadequate under- ing low self-es-
standing by patient's spouse teem, and the pa-
31 / 37
Stroke NCLEX All
d. Impaired nutrition: less than body requirements tient is attempt-
related to hemiplegia and aphasia ing independence.
The data do not
support an inter-
ruption in fami-
ly processes be-
cause this may
be a typical pat-
tern for the couple.
There is no indi-
cation that the pa-
tient has impaired
nutrition.
59. Nurses in change-of-shift report are discussing the D. Protection of the

care of a patient with a stroke who has progressive- airway is the prior-
ly increasing weakness and decreasing level of con- ity of nursing care
sciousness (LOC). Which nursing diagnosis do they for a patient having
determine has the highest priority for the patient? an acute stroke.
a. Impaired physical mobility related to weakness The other diag-
b. Disturbed sensory perception related to brain injury noses are also ap-
c. Risk for impaired skin integrity related to immobility propriate, but in-
d. Risk for aspiration related to inability to protect terventions to pre-
airway vent aspiration are
the priority at this
time.
60. Several weeks after a stroke, a 50-year-old male pa- B. Developing a

tient has impaired awareness of bladder fullness, re- regular voiding
sulting in urinary incontinence. Which nursing inter- schedule will pre-
vention will be best to include in the initial plan for an vent incontinence
effective bladder training program? and may increase
a. Limit fluid intake to 1200 mL daily to reduce urine patient awareness
volume. of a full bladder.
b. Assist the patient onto the bedside commode every A 1200 mL flu-
2 hours. id restriction may
c. Perform intermittent catheterization after each void- lead to dehy-
ing to check for residual urine. dration. Intermit-
tent catheteriza-
32 / 37
Stroke NCLEX All
d. Use an external "condom" catheter to protect the tion and use of
skin and prevent embarrassment. a condom catheter
are appropriate in
the acute phase
of stroke, but
should not be con-
sidered solutions
for long-term man-
agement because
of the risks for
urinary tract infec-
tion (UTI) and skin
breakdown.
61. Which information about the patient who has had a B. To prevent cere-
subarachnoid hemorrhage is most important to com- bral vasospasm
municate to the health care provider? and maintain cere-
a. The patient complains of having a stiff neck. bral perfusion,
b. The patient's blood pressure (BP) is 90/50 mm Hg. blood pressure
c. The patient reports a severe and unrelenting needs to be main-
headache. tained at a lev-
d. The cerebrospinal fluid (CSF) report shows red el higher than 90
blood cells (RBCs). mm Hg systolic af-
ter a subarachnoid
hemorrhage. A low
BP or drop in BP
indicates a need
to administer fluids
and/or vasopres-
sors to increase
the BP. An ongoing
headache, RBCs
in the CSF, and
a stiff neck are
all typical clinical
manifestations of a
subarachnoid he-
morrhage and do
not need to be
33 / 37
Stroke NCLEX All
rapidly communi-
cated to the health
care provider.
62. The nurse is caring for a patient who has been experi- C. Administration
encing stroke symptoms for 60 minutes. Which action of subcutaneous
can the nurse delegate to a licensed practical/voca- medications is in-
tional nurse (LPN/LVN)? cluded in LPN/LVN
a. Assess the patient's gag and cough reflexes. education and
b. Determine when the stroke symptoms began. scope of practice.
c. Administer the prescribed short-acting insulin. The other actions
d. Infuse the prescribed IV metoprolol (Lopressor). require more edu-
cation and scope
of practice and
should be done
by the registered
nurse (RN).
63. After receiving change-of-shift report on the follow- A. tPA needs to be

ing four patients, which patient should the nurse see infused within the
first? first few hours after
a. A 60-year-old patient with right-sided weakness stroke symptoms
who has an infusion of tPA prescribed start in order to be
b. A 50-year-old patient who has atrial fibrillation and effective in mini-
a new order for warfarin (Coumadin) mizing brain injury.
c. A 40-year-old patient who experienced a transient The other medica-
ischemic attack yesterday who has a dose of aspirin tions should also
due be given as quick-
d. A 30-year-old patient with a subarachnoid hem- ly as possible, but
orrhage 2 days ago who has nimodipine (Nimotop) timing of the med-
scheduled ications is not as
critical.
64. The nurse is caring for a patient who has just re- B. Small emboli
turned after having left carotid artery angioplasty and can occur dur-
stenting. Which assessment information is of most ing carotid artery
concern to the nurse? angioplasty and
a. The pulse rate is 102 beats/min. stenting, and the
b. The patient has difficulty speaking. aphasia indicates
34 / 37
Stroke NCLEX All
c. The blood pressure is 144/86 mm Hg. a possible stroke
d. There are fine crackles at the lung bases. during the proce-
dure. Slightly ele-
vated pulse rate
and blood pres-
sure are not un-
usual because of
anxiety associat-
ed with the proce-
dure. Fine crackles
at the lung bases
may indicate at-
electasis caused
by immobility dur-
ing the procedure.
The nurse should
have the patient
take some deep
breaths.
65. A 70-year-old female patient with left-sided hemipare- C. The initial nurs-
sis arrives by ambulance to the emergency depart- ing action should
ment. Which action should the nurse take first? be to assess the
a. Monitor the blood pressure. airway and take
b. Send the patient for a computed tomography (CT) any needed ac-
scan. tions to ensure
c. Check the respiratory rate and effort. a patent airway.
d. Assess the Glasgow Coma Scale score. The other activi-
ties should take
place quickly after
the ABCs (airway,
breathing, and cir-
culation) are com-
pleted.
66. The home health nurse is caring for an 81-year-old B. The spouse's
who had a stroke 2 months ago. Based on information household and pa-
shown in the accompanying figure from the history, tient care respon-
physical assessment, and physical therapy/occupa- sibilities, in combi-
35 / 37
Stroke NCLEX All
tional therapy, which nursing diagnosis is the highest nation with chron-
priority for this patient? ic illnesses, indi-
a. Impaired transfer ability cate a high risk
b. Risk for caregiver role strain for caregiver role
c. Ineffective health maintenance strain. The nurse
d. Risk for unstable blood glucose level should further as-
sess the situa-
tion and take ap-
propriate actions.
The data about
the control of the
patient's diabetes
indicates that in-
effective health
maintenance and
risk for unstable
blood glucose are
not priority con-
cerns at this time.
Because the pa-
tient is able to am-
bulate with a cane,
the nursing diag-
nosis of impaired
transfer ability is
not supported.
67. A 63-year-old patient who began experiencing right C, D, A, B

arm and leg weakness is admitted to the emergency The initial actions
department. In which order will the nurse implement should be those
these actions included in the stroke protocol? that help with
a. Obtain computed tomography (CT) scan without airway, breathing,
contrast. and circulation.
b. Infuse tissue plasminogen activator (tPA). Baseline neuro-
c. Administer oxygen to keep O2 saturation >95%. logic assessments
d. Use National Institute of Health Stroke Scale to should be done
assess patient. next. A CT scan
will be needed to
rule out hemor-
36 / 37
Stroke NCLEX All
rhagic stroke be-
fore tPA can be ad-
ministered.
37 / 37
Exam 5: Stroke NCLEX Quetions
Study online at https://quizlet.com/_7j36k2
1. c The nurse expects that management of the patient who

experiences a brief episode of tinnitus, diplopia, and
dysarthria with no residual effects will include
a. prophylactic clipping of cerebral aneurysms.

b. heparin via continuous intravenous infusion.
c. oral administration of low dose aspirin therapy.
d. therapy with tissue plasminogen activator (tPA).
2. c Aspirin is ordered for a patient who is admitted with a

possible stroke. Which information obtained during the
admission assessment indicates that the nurse should
consult with the health care provider before giving the
aspirin?
a. The patient has dysphasia.

b. The patient has atrial fibrillation.
c. The patient states, My symptoms started with a terrible
headache.
d. The patient has a history of brief episodes of right-sided
hemiplegia.
3. d A patient with a stroke experiences right-sided arm and

leg paralysis and facial drooping on the right side. When
admitting the patient, which clinical manifestation will the
nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided reflexes
d. Difficulty in understanding commands
4. c The nurse receives a verbal report that a patient has an

occlusion of the left posterior cerebral artery. The nurse
will anticipate that the patient may have
a. dysphasia.
b. confusion.
1 / 25
c. visual deficits.
d. poor judgment.
5. b The health care provider prescribes clopidogrel (Plavix)

for a patient with cerebral atherosclerosis. When teaching
about the new medication, the nurse will tell the patient
a. to monitor and record the blood pressure daily.

b. to call the health care provider if stools are tarry.
c. that Plavix will dissolve clots in the cerebral arteries.
d. that Plavix will reduce cerebral artery plaque formation.
6. a The health care provider recommends a carotid en-

darterectomy for a patient with carotid atherosclerosis and
a history of transient ischemic attacks (TIAs). The patient
asks the nurse to describe the procedure. Which response
by the nurse is appropriate?
a. The carotid endarterectomy involves surgical removal of

plaque from an artery in the neck.
b. The diseased portion of the artery in the brain is re-
moved and replaced with a synthetic graft.
c. A wire is threaded through an artery in the leg to the
clots in the carotid artery and the clots are removed.
d. A catheter with a deflated balloon is positioned at the
narrow area, and the balloon is inflated to flatten the
plaque.
7. d When assessing a patient with a possible stroke, the nurse

finds that the patients aphasia started 3.5 hours previously
and the blood pressure is 170/92 mm Hg. Which of these
orders by the health care provider should the nurse ques-
tion?
a. Infuse normal saline at 75 mL/hr.

b. Keep head of bed elevated at least 30 degrees.
c. Administer tissue plasminogen activator (tPA) per pro-
tocol.
2 / 25
d. Titrate labetolol (Normodyne) drip to keep BP less than
140/90 mm Hg.
8. d A patient with a history of several transient ischemic at-

tacks (TIAs) arrives in the emergency department with
hemiparesis and dysarthria that started 2 hours previous-
ly. The nurse anticipates the need to prepare the patient
for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.
9. b The nurse identifies the nursing diagnosis of impaired ver-

bal communication for a patient with expressive aphasia.
An appropriate nursing intervention to help the patient
communicate is to
a. have the patient practice facial and tongue exercises.

b. ask simple questions that the patient can answer with
yes or no.
c. develop a list of words that the patient can read and
practice reciting.
d. prevent embarrassing the patient by changing the sub-
ject if the patient does not respond.
10. b A patient has a stroke affecting the right hemisphere of

the brain. Based on knowledge of the effects of right brain
damage, the nurse establishes a nursing diagnosis of
a. impaired physical mobility related to right hemiplegia.

b. risk for injury related to denial of deficits and impulsive-
ness.
c. impaired verbal communication related to speech-lan-
guage deficits.
d. ineffective coping related to depression and distress
about disability.
11. c
3 / 25
When caring for a patient with left-sided homonymous
hemianopsia resulting from a stroke, which intervention
should the nurse include in the plan of care during the
acute period of the stroke?
a. Apply an eye patch to the left eye.

b. Approach the patient from the left side.
c. Place objects needed for activities of daily living on the
patients right side.
d. Reassure the patient that the visual deficit will resolve
as the stroke progresses.
12. c The nurse identifies the nursing diagnosis of imbalanced

nutrition: less than body requirements related to impaired
self-feeding ability for a patient with right-sided hemiplegia.
Which intervention should be included in the plan of care?
a. Provide a wide variety of food choices.

b. Provide oral care before and after meals.
c. Assist the patient to eat with the left hand.
d. Teach the patient the chin-tuck technique.
13. a A 32-year-old patient has a stroke resulting from a rup-

tured aneurysm and subarachnoid hemorrhage. Which
intervention will be included in the care plan?
a. Applying intermittent pneumatic compression stockings

b. Assisting to dangle on edge of bed and assess for
dizziness
c. Encouraging patient to cough and deep breathe every
4 hours
d. Inserting an oropharyngeal airway to prevent airway
obstruction
14. c A patient who has had a stroke has a new order to attempt
oral feedings. The nurse should assess the gag reflex and
then
a. order a varied pureed diet.
4 / 25
b. assess the patients appetite.
c. assist the patient into a chair.
d. offer the patient a sip of juice.
15. c A patient who has right-sided weakness after a stroke is

attempting to use the left hand for feeding and other activi-
ties. The patients wife insists on feeding and dressing him,
telling the nurse, I just dont like to see him struggle. Which
nursing diagnosis is most appropriate for the patient?
a. Situational low self-esteem related to increasing depen-

dence on others
b. Interrupted family processes related to effects of illness
of a family member
c. Disabled family coping related to inadequate under-
standing by patients spouse
d. Impaired nutrition: less than body requirements related
to hemiplegia and aphasia
16. b Several weeks after a stroke, a patient has urinary incon-

tinence resulting from an impaired awareness of bladder
fullness. For an effective bladder training program, which
nursing intervention will be best to include in the plan of
care?
a. Limit fluid intake to 1200 mL daily to reduce urine

volume.
b. Assist the patient onto the bedside commode every 2
hours.
c. Perform intermittent catheterization after each voiding
to check for residual urine.
d. Use an external condom catheter to protect the skin and
prevent embarrassment.
17. c A patient who has a history of a transient ischemic attack

(TIA) has an order for aspirin 160 mg daily. When the nurse
is administering the medications, the patient says, I dont
need the aspirin today. I dont have any aches or pains.
Which action should the nurse take?
5 / 25
a. Document that the aspirin was refused by the patient.

b. Tell the patient that the aspirin is used to prevent aches.
c. Explain that the aspirin is ordered to decrease stroke
risk.
d. Call the health care provider to clarify the medication
order.
18. b A patient is admitted to the hospital with dysphasia and

right-sided weakness that resolves in a few hours. The
nurse will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop).
19. d A patient with a left-sided brain stroke suddenly bursts into

tears when family members visit. The nurse should
a. use a calm voice to ask the patient to stop the crying

behavior.
b. explain to the family that depression is normal following
a stroke.
c. have the family members leave the patient alone for a
few minutes.
d. teach the family that emotional outbursts are common
after strokes.
20. d The nurse obtains all of the following information about a

65-year-old patient in the clinic. When developing a plan
to decrease stroke risk, which risk factor is most important
for the nurse to address?
a. The patient has a daily glass of wine to relax.

b. The patient is 25 pounds above the ideal weight.
c. The patient works at a desk and relaxes by watching
television.
6 / 25
d. The patients blood pressure (BP) is usually about
180/90 mm Hg.
21. d A patient with sudden-onset right-sided weakness has

a CT scan and is diagnosed with an intracerebral he-
morrhage. Which information about the patient is most
important to communicate to the health care provider?
a. The patients speech is difficult to understand.

b. The patients blood pressure is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of
hypertension.
d. The patient has atrial fibrillation and takes warfarin
(Coumadin).
22. d A patient with right-sided weakness that started 90 min-

utes earlier is admitted to the emergency department and
all these diagnostic tests are ordered. Which test should
be done first?
a. Electrocardiogram (ECG)
b. Complete blood count (CBC)
c. Chest radiograph (Chest x-ray)
d. Noncontrast computed tomography (CT) scan
23. d A patient with a stroke has progressive development

of neurologic deficits with increasing weakness and de-
creased level of consciousness (LOC). Which nursing di-
agnosis has the highest priority for the patient?
a. Impaired physical mobility related to weakness

b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
24. a A patient who has had a subarachnoid hemorrhage is be-

ing cared for in the intensive care unit. Which information
about the patient is most important to communicate to the
health care provider?
7 / 25
a. The patients blood pressure is 90/50 mm Hg.
b. The patient complains about having a stiff neck.
c. The cerebrospinal fluid (CSF) report shows red blood
cells (RBCs).
d. The patient complains of an ongoing severe headache.
25. c Which of these nursing actions included in the care of a

patient who has been experiencing stroke symptoms for
60 minutes can the nurse delegate to an LPN/LVN?
a. Assess the patients gag and cough reflexes.

b. Determine when the stroke symptoms began.
c. Administer the prescribed clopidogrel (Plavix).
d. Infuse the prescribed IV metoprolol (Lopressor).
26. a After receiving change-of-shift report on the following four

patients, which patient should the nurse see first?
a. A patient with right-sided weakness who has an infusion

of tPA prescribed
b. A patient who has atrial fibrillation and a new order for
warfarin (Coumadin)
c. A patient who experienced a transient ischemic attack
yesterday who has a dose of aspirin due
d. A patient with a subarachnoid hemorrhage 2 days ago
who has nimodipine (Nimotop) scheduled
27. b The nurse is caring for a patient with carotid artery narrow-
ing who has just returned after having left carotid artery
angioplasty and stenting. Which assessment information
is of most concern to the nurse?
a. The pulse rate is 104 beats/min.

b. The patient has difficulty talking.
c. The blood pressure is 142/88 mm Hg.
d. There are fine crackles at the lung bases.
28. a A patient with left-sided hemiparesis arrives by ambulance

to the emergency department. Which action should the
nurse take first?
8 / 25
a. Check the respiratory rate.

b. Monitor the blood pressure.
c. Send the patient for a CT scan.
d. Obtain the Glasgow Coma Scale score.
29. c A 58-year-old patient who began experiencing right-sided

d arm and leg weakness is admitted to the emer-
a gency department. In which order will the nurse im-
b plement these actions included in the stroke protocol?
____________________
a. Obtain CT scan without contrast.

b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess
patient.
30. d Of the following patients, the nurse recognizes that the one
with the highest risk for a stroke is
a. obese 45 year old Native American

b. 35 year old Asian American woman who smokes
c. 32 year old white woman taking oral contraceptives
d. 65 year old African American man with hypertension
31. c The factor related to cerebral blood flow that most often
determines the extent of cerebral damage from a stroke is
the
a. amount of cardiac output

b. O2 content of the blood
c. degree of collateral circulation
d. level of CO2 in the blood
32. d Information provided by the patient that would help dif-

ferentiate a hemorrhagic stroke from a thrombotic stroke
includes
a. sensory disturbance
9 / 25
b. a history of hypertension
c. presence of motor weakness
d. sudden onset of severe headache
33. c A patient is exhibiting word finding difficulty and weakness

in his right arm. What area of the brain is most likely
involved?
a. brainstem
b. vertebral artery
c. left middle cerebral artery
d. right middle cerebral artery
34. c The nurse explains to the patient with a stroke who is

scheduled for angiography that this test is used to deter-
mine the
a. presence of increased ICP

b. site and size of the infarction
c. patency of the cerebral blood vessels
d. presence of blood in the cerebrospinal fluid
35. c A patient experiencing TIAs is scheduled for a carotid

endarterectomy. The nurse explains that this procedure is
done to
a. decrease cerebral edema

b. reduce the brain damage that occurs during a stroke in
evolution
c. prevent a stroke by removing atherosclerotic plaques
blocking cerebral blood flow
d. provide a circulatory bypass around thrombotic plaques
obstructing cranial circulation
36. b For a patient who is suspected of having a stroke, one of

the most important pieces of information that the nurse
can obtain is
a. time of the patient's last meal

b. time at which stroke symptoms first appeared
10 / 25
c. patient's hypertension history and management
d. family history of stroke and other cardiovascular dis-
eases
37. c Bladder training in a male patient who has urinary incon-

tinence after a stroke includes
a. limiting fluid intake

b. keeping a urinal in place at all times
c. assisting the patient to stand to void
d. catheterizing the patient every 4 hours
38. a Common psychosocial reactions of the stroke patient to

d the stroke include (Select all that apply)
e
a. depression
b. disassociation
c. intellectualization
d. sleep disturbances
e. denial of severity of stroke
39. c In promoting health maintenance for prevention of strokes,

the nurse understands that the highest risk for the most
common type of stroke is present in which people?
a. african americans
b. women who smoke
c. individuals with hypertension and diabetes
d. those who are obese with high dietary fat intake
40. c A thrombus that develops in a cerebral artery does not

always cause a loss of neurologic function because
a. the body can dissolve atherosclerotic plaques as they

form
b. some tissues of the brain do not require constant blood
supply to prevent damage
c. circulation via the Circle of Willis may provide blood
supply to the affected area of the brain
d. neurologic deficits occur only when major arteries are
11 / 25
occluded by thrombus formation around atherosclerotic
plaque
41. d A patient comes to the emergency department immediate-

ly after experiencing numbness of the face and an inability
to speak, but while the patient awaits examination, the
symptoms disappear and the patient requests discharge.
Why should the nurse emphasize that it is important for
the patient to be treated before leaving?
a. the patient has probably experienced an asymptomatic

lacunar stroke
b. the symptoms are likely to return and progress to wors-
ening neurologic deficit in the next 24 hours
c. neurologic deficits that are transient occur most often as
a result of small hemorrhages that clot off
d. the patient has probably experienced a transient is-
chemic attack, which is a sign of progressive cerebrovas-
cular disease
42. a What are characteristics of a stroke caused by an intrac-

b erebral hemorrhage? (Select all that apply)
c
e a. carries a poor prognosis
b. caused by rupture of a vessel
c. strong association with hypertension
d. commonly occurs during or after sleep
e. creates a mass that compresses the brain
43. a Which type of stroke is associated with endocardial dis-

orders, has a rapid onset, and is likely to occur during
activity?
a. embolic
b. thrombotic
c. intracerebral hemorrhage
d. subarachnoid hemorrhage
44. c What primarily determines the neurologic functions that

are affected by a stroke?
12 / 25
a. the amount of tissue area involved

b. the rapidity of the onset of symptoms
c. the brain area perfused by the affected artery
d. the presence or absence of collateral circulation
45. c The patient has a lack of comprehension of both verbal

and written language. Which type of communication diffi-
culty does this patient have?
a. dysarthria
b. fluent dysphagia
c. receptive aphasia
d. expressive aphasia
46. c A patient is admitted to the hospital with a left hemiple-

gia. To determine the size and location and to ascertain
whether a stroke is ischemic or hemorrhagic, what will the
nurse anticipate that the HCP will request?
a. lumbar puncture
b. cerebral angiography
c. magnetic resonance imagine (MRI)
d. computed tomography (CT) scan with contrast
47. c A carotid endarterectomy is being considered as treat-

ment for a patient who has had several TIAs. What should
the nurse explain to the patient about this surgery?
a. it involves intracranial surgery to join a superficial ex-

tracranial artery to an intracranial artery
b. it is used to restore blood circulation to the brain follow-
ing an obstruction of a cerebral artery
c. it involves removing an atherosclerotic plaque in the
carotid artery to prevent an impending stroke
d. it is used to open a stenosis in a carotid artery with a
balloon and stent to restore cerebral circulation
48. d The incidence of ischemic stroke in patients with TIAs

and other risk factors is reduced with the administration
13 / 25
of which medication?
a. nimodipine
b. furosemide (lasix)
c. warfarin (coumadin)
d. daily low-dose aspirin
49. d What is a priority intervention in the ED for a patient with

a stroke?
a. IV fluid replacement
b. administration of osmotic diuretics to reduce cerebral
edema
c. initiation of hypothermia to decrease the oxygen needs
of the brain
d. maintenance of respiratory function with a patent airway
and oxygen administration
50. b A diagnosis of a ruptured cerebral aneurysm has been

made in a patient with manifestations of a stroke. The
nurse anticipates which treatment option that would be
considered for the patient?
a. hyperventilation therapy
b. surgical clipping of the aneurysm
c. administration of hyperosmotic agents
d. administration of thrombolytic therapy
51. a During the acute phase of a stroke, the nurse assesses the
patient's vital signs and neurologic status at least every 4
hours. What is a cardiovascular sign that the nurse would
see as the body attempts to increase cerebral blood flow?
a. hypertension
b. fluid overload
c. cardiac dysrhythmias
d. S3 and S4 heart sounds
52. a During the secondary assessment of the patient with a

b stroke, what should be included? (Select all that apply)
14 / 25
c
d a. gaze
f b. sensation
c. facial palsy
d. proprioception
e. current medications
f. distal motor function
53. d What is a nursing intervention that is indicated for the

patient with hemiplegia?
a. the use of a footboard to prevent plantar flexion

b. immobilization of the affected arm against the chest with
a sling
c. positioning the patient in bed with each joint lower than
the joint proximal to it
d. having the patient perform passive range of motion of
the affected limb with the unaffected limb
54. a A newly admitted patient diagnosed with a right-sided

brain stroke has a nursing diagnosis of disturbed visual
sensory perception related to homonymous hemianopsia.
Early in the care of the patient, what should the nurse do?
a. place objects on the right side within the patient's field

of vision
b. approach the patient from the left side to encourage the
patient to turn the head
c. place objects on the patient's left side to assess the
patient's ability to compensate
d. patch the affected eye to encourage the patient to turn
the head to scan the environment
55. a Four days following a stroke, a patient is to start oral fluids

and feedings. Before feeding the patient, what should the
nurse do first?
a. check the patient's gag reflex

b. order a soft diet for the patient
15 / 25
c. raise the had of bed to a sitting position
d. evaluate the patient's ability to swallow small amounts
of crushed ice or ice water
56. c What is an appropriate food for a patient with a stroke who

has mild dysphagia?
a. fruit juices
b. pureed meat
c. scrambled eggs
d. fortified milkshakes
57. d A patient's wife asks the nurse why her husband did not
receive the clot busting medication (tissue plasminogen
activator) she has been reading about. Her husband is
diagnosed with a hemorrhagic stroke. What is the best
response by the nurse to the wife?
a. "He didn't arrive within the timeframe for that therapy."

b. "Not everyone is eligible for this drug. Has he had
surgery lately?'"
c. "You should discuss the treatment of your husband with
his doctor."
d. "The medication you are talking about dissolves clots
and could cause more bleeding in your husband's brain."
58. c The rehabilitation nurse assesses the patient, caregiver,

d and family before planing the rehabilitation program for
f this patient. What must be included in this assessment?
(Select all that apply)
a. cognitive status of the family

b. patient resources and support
c. physical status of all body systems
d. rehabilitation potential of the patient
e. body strength remaining after the stroke
f. patient and caregiver expectations of the rehabilitation
59. a What is an appropriate nursing intervention to promote

communication during rehabilitation of the patient with
16 / 25
aphasia?
a. allow time for the individual to complete their thoughts

b. use gestures, pictures, and music to stimulate patient
responses
c. structure statements so that the patient does not have
to respond verbally
d. use flashcards with simple words and pictures to pro-
mote recall of language
60. c A patient with a right hemisphere stroke has a nursing di-

agnosis of unilateral neglect related to sensory-perceptual
deficits. During the patient's rehabilitation, what nursing
intervention is important for the nurse to do?
a. avoid positioning the patient on the affected side

b. place all objects for care on the patient's unaffected side
c. teach the patient to care consciously for the affected
side
d. protect the affected side from injury with pillows and
supports
61. c A patient with a stroke has a right-sided hemiplegia. What

does the nurse teach the family to prepare them to cope
with the behavior changes seen with this type of stroke?
a. ignore undesirable behaviors manifested by the patient

b. provide directions to the patient verbally in small steps
c. distract the patient from inappropriate emotional re-
sponses
d. supervise all activities before allowing the patient to
pursue them independently
62. d The nurse can best assist the patient and family in coping
with the long-term effects of a stroke by doing what?
a. informing family members that the patient will need

assistance with almost all ADLs
b. explaining that the patient's prestroke behavior will re-
17 / 25
turn as improvement progresses
c. encouraging the patient and family members to seek
assistance from family therapy or stroke support groups
d. helping the patient and family to understand the sig-
nificance of residual stroke damage to promote problem
solving and planning
63. c Which intervention should the nurse delegate to the li-

censed practical nurse when caring for a patient following
an acute stroke?
a. assess the patient's neurologic status

b. assess the patient's gag reflex before beginning feeding
c. administer ordered antihypertensives and platelet in-
hibitors
d. teach the patient's caregivers strategies to minimize
unilateral neglect
64. d The nurse in a primary care provider's office is assessing

several patients today. Which patient is most at risk for a
stroke?
a. A 92-yr-old female patient who takes warfarin

(Coumadin) for atrial fibrillation
b. A 28-yr-old male patient who uses marijuana after
chemotherapy to control nausea
c. A 42-yr-old female patient who takes oral contraceptives
and has migraine headaches
d. A 72-yr-old male patient who has hypertension and
diabetes mellitus and smokes tobacco
65. d The nurse is teaching a senior citizen's group about signs

and symptoms of a stroke. Which statement by the nurse
would provide accurate information?
a. "Take the person to the hospital if a headache lasts for

more than 24 hours."
b. "Stroke symptoms usually start when the person is
awake and physically active."
18 / 25
c. "A person with a transient ischemic attack has mild
symptoms that will go away."
d. "Call 911 immediately if a person develops slurred
speech or difficulty speaking."
66. c When providing care to the patient with an acute stroke,

which duty can be delegated to the LPN/LVN?
a. Screen patient for tPA eligibility.

b. Assess the patient's ability to swallow.
c. Administer scheduled anticoagulant medications.
d. Place equipment needed for seizure precautions in
room.
67. d The nurse observes a student nurse assigned to initiate

oral feedings for a 68-yr-old woman with an ischemic
stroke. Which action by the student will require the nurse
to intervene?
a. Giving the patient 1 oz of water to swallow

b. Telling the patient to perform a chin tuck before swallow-
ing
c. Assisting the patient to sit in a chair before feeding the
patient
d. Assessing cranial nerves III, IV, and VI before attempting
feeding
68. d A 74-yr-old man who has right-sided extremity paraly-

sis related to a thrombotic stroke develops constipation.
Which action should the nurse take first?
a. Assist the patient to the bathroom every 2 hours.

b. Provide incontinence briefs to wear during the day.
c. Administer a bisacodyl (Dulcolax) rectal suppository
every day.
d. Arrange for several servings per day of cooked fruits and
vegetables.
69. a Which modifiable risk factor for stroke would be most

important for the nurse to include when planning a com-
19 / 25
munity education program?
a. Hypertension
b. Hyperlipidemia
c. Alcohol consumption
d. Oral contraceptive use
70. b The nurse would expect to find what clinical manifestation

in a patient admitted with a left-sided stroke?
a. Impulsivity
b. Impaired speech
c. Left-side neglect
d. Short attention span
71. d Which intervention is most appropriate when communicat-

ing with a patient with aphasia after a stroke?
a. Present several thoughts at once so that the patient can

connect the ideas.
b. Ask open-ended questions to provide the patient the
opportunity to speak.
c. Finish the patient's sentences to minimize frustration
associated with slow speech.
d. Use simple, short sentences accompanied by visual
cues to enhance comprehension.
72. a A CT scan of a 68-yr-old male patient's head reveals that

he has experienced a hemorrhagic stroke. What is the pri-
ority nursing intervention in the emergency department?
a. Maintenance of the patient's airway

b. Positioning to promote cerebral perfusion
c. Control of fluid and electrolyte imbalances
d. Administration of tissue plasminogen activator (tPA)
73. b A female patient has left-sided hemiplegia after an is-

chemic stroke 4 days earlier. How should the nurse pro-
mote skin integrity?
20 / 25
a. Position the patient on her weak side the majority of the
time.
b. Alternate the patient's positioning between supine and
side-lying.
c. Avoid the use of pillows in order to promote indepen-
dence in positioning.
d. Establish a schedule for the massage of areas where
skin breakdown emerges.
74. c Which sensory-perceptual deficit is associated with

left-sided stroke (right hemiplegia)?
a. Overestimation of physical abilities

b. Difficulty judging position and distance
c. Slow and possibly fearful performance of tasks
d. Impulsivity and impatience at performing tasks
75. d The female patient has been brought to the emergency

department complaining of the most severe headache of
her life. Which type of stroke should the nurse anticipate?
a. TIA
b. Embolic stroke
c. Thrombotic stroke
d. Subarachnoid hemorrhage
76. a The patient with diabetes mellitus had a right-sided stroke.

Which nursing intervention should the nurse plan to pro-
vide for this patient?
a. Safety measures
b. Patience with communication
c. Mobility assistance on the right side
d. Place food in the left side of patient's mouth.
77. c The nurse is planning psychosocial support for the family

of the patient who suffered a stroke. What factor will have
the greatest impact on family coping?
a. Specific patient neurologic deficits

21 / 25
b. The patient's ability to communicate
c. Rehabilitation potential of the patient
d. Presence of complications of a stroke
78. a The nurse is discharging a patient admitted with a tran-

b sient ischemic attack (TIA). For which medications might
d the nurse expect to provide discharge instructions? (Se-
e lect all that apply)
a. Ticlopidine
b. Clopidogrel
c. Enoxaparin
d. Dipyridamole
e. Enteric-coated aspirin
f. Tissue plasminogen activator (tPA)
79. 1 Which actions should the nurse delegate to an experi-

2 enced unlicensed assistive personnel (UAP) when caring
3 for a client with a thrombotic stroke who has residual
5 left-sided weakness? (Select all that apply)
6
1. Assisting the client to reposition every 2 hours
2. Reapplying pneumatic compression boots
3. Reminding the client to perform active range-of-motion
(ROM) exercises
4. Assessing the extremities for redness and edema
5. Setting up meal trays and assisting with feeding
6. Using a lift to assist the client up to a bedside chair
80. 1 A client who had a stroke needs to be fed. What instruction

should the nurse give to the unlicensed assistive person-
nel (UAP) who will feed the client?
1. Position the client sitting up in bed before he or she is

fed.
2. Check the client's gag and swallowing reflexes.
3. Feed the client quickly because there are three more
clients to feed.
4. Suction the client's secretions between bites of food.
22 / 25
81. 1 The RN is supervising a senior nursing student who is car-
ing for a client with a right hemisphere stroke. Which action
by the student nurse requires that the RN intervene?
1. Instructing the client to sit up straight and the client

responds with a puzzled expression
2. Moving the client's food tray to the right side of his
over-bed table
3. Assisting the client with passive range-of-motion (ROM)
exercises
4. Combing the hair on the left side of the client's head
when the client always combs his hair on the right side
82. 3 The nurse is providing care for a client with an acute

hemorrhagic stroke. The client's spouse tells the nurse
that he has been reading a lot about strokes and asks why
his wife has not received alteplase. What is the nurse's
best response?
1. "Your wife was not admitted within the time frame that
alteplase is usually given."
2. "This drug is used primarily for clients who experience
an acute heart attack."
3. "Alteplase dissolves clots and may cause more bleeding
into your wife's brain."
4. "Your wife had gallbladder surgery just 6 months ago, so
we can't use alteplase."
83. a A nurse is caring for a client who has experienced

b right-hemispheric stroke. The nurse should expect the
c client to have difficulty with which of the following? (Select
e all that apply)
a. impulse control
b. moving the left side
c. depth perception
d. speaking
e. situational awareness
23 / 25
84. b A nurse is caring for a client who has left homonymous
hemianopsia. Which of the following is an appropriate
nursing intervention?
a. teach the client to scan to the right to see objects on the

right side of the body
b. place the bedside table on the right side of the bed
c. orient the client to food on the plate using the clock
method
d. place the wheelchair on the client's left side
85. a A nurse is planning care for a client who has dysphagia

b and a new dietary prescription. Which of the following
c should the nurse include in the plan of care? (Select all
e that apply)
a. have suction equipment ready for use

b. feed the client thickened liquids
c. place food on the unaffected side of the client's mouth
d. assign an assistive personnel to feed the client slowly
e. teach the client to swallow with the neck flexed
86. a A nurse is caring for a client who has global aphasia.

b Which of the following should the nurse include in the
e client's plan of care? (Select all that apply)
a. speak to the client at a slower rate

b. assist the client to use cards with pictures
c. speak to the client in a loud voice
d. complete sentences that the client cannot finish
e. give instructions one step at a time
87. c A nurse is assessing a client. Which of the following find-

ings indicates that the client has experienced a left-hemi-
spheric stroke?
a. impulse control difficulty

b. poor judgement
24 / 25
c. inability to recognize familiar objects
d. loss of depth perception
88. d As one of your clinical assignments, you are assisting an

RN with health screening at a health fair. Which individual
is at greatest risk for experiencing a stroke?
a.A 46-year-old white female with hypertension and oral

contraceptive use for 10 years
b.A 58-year-old white male salesman who has a total
cholesterol level of 285 mg/dl
c.A 42-year-old African American female with diabetes
mellitus who has smoked for 30 years
d.A 62-year-old African American male with hypertension
who is 35 pounds overweight
89. c P.D. is diagnosed with a thrombotic stroke. Over the next

72 hours, you plan care with the knowledge that he
a. is ready for aggressive rehabilitation.

b. will show gradual improvement of the initial neurologic
deficits.
c. may show signs of deteriorating neurologic function as
cerebral edema increases.
d. should not be turned or exercised to prevent extension
of the thrombus and increased neurologic deficits.
25 / 25
stroke nclex questions
Study online at https://quizlet.com/_907bl9
1. in promoting health maintenance for prevention of c

strokes, the nurse understands that the highest risk
for the most common type of stroke is present in
which people?
a. blacks
b. women who smoke
c. persons with hypertension and diabetes
d. those who are obese with high dietary fat intake
2. a thrombus that develops in a cerebral artery does not c

always cause a loss of neurologic function because
a. the body can dissolve atherosclerotic plaques as
they form
b. some tissues of the brain do not require constant
blood supply to prevent damage
c. circulation via the circle of willis may provide blood
supply to the affected area of the brain
d. neurologic deficits occur only when major arteries
are occluded by thrombus formation around athero-
sclerotic plaque
3. a patient comes to the ED with numbest of the face d

and an inability to speak. while the patient awaits
examination, the symptoms disappear and the patient
requests discharge. why should the nurse emphasize
that it is important for the patient to be treated before
leaving
a. the patient has probably experience an asymptotic
lacunar stroke
b. the symptoms are likely to return and progress to
worsening neurologic deficit in the next 24 hours
c. neurologic deficits that are transient occur most
often as a result of small hemorrhages that clot off
d. the patient has probably had a transient ischemic
attack (TIA) which is a sign of progressive cerebrovas-
cular disease
4. which statement describe characteristics of a stroke a, b, c, e

caused by an intracerebral hemorrhage> (select all
1/7
that apply)?
a. carries poor prognosis
b. caused by rupture of a vessel
c. strong association with hypertension
d. commonly occurs during or after sleep
e. creates a mass that compresses the brain
5. which type of stroke is associated with endocardial a

disorders, has a rapid onset and is likely to occur
during activity?
a. embolic
b. thrombotic
c. intracerebral hemorrhage
d. subarachnoid hemorrhage
6. what primarily determines the neurological functions c

that are affected by a stroke?
a. the amount of tissue area involved
b. the rapidity of the onset of symptoms
c. the brain area perfused by the affected artery
d. the presence or absence of collateral circulation
7. right or left brain damage? aphasia, inability to re- left

member words, hemiplegia of the right side of the
body
8. right or left brain damage? impaired judgment, quick right

and impulse behavior, left homonymous hemianopsia,
neglect of left side of body
9. the patient has a lack of comprehension of both verbal c

and written language. which type of communication
difficulty does this patient. have?
a. dysarthria
b. fluent dysphasia
c. receptive aphasia
d. expressive aphasia
10. A patient is admitted to the hospital with a left hemi- c

plegia. To determine the size and location and to as-
2/7
certain whether a stroke is ischemic or hemorrhagic,
the nurse anticipates that the health care provider will
request a
a. lumbar puncture
b. cerebral angiography
c. MRI
d. CT scan with contrast
11. A carotid endarterectomy is being considered as a d

treatment for a patient who has had several TIAs. The
nurse explains to the patient that this surgery
a. involves intracranial surgery to join a superficial
extracranial artery to an intracranial artery
b. is used to restore blood to the brain following an
obstruction of a cerebral artery
c. is used to open a stenosis in a carotid artery with
a balloon and stent to restore cerebral circulation
d. involves removing an atherosclerotic plaque in the
carotid artery to prevent an impending stroke
12. The incidence of ischemic stroke in patients with TIAs d

and other risk factors is reduced with administration
of
a. nimodipine (Nimotop)
b. furosemide (Lasix)
c. warfarin (Coumadin)
d. daily low dose aspirin
13. what is the priority intervention in the ED for the pa- d

tient with a stroke?
a. IV fluid replacement
b. giving osmotic diuretics to reduce cerebral edema
c. starting hypothermia to decrease the oxygen needs
of the brain
d.maintaining respiratory function with a patent air-
way and oxygen administration
14. A diagnosis of a ruptured cerebral aneurysm has been b

made in a patient with manifestations of a stroke. The
nurse anticipates that treatment options that would be
3/7
evaluated for the patient include
a. hyperventilation therapy
b. surgical clipping of the aneurysm
c. administration of hyperosmotic agents
d. administration of thrombolytic therapy
15. During the acute phase of a stroke, the nurse as- a

sesses the patient's vital signs and neurologic status
every 4 hours. A cardiovascular sign that the nurse
would see as the body attempts to increase cerebral
blood flow is
a. hypertension
b. fluid overload
c. cardiac dysrhythmias
d. S3 and S4 heart sounds
16. During the secondary assessment of a patient with a a, b, c, d, f

stroke, what should be included (select all that apply)?
a. gaze
b. sensation
c. facial palsy
d. proprioception
e. current medications
f. distal motor function
17. what is a nursing intervention that is indicated for the d

patient with hemiplegia?
a. the use of a footboard to prevent plantar flexion
b. immobilization of the affected arm against the chest
with a sling
c. positioning the patient in bed with each joint lower
than the joint proximal to it
d. having the patient perform passive rang of motion
(ROM) of the affected limb with the unaffected limb
18. a newly admitted patient diagnosed with a right sided a

brain stroke has homonymous hemianopsia. early in
the case of the patient what should the nurse do ?
a. place objects on the right side within the patients
field of vision
4/7
b. approach the patient from the left side to assess the
patients ability to compensate
c. place objects on the left side to assess the patients
ability to compensate
d. patch the affected eye to encourage patient to turn
the head to scan the environments
19. four days following a stroke, a patient is to start oral a

fluids and feedings. before feeding the patient, what
should the nurse do first?
a. check the patient's gag reflex
b. order a soft diet for the paitnet
c. raise the head of the bed to a sitting position
d. assess the patients ability to swallow tiny amounts
of crushed ice
20. what is an appropriate food for a patient with a stroke c

who has mild dysphagia?
a. fruit juices
b. pureed meats
c. scrambled eggs
d. fortified milkshakes
21. a patients wife asks the nurse why her husband did d
not receive the clot-busting medication (tissue plas-
minogen activators [tPA]) she has been riding about.
her husband is diagnosed with a hemorrhagic stroke.
what is the best response by the nurse to the patients
wife?
a. " he didn't arrive within the time frame for that
therapy"
b. " not everyone is eligible for this drug. has he had
surgery lately?"
c. "you should discuss the treatment of your husband
with his doctors"
d. "the medication you are talking about dissolves
clots and could cause more bleeding in your hus-
bands brain"
22. c, d, f
5/7
the rehab nurse assesses the patient, caregiver and
family before planning the rehab program for this
patient. what must be included in this assessment
(select all that apply)?
a. cognitive status of the family
b. patient resources and support
c. physical status of all body systems
d. rehab potential of patient
e. body strength remaining after the stroke
f. patient and caregiver expectation of the rehab
23. what is an appropriate nursing intervention to pro- a

mote communication during rehab of the patient with
aphasia?
a. allow time for the individual to complete their
thoughts
b. use gestures, pic utters, and music to stimulate
patients responses
c. structure statements so that the patient does not
have to respond verbally
d. use flashcards with simple words and pictures to
promote recall of language
24. A patient with right hemisphere stroke has unilateral c

neglect . During the patient's rehabilitation, it is impor-
tant for the nurse to
a. avoid positioning the patient on the affected side
b. place all objects for care on the patient's unaffected
side
c. teach the patient to care consciously for the affect-
ed side
d. protect the affected side from injury with pillows
and supports
25. A patient with a stroke has a right sided hemiplegia. c

The nurse prepares family members to help control
behavior changes seen with this type of stroke by
teaching them to
a. ignore undesirable behaviors manifested by the
6/7
patient
b. provide directions to the patient verbally in small
steps
c. distract the patient from inappropriate emotional
responses
d. supervise all activities before allowing the patient
to pursue them independently
26. the nurse can best assist the patient and family in d
coping with the long-term effects of a stroke by doing
what?
a. informing family members that the patient will need
assistance with almost all ADLs
b. explain that the patents prestroke behavior will re-
turn as improvement progresses
c. encouraging the patient and family members to
seek assistance from family therapy or stroke support
groups
d. helping the patient and family understand the sig-
nificance of residual stroke damage to promote prob-
lem solving and planning
27. which intervention can the nurse delegate to the li- c

censes practical nurse when caring for a patient fol-
lowing an acute stroke
a. assess the patients neurological status
b. assess the patients gag reface before beginning
feeding
c. administer ordered antihypertensives and platelet
inhibitors
d. teach the patients caregivers strategies to minimize
unilateral neglect
7/7
Stroke Questions: NCLEX Style
Study online at https://quizlet.com/_3z9pwi
1. Regular oral hygiene is an essential intervention for Answer: A

the client who has had a stroke. Which of the following
nursing measures is inappropriate when providing
oral hygiene?
A: Placing client on back with small pillow under the
head
B: Keeping portable suctioning equipment at the bed-
side
C: Opening the client's mouth with a padded tongue
blade
D: Cleaning the clients mouth and teeth with tooth-
brush
2. A 78 year old client is admitted to the ED with numb- Answer: C

ness and weakness of the left arm and slurred speech.
Which nursing intervention is priority?
A: Prepare to administer recombinant tissue plas-
minogen activator (rt-PA)
B: Discuss the precipitating factors that caused the
symptoms
C: Schedule a STAT CT scan of head
D: Notify speech pathologist for emergency consult
3. A client arrives at the ED with ischemic stroke and Answer: C

receives tissue plasminogen activator (t-PA) adminis-
tration. Which is priority nursing assessment?
A: Current medications
B: Complete physical and history
C: Time of onset of current stroke
D: Upcoming surgical procedures
4. During the first 24 hours after thrombolytic therapy Answer: C

for ischemic stroke, the primary goal is to control the
clients:
A: Pulse
B: Respiration
C: BP
D: Temperature
1/3
5. What is a priority nursing assessment in the first Answer: B
24 hours after admission of client with a thrombotic
stroke?
A: Cholesterol level
B: Pupil size and papillary response
C: Vowel sounds
D: Echo
6. What is expected outcome of thrombolytic drug ther- Answer: C

apy?
A: Increased vascular permeability
B: Vasoconstriction
C: Dissolved emboli
D: Prevention of hemorrhage
7. The client diagnosed with A-fib, has experienced a Answer: A

TIA. Which medication would the nurse anticipate be-
ing ordered for the client on discharge?
A: PO anticoagulant medication
B: Beta-blocker medication
C: Anti-hyperuricemic medication
D: Thrombolytic medication
8. Which client would the nurse identify as being MOST Answer: A

at risk for experiencing a CVA?
A: 55yr. old African American Male
B: 84yr. old Japanese female
C: 67yr. old white male
D: 39yr. old prego female
9. Which assessment data would indicate to nurse that Answer: C

the client would be at risk for hemorrhagic stroke?
A: Blood glucose level of 480mg/dL
B: Right sided carotid bruit
C: BP of 220/120 mm Hg
D: Presence of bronchogenic carcinoma
10. The Nurse and UAP are caring for a client with Answer: C
right-sided paralysis. Which action by the UAP re-
quires the nurse to intervene?
2/3
A: Place gait belt around client's waster prior to am-
bulating
B: Places client on back with client's head to the side
C: Places her hand under the client's right axilla to
help them move up in bed
D: Praises the client for attempting to perform ADL's
independently
3/3
Stroke NCLEX Practice Questions
Study online at https://quizlet.com/_9l9w70
1. The nurse caring for a client Beta Blocker

with a history of transient
ischemic attacks (TIAs) is Even though beta blockers are useful in lower-
reviewing medications or- ing blood pressure, they are very limited in pre-
dered to prevent a stroke. venting stroke. Anticoagulants and antiplatelets
Which medication therapy are used to reduce the risk of stroke in clients
requires follow-up? with TIAs. Hypertension is the leading cause
of stroke. Research indicates that thiazide di-
Thiazide diuretic uretics and certain other antihypertensives are
useful in reducing stroke risk.
Anticoagulant
Antiplatelet
Beta blocker
2. Which description of an A blood clot lodges in a cerebral vessel and

acute embolic stroke given blocks blood flow.
by the nurse is most accu-
rate? In embolic stroke, a blood clot or other mat-
ter traveling through cerebral blood vessels
The local cerebral tissue becomes lodged in a narrow vessel blocking
becomes engorged with blood flow. The area of the brain supplied by
blood from a ruptured cere- the blocked vessel becomes ischemic. The clot
bral vessel. may originate from a thrombus formed in the
left side of the heart during atrial fibrillation,
A blood clot lodges in a bacterial endocarditis, recent myocardial in-
cerebral vessel and blocks farction (MI), atherosclerotic plaque from the
blood flow. carotid artery, rheumatic heart disease, or ven-
tricular aneurysm. Infarcted areas of the brain
Infarcted areas in the brain become ischemic but do not slough off. Hem-
slough off, leaving cavities orrhagic stroke is when local cerebral tissue
in the brain tissue. becomes engorged with blood from a ruptured
cerebral vessel. An embolic stroke is not the
Cerebral vascular pressure result of cerebral vascular pressure increases.
exceeds the elasticity of the
vessel wall, resulting in he-
morrhages.
1 / 11
3. The nurse is teaching a Ruptured aneurysm in the brain
class about the causes of a
hemorrhagic stroke. Which Rupture of a fragile arterial vessel in the brain
should the nurse include?
(Select all that apply.) Traumatic injury to the brain
Damage to the blood-brain Arterial bleeds in the brain cause hemorrhagic

barrier stroke. Blood enters the brain and puts pres-
sure on brain tissue. Manifestations occur sud-
Ruptured aneurysm in the denly because of the rapid rise in intracranial
brain pressure (ICP). Aneurysms in the brain enlarge
over time. This causes the arterial walls to be-
Atherosclerotic plaque come thin and subject to rupturing. Falls and
breaking off in the artery other traumatic injuries can cause the arterial
walls to rupture. This causes intracranial bleed-
Rupture of a fragile arterial ing with accompanying increased ICP. Stroke
vessel in the brain caused by traumatic injury has the poorest out-
come with greater likelihood of death. Ather-
Traumatic injury to the osclerotic plaque that breaks off causes ob-
brain struction in the vessel lumen. This is ischemic
stroke, rather than hemorrhagic. Hemorrhagic
stroke involves bleeding into the brain. The
blood-brain barrier prevents potentially harm-
ful substances from entering the brain. Hem-
orrhagic stroke is not caused by damage to
the blood-brain barrier. However, hemorrhagic
stroke could cause damage to the blood-brain
barrier and therefore allow harmful substances
to enter the brain.
4. The nurse is teaching a Brief period of a neurologic deficit

client about the cause of
a transient ischemic at- A TIA is a type of ischemic stroke resulting
tack (TIA). Which should the from a localized neurologic deficit lasting 24
nurse include? hours or less. Vascular blockage is the cause
of an embolic stroke. Intracranial bleeds cause
Brief period of a neurologic hemorrhagic strokes. A thrombotic stroke is the
deficit result of the formation of a clot in a blood ves-
sel.
2 / 11
Vascular blockage
Sudden intracranial bleed
Formation of a clot in a
blood vessel
5. A client was diagnosed with Dysphagia

a thrombotic stroke of the
vertebral artery. Which as- Dysphagia is the clinical manifestation that is
sessment does the nurse associated with a stroke that affects the verte-
expect to make? bral artery. The other clinical manifestations are
seen with internal carotid and middle cerebral
Stupor artery involvement.
Global aphasia
Contralateral paralysis
Dysphagia
6. An adult client had a Speaking

stroke involving the in-
ternal carotid artery of Clinical manifestations of a stroke involving
the dominant hemisphere. the internal carotid artery include contralat-
The nurse should antici- eral paralysis of face and limbs, contralater-
pate that the client will have al sensory deficits of face and limbs, apha-
difficulty with which func- sia, apraxia, agnosia, unilateral neglect, and
tion? homonymous hemianopia. Difficulty swallow-
ing, drowsiness, and urine retention are not
Speaking expected in this type of stroke.
Staying alert
Retaining urine
Swallowing
7.
3 / 11
The nurse is caring for Improving muscle strength and coordination
a client recovering from a
stroke in the rehabilitation During the rehabilitation treatment stage of
setting. Which is the goal of stroke, the focus is on client safety and im-
care during this stage? provement of muscle strength and coordina-
tion. Priorities during the treatment stage of
Minimizing brain injury acute care immediately following a stroke in-
clude rapid EMS dispatch, diagnosing the type
Dispatching rapid emer- and cause of stroke, and other interventions
gency medical services to minimize brain injury and maximize client
(EMS) recovery.
Diagnosing the type and

cause of stroke
Improving muscle strength

and coordination
8. The nurse on the stroke Providing reassurance and support

rehabilitation unit is plan-
ning care for a client The client with sensory-perceptual deficits
who is experiencing vision needs reassurance and support. There is no
and equilibrium deficits, al- indication that the client cannot maintain flu-
tered proprioception, hemi- id, oxygen, and nutritional status, cannot com-
anopia, and neglect syn- municate well, or has cognitive or behavioral
drome. Which nursing ther- changes.
apy is the most important to
include?
Maintaining fluid, oxygen,

and nutritional status
Providing reassurance and

support
Developing an alternate
means of communicating
Providing behavioral and

4 / 11
cognitive therapy when the
condition stabilizes
9. The nurse taught a group The client with right-sided paralysis flexing and
of clients recovering from a extending only the left knee
stroke how to perform ac-
tive range-of-motion exer- The client can use the left side to help flex and
cises. Which client requires extend the right knee. Both sides should be ex-
further teaching? ercised. All the other range-of-motion exercises
are appropriate.
The client performing flex-
ion, extension, and hyper-
extension of the hips bilat-
erally
The client with right-sided

paralysis flexing and ex-
tending only the left knee
The client performing ex-

tension and hyperexten-
sion of the neck
The client with left-sided

paralysis using the right
arm to help flex and extend
the left wrist
10. The nurse is reviewing in- Encouraging active range-of-motion exercises

terventions aimed at main-
taining cerebral perfusion
Active range-of-motion exercises promote
in a client who had a throm-
physical mobility but will not directly assist in
botic stroke. Which inter-
maintaining cerebral perfusion. The initial fo-
vention should the nurse cus of care is to identify changes in airway,
question? breathing, and circulation that could indicate
decreased cerebral perfusion. Maintaining ad-
Encouraging active equate oxygenation and positioning to facilitate
range-of-motion exercises breathing is appropriate.
5 / 11
Placing the client in a
side-lying position
Monitoring mental status

and level of consciousness
Monitoring respiratory sta-

tus
11. A client has a history of Antiplatelet

transient ischemic attack-
s (TIAs). Which medication An antiplatelet may be prescribed for clients
does the nurse expect to who have TIAs or who have had previous
find in the client's list of strokes. Its purpose is to prevent clot formation
prescriptions? with the resulting vessel occlusion. An oral anti-
coagulant medication may be prescribed short-
Beta blocker ly after a stroke to prevent blood clot formation
and to enhance cerebral blood flow by keeping
Antiplatelet the blood thin. A beta blocker is useful for low-
ering blood pressure but is limited in preventing
Anticoagulant stroke. Docusate sodium (Colace) is a stool
softener that may be prescribed after a stroke
Stool softener to prevent straining at stool, which increases
intracranial pressure (ICP).
12. A client who is diagnosed The stroke must have occurred within 3 hours
with a stroke has an order of administering the medication.
for a tissue plasminogen
activator (tPA). Which cir-
For the safe administration of tPA, the medica-
cumstance does the nurse tion must be administered within 3 hours of the
suspect is present? onset of the symptoms of stroke. The stroke
cannot be hemorrhagic in nature because the
The stroke must be hemor- action of the medication is to dissolve the clot,
rhagic in nature. which would not be intended for a reclotted
ruptured hemorrhagic vessel. There is no min-
Aspirin therapy must have imal or maximal degree of plaque buildup that
been received for 6 months is necessary for the safe administration of the
for tPA to be effective. medication. Aspirin therapy is not a require-
ment for tPA to be administered.
6 / 11
The stroke must have oc-
curred within 3 hours of ad-
ministering the medication.
Atherosclerotic buildup in
affected arteries must be
greater than 90%.
13. A client who is diagnosed 1

with stroke is very drowsy
but can respond when A score of 1 means that the client is not alert
awakened. Using the Na- but is arousable by minor stimulation to obey,
tional Institutes of Health answer, or respond. A score of 0 means that the
Stroke Scale, which level of client is alert and keenly responsive. A score
consciousness should the of 2 means that the client is not alert, requires
nurse document? repeated stimulation to attend, or is obtunded
and requires strong or painful stimuli to make
1 movements. A score of 3 means that the client
responds only with motor or autonomic effects
2 or is totally unresponsive, flaccid, and areflexic.
14. A client who had a stroke Carotid angioplasty with stenting

secondary to cerebral
stenosis discussed surgi-Carotid angioplasty with stenting is used to
cal options with the sur-surgically treat cerebral stenosis. Carotid en-
geon. Which option shoulddarterectomy is used to remove plaque from
the nurse anticipate will be
a carotid artery. An extracranial-intracranial by-
performed? pass may be required if an occluded or stenotic
vessel is not directly accessible. The client has
Cautious observation only already had a stroke from the stenosis, and
there is no indication that comorbidities could
Extracranial-intracranial prevent the surgery.
bypass
Carotid angioplasty with
7 / 11
stenting
Carotid endarterectomy
15. A client diagnosed with a Physical therapy

stroke is having difficulty
walking and may require Occupational therapy can help a client learn to
the use of a walker. Whichuse assistive devices and create a plan for re-
area should the nurse makegaining motor skills. Physical therapy helps in-
a referral to? crease physical strength and coordination and
prevent contractures. Speech and language
Speech and language ther- therapy improve communication and swallow-
apy ing. Home health may be needed, but the pri-
ority is learning to use the assistive device.
Occupational therapy
Home health
Physical therapy
16. The nurse is reviewing the Encouraging active range-of-motion exercises

plan of care for a client who
is unresponsive following a
Each of the nursing implementations listed
stroke. Which interventionare appropriate for promoting physical mobil-
should the nurse question?ity. However, the client is unresponsive and
therefore cannot complete active range-of-mo-
Encouraging active tion exercises; they would require passive
range-of-motion exercises range-of-motion exercises.
Elevating the head of the

bed 30 degrees
Turning the client every 2

hours
Monitoring lower extremi-

ties for symptoms of throm-
bophlebitis
8 / 11
17. The nurse is reviewing doc- Onset of facial drooping at 1430
umentation of a physical
examination of a client who Time of onset of stroke symptoms should be in-
is suspected of having a cluded in the client interview. All other assess-
stroke. Which documenta- ments are part of the physical assessment.
tion requires follow-up?
Alert and oriented to per-

son but not oriented to
place or time
Onset of facial drooping at

1430
Right-sided grip stronger

than left-sided grip
Stroke scale completed
18. The nurse is planning care The client will participate in therapies to prevent
for a client who has unilat- contractures.
eral neglect and left-sided
paralysis after experienc- Preventing contractures is a good goal for
ing a thrombotic stroke. a client with left-sided paralysis and unilat-
Which goal of care should eral neglect. The client will be taught active
the nurse choose? range-of-motion exercises and ambulate as
able, so maintaining bedrest is not appropriate.
The client will maintain An appropriate goal for blood pressure is within
bedrest. normal limits, rather than 40% of normal. There
is no indication that the client needs assistance
The client will participate in with communication.
therapies to prevent con-
tractures.
The client will improve com-

munication techniques.
The client's blood pressure
9 / 11
will remain within 40% of
normal.
19. The nurse is observing the "When getting dressed, first put clothing on the
unlicensed assistive per- left side."
sonnel (UAP) helping a
client with unilateral ne- The client should be taught to dress the af-
glect of the right side fected extremities first and then the unaffected
perform self-care. Which extremities. This will enable the client to dress
statement by the UAP re- herself with minimal assistance. The other op-
quires an intervention by tions are all appropriate instructions to teach
the nurse? the client to perform self-care.
"When getting dressed,

first put clothing on the left
side."
"Use the left arm to bathe,

brush teeth, comb hair, and
eat."
"The occupational thera-

pist will teach you how
to promote upper extremity
strength."
"The occupational thera-

pist will assist you in learn-
ing to walk using a walker."
20. After performing swallow- Carefully monitoring for coughing after giving
ing studies for a client the client a thickened beverage
recovering from a stroke,
the speech therapist rec- Maintaining client safety is a priority when feed-
ommends a pureed diet and ing for the first time. While all the answer op-
honey-thick liquids. Which tions are appropriate, the priority is to assess
is a priority for the nurse? the client for coughing when eating or drinking
a thickened liquid.
Calling the healthcare
10 / 11
provider about the results
Ordering a pureed diet
Documenting the results of

the swallowing studies
Carefully monitoring for

coughing after giving the
client a thickened beverage
11 / 11
Stroke (CVA) NCLEX Q registerednurseRN.com site
Study online at https://quizlet.com/_4zzkuy
1. 1. A patient is admitted with uncontrolled atrial fibril- B. Ischemic em-

lation. The patient's medication history includes vita- bolism
min D supplements and calcium. What type of stroke The answer is B. If
is this patient at MOST risk for?* a patient is in un-
A. Ischemic thrombosis controlled a-fib they
B. Ischemic embolism are at risk for clot
C. Hemorrhagic formation within the
D. Ischemic stenosis heart chambers.
This clot can leave
the heart and travel
to the brain. Hence,
an ischemic em-
bolism type stroke
can occur. An is-
chemic thrombo-
sis type stroke is
where a clot forms
within the artery
wall of the neck or
brain.
2. 2. Which patient below is at most risk for a hemor- C. A 88 year old

rhagic stroke? male with uncon-
A. A 65 year old male patient with carotid stenosis. trolled hyperten-
B. A 89 year old female with atherosclerosis. sion and a history
C. A 88 year old male with uncontrolled hypertension of brain aneurysm
and a history of brain aneurysm repair 2 years ago. repair 2 years ago.
D. A 55 year old female with atrial flutter. The answer is C. A
hemorrhagic stroke
occurs when bleed-
ing in the brain hap-
pens due to a break
in a blood vessel.
Risk factors for a
hemorrhagic stroke
is uncontrolled hy-
pertension, history
of brain aneurysm,
old age (due to ag-
1 / 10
ing blood vessels.)
All the other op-
tions are at risk for
an ischemic type of
stroke.
3. 3. You're educating a patient about transient ischemic B. TIAs produce

attacks (TIAs). Select all the options that are incorrect signs and symp-
about this condition: toms that can last
A. TIAs are caused by a temporary decrease in blood for several weeks to
flow to the brain. months.
B. TIAs produce signs and symptoms that can last D. TIAs don't re-
for several weeks to months. quire medical treat-
C. A TIAs is a warning sign that an impending stroke ment.
may occur. The answers are
D. TIAs don't require medical treatment. B and D. Op-
tions A and C are
CORRECT state-
ments about TIAs.
However, option B
is wrong because
TIAs produce signs
and symptoms that
can last a few
minutes to hours
and resolve (NOT
several weeks to
months). Option D
is wrong be TIAs
do require medical
treatment.
4. 4. A patient who suffered a stroke one month ago D. Temporal

is experiencing hearing problems along with issues The answer is D.
learning and showing emotion. On the MRI what lobe The temporal lobe
in the brain do you expect to be affected? is responsible for
A. Frontal lobe hearing, learning,
B. Occipital lobe and feelings/emo-
tions.
2 / 10
C. Parietal lobe
D. Temporal
5. 5. A patient's MRI imaging shows damage to the B. Balance impair-

cerebellum a week after the patient suffered a stroke. ment
What assessment findings would correlate with this The answer is B.
MRI finding?* The cerebellum is
A. Vision problems important for coor-
B. Balance impairment dination and bal-
C. Language difficulty ance.
D. Impaired short-term memory
6. 6. A patient is demonstrating signs and symptoms of D. Occipital lobe

stroke. The patient reports loss of vision. What area The answer is D.
of the brain do you suspect is affected based on this The occipital lobe is
finding?* responsible for vi-
A. Brain stem sion and color per-
B. Hippocampus ception.
C. Parietal lobe
D. Occipital lobe
7. 7. A patient has right side brain damage from a stroke. B. Confusion on

Select all the signs and symptoms that occur with date, time, and
this type of stroke:* place
A. Right side hemiplegia D. Unilateral ne-
B. Confusion on date, time, and place glect
C. Aphasia F. Impulsive
D. Unilateral neglect G. Short attention
E. Aware of limitations span
F. Impulsive The answers are
G. Short attention span B, D, F, and G.
H. Agraphia Patients who have
right side brain
damage will have
LEFT side hemiple-
gia (opposite side),
confused on date,
time, and place,
unilateral neglect
3 / 10
(left side neglect),
DENIAL about lim-
itations, be im-
pulsive, and have
a short attention
span. Agraphia,
right side hemiple-
gia, aware of limi-
tations, and apha-
sia occur in a LEFT
SIDE brain injury.
8. 8. You're educating a group of nursing students about A. Aphasia

left side brain damage. Select all the signs and symp- C. Impaired math
toms noted with this type of stroke:* skills
A. Aphasia D. Issues with see-
B. Denial about limitations ing on the right side
C. Impaired math skills F. Depression and
D. Issues with seeing on the right side anger
E. Disoriented H. Agraphia
F. Depression and anger The answers are A,
G. Impulsive C, D, F, and H.
H. Agraphia Patients who have
left side brain dam-
age will have apha-
sia, be AWARE of
their limitations, im-
paired math skills,
issues with see-
ing on the right
side, no deficit in
memory, depres-
sion/anger, cau-
tious, and agraphia.
All the other op-
tions are found in
right side brain in-
jury.
4 / 10
9. 9. During discharge teaching for a patient who expe- A. Smoking
rienced a mild stroke, you are providing details on D. Obesity
how to eliminate risk factors for experiencing another E. Sedentary
stroke. Which risk factors below for stroke are modi- lifestyle
fiable?* The answers are A,
A. Smoking D, and E. These
B. Family history risk factors are
C. Advanced age modifiable in that
D. Obesity the patient can at-
E. Sedentary lifestyle tempt to change
them to prevent
another stroke in
the future. The oth-
er risk factors are
NOT modifiable.
10. 10. You're patient who had a stroke has issues with D. Receptive; Wer-
understanding speech. What type of aphasia is this nicke's area
patient experiencing and what area of the brain is
affected?*
A. Expressive; Wernicke's area
B. Receptive, Broca's area
C. Expressive; hippocampus
D. Receptive; Wernicke's area
11. 11. You're patient has expressive aphasia. Select all C. Ask questions
the ways to effectively communicate with this pa- that require a sim-
tient?* ple response.
A. Fill in the words for the patient they can't say. D. Use a communi-
B. Don't repeat questions. cation board.
C. Ask questions that require a simple response. The answers are C
D. Use a communication board. and D. Patients with
E. Discourage the patient from using words. expressive apha-
sia can understand
spoken words but
can't respond back
effectively or at
all. Therefore be
patient, let them
5 / 10
speak, be direct
and ask simple
questions that re-
quire a simple re-
sponse, and com-
municate with a dry
erase board etc.
12. 12. While conversing with a patient who had a stroke A. Dysarthria
six months ago, you note their speech is hard to
understand and slurred. This is known as:*
A. Dysarthria
B. Apraxia
C. Alexia
D. Dysphagia
13. 13. You're reading the physician's history and physi- C. The patient is
cal assessment report. You note the physician wrote unable to wink or
that the patient has apraxia. What assessment find- move his arm to
ing in your morning assessment correlates with this scratch his skin
condition?*
A. The patient is unable to read.
B. The patient has limited vision in half of the visual
field.
C. The patient is unable to wink or move his arm to
scratch his skin.
D. The patient doesn't recognize a pencil or televi-
sion.
14. 14. You need to obtain informed consent from a A. Agraphia

patient for a procedure. The patient experienced a
stroke three months ago. The patient is unable to
sign the consent form because he can't write. This is
known as what:*
A. Agraphia
B. Alexia
C. Hemianopia
D. Apraxia
15. A. Hemianopia
6 / 10
15. You're assessing your patient's pupil size and
vision after a stroke. The patient says they can only
see half of the objects in the room. You document this
finding as:*
A. Hemianopia
B. Opticopsia
C. Alexia
D. Dysoptic
16. 16. A patient who has hemianopia is at risk for injury. C. Scanning the
What can you educate the patient to perform regular- room from side to
ly to prevent injury?* side frequently
A. Wearing anti-embolism stockings daily The answer is C.
B. Consume soft foods and tuck in chin while swal- Hemianopia is lim-
lowing ited vision in half
C. Scanning the room from side to side frequently of the visual field.
D. Muscle training The patient needs
to scan the room
from side to side to
prevent injury.
17. 17. You receive a patient who is suspected of expe- B. Severe stroke
riencing a stroke from EMS. You conduct a stroke symptoms
assessment with the NIH Stroke Scale. The patient The answer is
scores a 40. According to the scale, the result is:* B. Scores on the
A. No stroke symptoms NIH stroke scale
B. Severe stroke symptoms range from 0 to
C. Mild stroke symptoms 42, with 0 (no
D. Moderate stroke symptoms stroke symptoms)
and 21-42 (severe
stroke symptoms).
18. 18. In order for tissue plasminogen activator (tPA) to C. 3 hours after
be most effective in the treatment of stroke, it must the onset of stroke
be administered?* symptoms
A. 6 hours after the onset of stroke symptoms The answer is C.
B. 3 hours before the onset of stroke symptoms tPa dissolves the
C. 3 hours after the onset of stroke symptoms clot causing the
D. 12 hours before the onset of stroke symptoms blockage in stroke
7 / 10
by activating the
protein that caus-
es fibrinolysis. It
should be given
within 3 hours af-
ter the onset of
stroke symptoms. It
can be given 3
to 4.5 hours after
onset IF the pa-
tient meets strict
criteria. It is used
for acute ischemia
stroke, NOT hem-
orrhagic!!
19. 19. Which patients are NOT a candidate for tis- B. A patient whose
sue plasminogen activator (tPA) for the treatment of blood pressure is
stroke?* 200/110.
A. A patient with a CT scan that is negative. D. A patient who re-
B. A patient whose blood pressure is 200/110. ceived Heparin 24
C. A patient who is showing signs and symptoms of hours ago.
ischemic stroke. The answers are
D. A patient who received Heparin 24 hours ago. B and D. Patients
who are experi-
encing signs and
symptoms of a he-
morrhagic stroke,
who have a BP for
>185/110, and has
received heparin or
any other anticoag-
ulants etc. are NOT
a candidate for tPA.
tPA is only for an is-
chemic stroke.
20. 20. You're assisting a patient who has right side hemi- B. Check for pouch-
paresis and dysphagia with eating. It is very impor- ing of food in the
8 / 10
tant to:* right cheek.
A. Keep the head of bed less than 30'. The answer is B.
B. Check for pouching of food in the right cheek. Because the pa-
C. Prevent aspiration by thinning the liquids. tient has weakness
D. Have the patient extend the neck upward away on the right side
from the chest while eating. and dysphagia the
nurse should reg-
ularly check for
pouching of food
in the right cheek.
Pouching of food
in the cheek can
lead to aspiration or
choking. The HOB
should be >302, liq-
uids thickened per
MD order, and the
patient should tuck
in the chin to the
chest while swal-
lowing.
21. 21. A patient has experienced right side brain dam- A. Remind the pa-
age. You note the patient is experiencing neglect syn- tient to use and
drome. What nursing intervention will you include in touch both sides of
the patient's plan of care?* the body daily.
A. Remind the patient to use and touch both sides of The answer is
the body daily. A. It is impor-
B. Offer the patient a soft mechanical diet with honey tant to watch for
thick liquids. neglect syndrome.
C. Ask direct questions that require one word re- This tends to hap-
sponses. pen in right side
D. Offer the bedpan and bedside commode every 2 brain damage. The
hours. patient ignores the
left side of the body
in this condition.
The nurse needs
to remind the pa-
tient to use and
9 / 10
touch both sides
of the body daily
and that the patient
must make a con-
scious effort to do
so.
10 / 10
Stroke NCLEX
Study online at https://quizlet.com/_1d8th5
1. After a patient experienced a brief C. The patient's symptoms are con-

episode of tinnitus, diplopia, and sistent with transient ischemic attack
dysarthria with no residual effects, (TIA), and drugs that inhibit platelet
the nurse anticipates teaching the aggregation are prescribed after a
patient about TIA to prevent stroke. Continuous he-
a. cerebral aneurysm clipping. parin infusion is not routinely used af-
b. heparin intravenous infusion. ter TIA or with acute ischemic stroke.
c. oral low-dose aspirin therapy. The patient's symptoms are not con-
d. tissue plasminogen activator sistent with a cerebral aneurysm. tPA
(tPA). is used only for acute ischemic stroke,
not for TIA.
2. A 68-year-old patient is being admit- C. A sudden onset headache is typ-

ted with a possible stroke. Which in- ical of a subarachnoid hemorrhage,
formation from the assessment indi- and aspirin is contraindicated. Atrial
cates that the nurse should consult fibrillation, dysphasia, and transient
with the health care provider before ischemic attack (TIA) are not con-
giving the prescribed aspirin? traindications to aspirin use, so the
a. The patient has dysphasia. nurse can administer the aspirin.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms
began with a severe headache.
d. The patient has a history of brief
episodes of right-sided hemiplegia.
3. A 73-year-old patient with a stroke D. Right-sided paralysis indicates a

experiences facial drooping on the left-brain stroke, which will lead to dif-
right side and right-sided arm and ficulty with comprehension and use
leg paralysis. When admitting the of language. The left-side reflexes are
patient, which clinical manifestation likely to be intact. Impulsive behavior
will the nurse expect to find? and neglect are more likely with a
a. Impulsive behavior right-side stroke.
b. Right-sided neglect
c. Hyperactive left-sided tendon re-
flexes
d. Difficulty comprehending instruc-
tions
4.
1 / 12
Stroke NCLEX
During the change of shift report a C. Visual disturbances are expect-
nurse is told that a patient has an oc- ed with posterior cerebral artery oc-
cluded left posterior cerebral artery. clusion. Aphasia occurs with middle
The nurse will anticipate that the pa- cerebral artery involvement. Cogni-
tient may have tive deficits and changes in judgment
a. dysphasia. are more typical of anterior cerebral
b. confusion. artery occlusion.
c. visual deficits.
d. poor judgment.
5. When teaching about clopidogrel D. Clopidogrel (Plavix) inhibits platelet

(Plavix), the nurse will tell the patient function and increases the risk for
with cerebral atherosclerosis gastrointestinal bleeding, so patients
a. to monitor and record the blood should be advised to notify the
pressure daily. health care provider about any signs
b. that Plavix will dissolve clots in of bleeding. The medication does
the cerebral arteries. not lower blood pressure, decrease
c. that Plavix will reduce cerebral plaque formation, or dissolve clots.
artery plaque formation.
d. to call the health care provider if
stools are bloody or tarry.
6. A patient with carotid atheroscle- A. In a carotid endarterectomy, the

rosis asks the nurse to describe carotid artery is incised and the
a carotid endarterectomy. Which re- plaque is removed. The response be-
sponse by the nurse is accurate? ginning, "The diseased portion of the
a. "The obstructing plaque is surgi- artery in the brain is replaced" de-
cally removed from an artery in the scribes an arterial graft procedure.
neck." The answer beginning, "A catheter
b. "The diseased portion of the with a deflated balloon is positioned
artery in the brain is replaced with a at the narrow area" describes an an-
synthetic graft." gioplasty. The final response begin-
c. "A wire is threaded through an ning, "A wire is threaded through the
artery in the leg to the clots in the artery" describes the mechanical em-
carotid artery and the clots are re- bolus removal in cerebral ischemia
moved." (MERCI) procedure.
d. "A catheter with a deflated balloon
is positioned at the narrow area, and
2 / 12
Stroke NCLEX
the balloon is inflated to flatten the
plaque."
7. A patient admitted with possible D. Because elevated BP may be a

stroke has been aphasic for 3 hours protective response to maintain cere-
and his current blood pressure (BP) bral perfusion, antihypertensive ther-
is 174/94 mm Hg. Which order by apy is recommended only if mean ar-
the health care provider should the terial pressure (MAP) is >130 mm Hg
nurse question? or systolic pressure is >220 mm Hg.
a. Keep head of bed elevated at least Fluid intake should be 1500 to 2000
30 degrees. mL daily to maintain cerebral blood
b. Infuse normal saline intravenous- flow. The head of the bed should be
ly at 75 mL/hr. elevated to at least 30 degrees, un-
c. Administer tissue plasminogen less the patient has symptoms of poor
activator (tPA) per protocol. tissue perfusion. tPA may be admin-
d. Administer a labetalol (Normo- istered if the patient meets the other
dyne) drip to keep BP less than criteria for tPA use.
140/90 mm Hg.
8. A 56-year-old patient arrives in the D. The patient's history and clinical

emergency department with hemi- manifestations suggest an acute is-
paresis and dysarthria that started 2 chemic stroke and a patient who is
hours previously, and health records seen within 4.5 hours of stroke onset
show a history of several transient is likely to receive tPA (after screening
ischemic attacks (TIAs). The nurse with a CT scan). Heparin administra-
anticipates preparing the patient for tion in the emergency phase is not
a. surgical endarterectomy. indicated. Emergent carotid translu-
b. transluminal angioplasty. minal angioplasty or endarterectomy
c. intravenous heparin administra- is not indicated for the patient who is
tion. having an acute ischemic stroke.
d. tissue plasminogen activator
(tPA) infusion.
9. A female patient who had a stroke A. Communication will be facilitated

24 hours ago has expressive apha- and less frustrating to the patient
sia. The nurse identifies the nursing when questions that require a "yes"
diagnosis of impaired verbal com- or "no" response are used. When the
munication. An appropriate nursing language areas of the brain are in-
intervention to help the patient com- jured, the patient might not be able
3 / 12
Stroke NCLEX
municate is to to read or recite words, which will
a. ask questions that the patient can frustrate the patient without improv-
answer with "yes" or "no." ing communication. Expressive apha-
b. develop a list of words that the pa- sia is caused by damage to the lan-
tient can read and practice reciting. guage areas of the brain, not by the
c. have the patient practice her facial areas that control the motor aspects
and tongue exercises with a mirror. of speech. The nurse should allow
d. prevent embarrassing the patient time for the patient to respond.
by answering for her if she does not
respond.
10. A 72-year-old patient who has a his- C. Aspirin is ordered to prevent stroke
tory of a transient ischemic attack in patients who have experienced
(TIA) has an order for aspirin 160 mg TIAs. Documentation of the patient's
daily. When the nurse is administer- refusal to take the medication is an
ing medications, the patient says, "I inadequate response by the nurse.
don't need the aspirin today. I don't There is no need to clarify the order
have a fever." Which action should with the health care provider. The as-
the nurse take? pirin is not ordered to prevent aches
a. Document that the aspirin was re- and pains.
fused by the patient.
b. Tell the patient that the aspirin is
used to prevent a fever.
c. Explain that the aspirin is ordered
to decrease stroke risk.
d. Call the health care provider to
clarify the medication order.
11. For a patient who had a right hemi- A. The patient with right-sided brain
sphere stroke the nurse establishes damage typically denies any deficits
a nursing diagnosis of and has poor impulse control, lead-
a. risk for injury related to denial of ing to risk for injury when the patient
deficits and impulsiveness. attempts activities such as transfer-
b. impaired physical mobility related ring from a bed to a chair. Right-sided
to right-sided hemiplegia. brain damage causes left hemiple-
c. impaired verbal communication gia. Left-sided brain damage typically
related to speech-language deficits. causes language deficits. Left-sided
d. ineffective coping related to de- brain damage is associated with de-
4 / 12
Stroke NCLEX
pression and distress about disabil- pression and distress about the dis-
ity. ability.
12. A patient in the clinic reports a B. Following a transient ischemic at-

recent episode of dysphasia and tack (TIA), patients typically are start-
left-sided weakness at home that re- ed on medications such as aspirin to
solved after 2 hours. The nurse will inhibit platelet function and decrease
anticipate teaching the patient about stroke risk. tPA is used for acute is-
a. alteplase (tPA). chemic stroke. Coumadin is usually
b. aspirin (Ecotrin). used for patients with atrial fibrillation.
c. warfarin (Coumadin). Nimodipine is used to prevent cere-
d. nimodipine (Nimotop). bral vasospasm after a subarachnoid
hemorrhage.
13. When caring for a patient with a C. During the acute period, the nurse
new right-sided homonymous hemi- should place objects on the patient's
anopsia resulting from a stroke, unaffected side. Because there is a
which intervention should the nurse visual defect in the right half of each
include in the plan of care? eye, an eye patch is not appropriate.
a. Apply an eye patch to the right The patient should be approached
eye. from the left side. The visual deficit
b. Approach the patient from the may not resolve, although the patient
right side. can learn to compensate for the de-
c. Place objects needed on the pa- fect.
tient's left side.
d. Teach the patient that the left visu-
al deficit will resolve.
14. A 58-year-old patient with a D. Patients who have left-sided brain

left-brain stroke suddenly bursts stroke are prone to emotional out-
into tears when family members vis- bursts that are not necessarily related
it. The nurse should to the emotional state of the patient.
a. use a calm voice to ask the patient Depression after a stroke is common,
to stop the crying behavior. but the suddenness of the patient's
b. explain to the family that depres- outburst suggests that depression is
sion is normal following a stroke. not the major cause of the behavior.
c. have the family members leave the The family should stay with the pa-
patient alone for a few minutes. tient. The crying is not within the pa-
5 / 12
Stroke NCLEX
d. teach the family that emotional tient's control and asking the patient
outbursts are common after strokes. to stop will lead to embarrassment.
15. The nurse identifies the nursing C. Because the nursing diagnosis in-
diagnosis of imbalanced nutrition: dicates that the patient's imbalanced
less than body requirements relat- nutrition is related to the left-sided
ed to impaired self-feeding abili- hemiplegia, the appropriate interven-
ty for a left-handed patient with tions will focus on teaching the patient
left-sided hemiplegia. Which inter- to use the right hand for self-feeding.
vention should be included in the The other interventions are appropri-
plan of care? ate for patients with other etiologies
a. Provide a wide variety of food for the imbalanced nutrition.
choices.
b. Provide oral care before and after
meals.
c. Assist the patient to eat with the
right hand.
d. Teach the patient the "chin-tuck"
technique.
16. Which stroke risk factor for a C. Hypertension is the single most im-
48-year-old male patient in the clinic portant modifiable risk factor. People
is most important for the nurse to who drink more than 1 (for women)
address? or 2 (for men) alcoholic beverages a
a. The patient is 25 pounds above the day may increase risk for hyperten-
ideal weight. sion. Physical inactivity and obesity
b. The patient drinks a glass of red contribute to stroke risk but not as
wine with dinner daily. much as hypertension.
c. The patient's usual blood pres-
sure (BP) is 170/94 mm Hg.
d. The patient works at a desk and
relaxes by watching television.
17. A 40-year-old patient has a ruptured A. The patient with a subarachnoid

cerebral aneurysm and subarach- hemorrhage usually has minimal ac-
noid hemorrhage. Which interven- tivity to prevent cerebral vasospasm
tion will be included in the care or further bleeding and is at risk for ve-
plan? nous thromboembolism (VTE). Activ-
a. Apply intermittent pneumatic ities such as coughing and sitting up
6 / 12
Stroke NCLEX
compression stockings. that might increase intracranial pres-
b. Assist to dangle on edge of bed sure (ICP) or decrease cerebral blood
and assess for dizziness. flow are avoided. Because there is
c. Encourage patient to cough and no indication that the patient is un-
deep breathe every 4 hours. conscious, an oropharyngeal airway
d. Insert an oropharyngeal airway to is inappropriate.
prevent airway obstruction.
18. A patient in the emergency depart- D. The use of warfarin probably con-
ment with sudden-onset right-sided tributed to the intracerebral bleeding
weakness is diagnosed with an in- and remains a risk factor for further
tracerebral hemorrhage. Which in- bleeding. Administration of vitamin K
formation about the patient is most is needed to reverse the effects of the
important to communicate to the warfarin, especially if the patient is to
health care provider? have surgery to correct the bleeding.
a. The patient's speech is difficult to The history of hypertension is a risk
understand. factor for the patient but has no im-
b. The patient's blood pressure is mediate effect on the patient's care.
144/90 mm Hg. The BP of 144/90 indicates the need
c. The patient takes a diuretic be- for ongoing monitoring but not for any
cause of a history of hypertension. immediate change in therapy. Slurred
d. The patient has atrial fibrillation speech is consistent with a left-sided
and takes warfarin (Coumadin). stroke, and no change in therapy is
indicated.
19. A 47-year-old patient will attempt C. The patient should be as upright

oral feedings for the first time since as possible before attempting feed-
having a stroke. The nurse should ing to make swallowing easier and
assess the gag reflex and then decrease aspiration risk. To assess
a. order a varied pureed diet. swallowing ability, the nurse should
b. assess the patient's appetite. initially offer water or ice to the patient.
c. assist the patient into a chair. Pureed diets are not recommended
d. offer the patient a sip of juice. because the texture is too smooth.
The patient may have a poor appetite,
but the oral feeding should be at-
tempted regardless.
20. A patient with left-sided weakness D. Rapid screening with a noncontrast

that started 60 minutes earlier is ad- CT scan is needed before administra-
7 / 12
Stroke NCLEX
mitted to the emergency department tion of tissue plasminogen activator
and diagnostic tests are ordered. (tPA), which must be given within 4.5
Which test should be done first? hours of the onset of clinical mani-
a. Complete blood count (CBC) festations of the stroke. The sooner
b. Chest radiograph (Chest x-ray) the tPA is given, the less brain injury.
c. 12-Lead electrocardiogram (ECG) The other diagnostic tests give infor-
d. Noncontrast computed tomogra- mation about possible causes of the
phy (CT) scan stroke and do not need to be complet-
ed as urgently as the CT scan.
21. A male patient who has right-sided C. The information supports the di-
weakness after a stroke is making agnosis of disabled family coping be-
progress in learning to use the left cause the wife does not understand
hand for feeding and other activities. the rehabilitation program. There are
The nurse observes that when the no data supporting low self-esteem,
patient's wife is visiting, she feeds and the patient is attempting indepen-
and dresses him. Which nursing di- dence. The data do not support an
agnosis is most appropriate for the interruption in family processes be-
patient? cause this may be a typical pattern for
a. Interrupted family processes re- the couple. There is no indication that
lated to effects of illness of a family the patient has impaired nutrition.
member
b. Situational low self-esteem re-
lated to increasing dependence on
spouse for care
c. Disabled family coping related
to inadequate understanding by pa-
tient's spouse
d. Impaired nutrition: less than body
requirements related to hemiplegia
and aphasia
22. Nurses in change-of-shift report are D. Protection of the airway is the pri-
discussing the care of a patient ority of nursing care for a patient hav-
with a stroke who has progressively ing an acute stroke. The other diag-
increasing weakness and decreas- noses are also appropriate, but inter-
ing level of consciousness (LOC). ventions to prevent aspiration are the
Which nursing diagnosis do they de- priority at this time.
termine has the highest priority for
8 / 12
Stroke NCLEX
the patient?
a. Impaired physical mobility related
to weakness
b. Disturbed sensory perception re-
lated to brain injury
c. Risk for impaired skin integrity re-
lated to immobility
d. Risk for aspiration related to in-
ability to protect airway
23. Several weeks after a stroke, a B. Developing a regular voiding

50-year-old male patient has im- schedule will prevent incontinence
paired awareness of bladder full- and may increase patient awareness
ness, resulting in urinary inconti- of a full bladder. A 1200 mL fluid
nence. Which nursing intervention restriction may lead to dehydration.
will be best to include in the initial Intermittent catheterization and use
plan for an effective bladder training of a condom catheter are appropri-
program? ate in the acute phase of stroke, but
a. Limit fluid intake to 1200 mL daily should not be considered solutions
to reduce urine volume. for long-term management because
b. Assist the patient onto the bed- of the risks for urinary tract infection
side commode every 2 hours. (UTI) and skin breakdown.
c. Perform intermittent catheteriza-
tion after each voiding to check for
residual urine.
d. Use an external "condom"
catheter to protect the skin and pre-
vent embarrassment.
24. Which information about the patient B. To prevent cerebral vasospasm

who has had a subarachnoid hemor- and maintain cerebral perfusion,
rhage is most important to commu- blood pressure needs to be main-
nicate to the health care provider? tained at a level higher than 90 mm
a. The patient complains of having a Hg systolic after a subarachnoid he-
stiff neck. morrhage. A low BP or drop in BP
b. The patient's blood pressure (BP) indicates a need to administer fluids
is 90/50 mm Hg. and/or vasopressors to increase the
c. The patient reports a severe and BP. An ongoing headache, RBCs in
unrelenting headache. the CSF, and a stiff neck are all typical
9 / 12
Stroke NCLEX
d. The cerebrospinal fluid (CSF) re- clinical manifestations of a subarach-
port shows red blood cells (RBCs). noid hemorrhage and do not need
to be rapidly communicated to the
health care provider.
25. The nurse is caring for a patient C. Administration of subcutaneous

who has been experiencing stroke medications is included in LPN/LVN
symptoms for 60 minutes. Which ac- education and scope of practice. The
tion can the nurse delegate to a other actions require more education
licensed practical/vocational nurse and scope of practice and should be
(LPN/LVN)? done by the registered nurse (RN).
a. Assess the patient's gag and
cough reflexes.
b. Determine when the stroke symp-
toms began.
c. Administer the prescribed
short-acting insulin.
d. Infuse the prescribed IV metopro-
lol (Lopressor).
26. After receiving change-of-shift re- A. tPA needs to be infused within the
port on the following four patients, first few hours after stroke symptoms
which patient should the nurse see start in order to be effective in mini-
first? mizing brain injury. The other medica-
a. A 60-year-old patient with tions should also be given as quickly
right-sided weakness who has an in- as possible, but timing of the medica-
fusion of tPA prescribed tions is not as critical.
b. A 50-year-old patient who has atri-
al fibrillation and a new order for
warfarin (Coumadin)
c. A 40-year-old patient who expe-
rienced a transient ischemic attack
yesterday who has a dose of aspirin
due
d. A 30-year-old patient with a
subarachnoid hemorrhage 2 days
ago who has nimodipine (Nimotop)
scheduled
10 / 12
Stroke NCLEX
27. The nurse is caring for a patient who B. Small emboli can occur during
has just returned after having left carotid artery angioplasty and stent-
carotid artery angioplasty and stenting, and the aphasia indicates a pos-
ing. Which assessment information sible stroke during the procedure.
is of most concern to the nurse? Slightly elevated pulse rate and blood
a. The pulse rate is 102 beats/min. pressure are not unusual because
b. The patient has difficulty speak- of anxiety associated with the proce-
ing. dure. Fine crackles at the lung bases
c. The blood pressure is 144/86 mm may indicate atelectasis caused by
Hg. immobility during the procedure. The
d. There are fine crackles at the lung nurse should have the patient take
bases. some deep breaths.
28. A 70-year-old female patient with C. The initial nursing action should be
left-sided hemiparesis arrives by to assess the airway and take any
ambulance to the emergency de- needed actions to ensure a patent air-
partment. Which action should the way. The other activities should take
nurse take first? place quickly after the ABCs (airway,
a. Monitor the blood pressure. breathing, and circulation) are com-
b. Send the patient for a computed pleted.
tomography (CT) scan.
c. Check the respiratory rate and ef-
fort.
d. Assess the Glasgow Coma Scale
score.
29. The home health nurse is caring for B. The spouse's household and pa-
an 81-year-old who had a stroke 2 tient care responsibilities, in combina-
months ago. Based on information tion with chronic illnesses, indicate a
shown in the accompanying figure high risk for caregiver role strain. The
from the history, physical assess- nurse should further assess the sit-
ment, and physical therapy/occupa- uation and take appropriate actions.
tional therapy, which nursing diag- The data about the control of the pa-
nosis is the highest priority for this tient's diabetes indicates that ineffec-
patient? tive health maintenance and risk for
a. Impaired transfer ability unstable blood glucose are not pri-
b. Risk for caregiver role strain ority concerns at this time. Because
c. Ineffective health maintenance the patient is able to ambulate with
a cane, the nursing diagnosis of im-
11 / 12
Stroke NCLEX
d. Risk for unstable blood glucose paired transfer ability is not support-
level ed.
30. A 63-year-old patient who began ex- C, D, A, B

periencing right arm and leg weak- The initial actions should be those
ness is admitted to the emergency that help with airway, breathing, and
department. In which order will the circulation. Baseline neurologic as-
nurse implement these actions in- sessments should be done next. A
cluded in the stroke protocol? CT scan will be needed to rule out
a. Obtain computed tomography hemorrhagic stroke before tPA can be
(CT) scan without contrast. administered.
b. Infuse tissue plasminogen activa-
tor (tPA).
c. Administer oxygen to keep O2 sat-
uration >95%.
d. Use National Institute of Health
Stroke Scale to assess patient.
12 / 12
SCI NCLEX Practice Questions
Study online at https://quizlet.com/_9o4blj
1. Which condition is an indication Spinal nerve compression

for decompression surgery for a
client with spinal cord injury? (Se- Facet dislocation
lect all that apply.)
Progressive neurologic deterioration
Spinal nerve compression
Spinal decompression surgery is most
Facet dislocation often performed in clients with progres-
sive neurologic deterioration, facet dis-
Progressive neurologic deteriora- location (displacement of one vertebra
tion on another), spinal nerve compression,
and extradural lesions.
Cervical fracture without major
cord damage
Spinal stabilization
2. The nurse admitting a client who Complete loss of sensation

was in a motor vehicle crash
is concerned that the client has Flaccid paralysis
a spinal cord injury with spinal
shock. Which assessment finding Urinary incontinence
would cause this concern? (Select
all that apply.) Flaccid paralysis is an expected finding
during spinal shock. The client will de-
Hypertension velop spastic movements later as ede-
ma from the initial injury resolves. Com-
Complete loss of sensation plete loss of sensation is common dur-
ing spinal shock. This loss occurs be-
Flaccid paralysis cause of edema in the area of the injury.
Some sensation may return as the ede-
Warm, flushed skin ma resolves. Low blood pressure oc-
curs during spinal shock caused by lack
Urinary incontinence of vasoconstriction needed to maintain
blood pressure. This lack occurs be-
cause of damage to the nerve supply
to the peripheral blood vessels. Incon-
tinence occurs because of damage to
the nerves that supply the bladder. This
1 / 11
may or may not be permanent depend-
ing on the extent of the damage. Spinal
shock causes an inability to regulate
body temperature. The client's body will
assume a temperature similar to the
temperature of the environment. The
client's skin would not be warm and
flushed because of poor perfusion and
low blood pressure during spinal shock
3. The nurse is caring for a client Only sensory function will be present
diagnosed with a sensory incom- below the level of the injury.
plete spinal cord injury. The client
asks the nurse to explain the in- American Spinal Injury Association
jury. Which explanation should the (ASIA) Impairment Scale (AIS). A =
nurse give? Complete: No sensory or motor func-
tion is preserved in the sacral seg-
Only motor function will be present ments S4-S5. B = Sensory incomplete:
below the level of the injury. Sensory but not motor function is pre-
served below the neurologic level and
No sensory or motor function will includes the sacral segments S4-S5
be present below the level of injury. (light touch, pin prick at S4-S5, or deep
anal pressure), AND no motor function
Only half of the muscles below the is preserved more than three levels be-
level of injury will function. low the motor level on either side of
the body. C = Motor incomplete: Motor
Only sensory function will be pre- function is preserved below the neu-
sent below the level of the injury. rologic level, and more than half of
key muscle functions below the single
neurologic level of injury (NLI) have a
muscle grade of < 3 (grades 0-2). D
= Motor incomplete: Motor function is
preserved below the neurologic level,
and at least half of key muscle functions
below the NLI have a muscle grade
e3. E = Normal: If sensation and motor
function as tested with the International
Standards for Neurologic Classification
of Spinal Cord Injury (ISNCSCI) exam
2 / 11
are graded as normal in all segments,
and the client had prior deficits, then
the AIS grade is E. Someone without
an initial spinal cord injury (SCI) does
not receive an AIS grade.
Next Question
4. The nurse is discussing risk fac- Single young adult man

tors for spinal cord injury (SCI)
with a community group. Which Single young men are the individuals
group should the nurse include as who are most likely to engage in risky
being high risk for this type of in- behavior, such as diving into a too-shal-
jury? low pool, not wearing protective gear
while engaging in sports, or driving at
Asian American high speeds. Non-Hispanic Caucasian
Americans have the highest rates when
Hispanic race is compared, followed by non-His-
panic African Americans, Asian Ameri-
Single young adult man cans, and American Indians.
Older adult woman
5. A client with a spinal cord injury Hemiplegia

has no movement or sensation in
the left side of their body. Which
term does the nurse use to de-
scribe this condition?
Paraplegia
Quadriplegia
Hemiplegia
Tetraplegia
6. The nurse is planning care for Self-care Deficit

a client with a complete lumbar
spinal cord injury (SCI). Which Urinary Incontinence, Functional
3 / 11
problem diagnosis should the
nurse expect? (Select all that ap- Skin Integrity, Risk for Impaired
ply.)
The client is experiencing a lum-
Breathing Pattern, Ineffective bar spinal cord injury, which affects
the lower limbs, back, and abdomen.
Aspiration, Risk for When planning care for this client, the
nurse needs to identify the following
Self-care Deficit problems: impaired urinary elimination,
risk for skin breakdown, and self-care
Urinary Incontinence, Functional deficits. Since the injury does not af-
fect the diaphragm and chest area, im-
Skin Integrity, Risk for Impaired paired breathing patterns and risk of
aspiration do not apply to this client.
7. The nurse is caring for a preg- "You will need to watch for other symp-
nant woman who has a history of a toms of labor since you may not feel
complete L1 spinal cord injury. The labor pains."
client asks the nurse how to under-
stand the onset of labor. Which isPregnant women with decreased sen-
the nurse's correct response? sation in the lower trunk may not feel
the typical pains of labor, so they
"You will need to watch for other should be taught the common signs
symptoms of labor since you may of labor such as changes in breath-
not feel labor pains." ing, abdominal tightening, and back-
ache. Many women do not feel the labor
"You will have to be induced so pains, but do not necessarily need to be
that delivery is controlled." induced and may deliver vaginally.
"You will have to have a cesarean

birth since your uterus cannot con-
tract."
"You will definitely feel the cramp-

ing pain with contractions."
8. The nurse caring for a 76-year-old Using assistive devices such as a cane
client is teaching home safe- when needed for stability
ty strategies prior to discharge.
4 / 11
Which strategy should be taught toFalls are the most common cause of
prevent the most common type of SCI injury in the older adult popula-
spinal cord injury (SCI) in the older
tion. Therefore, a teaching strategy to
adult population? prevent falls is indicated. Wearing seat
belts, having daily checks, and partici-
Using assistive devices such as a pating in an emergency response sys-
cane when needed for stability tem are important for safety in the older
adult but will not prevent falls. Using
Having a system for family or assistive devices can help prevent falls.
neighbors to make daily checks
Wearing seat belts at all times

while in moving vehicle
Participating in an emergency re-

sponse system if living alone
9. A client with a T4 spinal cord in- Grieving

jury (SCI) calls the nurse to the
room for bowel incontinence. The This client is experiencing a common
client cries, "I am so sick of this! emotional reaction to an
Why is this happening to me? I just SCI—grief.
give up!" Which nursing diagnosis This should be addressed immediately,
is the priority? and emotional support should be giv-
en. Self-care Deficit: Toileting; Mobility:
Grieving Physical,
Impaired;
Skin Integrity, Impaired and Skin
Integrity,
Mobility: Physical, Impaired Impaired are all important to address,
but the client's grief needs to be ad-
Self-care Deficit, Toileting dressed first.
10. The nurse is caring for a client with Teaching the client to breathe deeply
a C3 spinal cord injury who has di- and cough every 2 hours
minished respiratory muscle con-
trol. Which intervention should the Encouraging frequent use of an incen-
nurse include to promote adequate tive spirometer
ventilation? (Select all that apply.)
5 / 11
Providing cough-assist treatments
Maintaining cervical alignment
during intubation or airway inser- With diminished muscle control, the
tion client is at risk for atelectasis and pneu-
monia. Teaching coughing and deep
Implementing a scheduled bowel breathing, using an incentive spirom-
program eter, and providing cough-assist treat-
ments will aid in clearing lungs of se-
Teaching the client to breathe cretions. Although maintaining cervical
deeply and cough every 2 hours alignment is important if inserting an
airway or intubating, this is actually
Encouraging frequent use of an in- done to prevent further spinal damage.
centive spirometer A bowel program is implemented to
prevent constipation.
Providing cough-assist treatments
11. A client with a spinal cord injury is To decrease inflammation and reduce
scheduled to receive a high dose damage to surrounding nerve cells
of methylprednisolone. Which rea-
son does the nurse recognize for Methylprednisolone in large doses is
administering this medication? given to decrease inflammation and
reduce damage to surrounding nerve
To decrease inflammation and re- cells. The acute pain of traumatic injury
duce damage to surrounding nerve is treated with opioids. To prevent DVT
cells and pulmonary embolism, heparin and
warfarin (Coumadin) are administered.
To treat the acute pain of the trau- Muscle relaxants are given to reduce
matic injury muscle spasticity.
To prevent deep venous thrombo-

sis (DVT) and pulmonary embolism
To reduce muscle spasticity
12. The nurse working in the emer- Maintaining the ability to breathe
gency department receives a client
involved in a boating accident. Maintaining an airway is the priority for
Which should be the nurse's prior- care in emergent situations. Once the
ity care for this client? airway has been established and stabi-
6 / 11
lized, the priority would be preventing
Preventing spinal shock movement, preventing shock, and then
stabilizing the spine with a brace or
Maintaining the ability to breathe traction.
Preventing movement that could

cause more damage
Realigning the spine with an emer-

gency brace or traction
13. The nurse is teaching a client with Avoid excessive exposure to the sun.
a spinal cord injury. Which infor-
mation should the nurse provide Monitor urine for color and odor.
to help the client avoid autonomic
dysreflexia? (Select all that apply.) Change positions frequently when sit-
ting in a chair.
Avoid excessive exposure to the
sun. When teaching a client about ways to
avoid autonomic dysreflexia, the client
Wear tight-fitting clothes. needs to consume a high-fiber diet with
adequate fluid to prevent constipation.
Monitor urine for color and odor. The client also needs to monitor urine
for color and odor. If the client experi-
Change positions frequently when ences manifestations of a urinary trac-
sitting in a chair. t infection, it must be treated immedi-
ately. The client needs to be instruct-
Consume a low-fiber diet. ed to wear loose-fitting clothes and to
change positions frequently when sit-
ting in the chair or when in bed. A client
with a spinal cord injury should also
avoid sunburn because it can lead to
autonomic dysreflexia.
14. Which client is most at risk for de- A client with injury at level of T6
veloping respiratory difficulty?
Clients with injuries above T12 will ex-
A client with injury at level of S2 perience some decrease in respiratory
7 / 11
A client with injury at level of T15 muscle control; the higher the level of
injury, the more severe the deficiencies.
A client with injury at level of L5
A client with injury at level of T6
15. Which nonpharmacologic inter- Providing passive range of motion

vention should the nurse imple- (ROM)
ment to prevent the development
of a deep venous thrombosis (DVT) Providing passive ROM is a nonphar-
in a client who has tetraplegia? macologic therapy that will help to pro-
mote venous circulation and decrease
Encouraging foods that are high in the risk of development of DVT. A diet
protein high in protein would be indicated if a
pressure wound develops to promote
Implementing incentive spirome- healing. Anticoagulants may be admin-
try istered but are a pharmacologic inter-
vention. The use of an incentive spirom-
Administering subcutaneous he- eter is a nonpharmacologic treatment
parin used to help prevent pneumonia, not
DVT.
Providing passive range of motion
(ROM)
16. The nurse on the medical-surgi- Checking the client for bowel impaction
cal unit is providing care for a
client with cervical spinal cord in- Checking the client's bladder
jury (SCI) from an accident sever-
al years ago. The client reports a Removing the client's compression
headache. The client's blood pres- stockings
sure is 230/115 mmHg. Which inter-
vention should the nurse provide? The client has manifestations of au-
(Select all that apply.) tonomic dysreflexia. This is a medical
emergency. A distended urinary blad-
Checking the client for bowel im- der can cause autonomic dysreflexia.
paction If the bladder is causing the problem,
the nurse can relieve manifestations by
Administering acetaminophen draining the client's bladder. A distend-
(Tylenol) ed bowel can cause autonomic dys-
8 / 11
reflexia. If the bowel is the problem,
Checking the client's bladder the nurse can relieve the manifesta-
tions by removing the impaction. The
Rechecking the blood pressure in compression stockings can contribute
2 hours to autonomic dysreflexia by creating
an irritation that causes the manifesta-
Removing the client's compres- tions. The stockings also elevate blood
sion stockings pressure by increasing venous return
to the heart. Rather than recheck-
ing the blood pressure every 2 hours,
the nurse would continue to look for
the cause until it is found and cor-
rected. Administering acetaminophen
would not address the manifestations
of autonomic dysreflexia.
17. Which nursing goal would be ap- he client will have arterial blood gases
propriate for a client who has a C2 (ABGs) within normal limits.
spinal cord injury with resolving
pneumonia? An appropriate goal for the client
with resolving ventilation complications
The client will maintain oxygen sat- would be to have ABGs within normal
uration less than 95%. limits. Oxygen saturations should be
maintained at greater than 95%. The
The client will remain free of symp- client should no longer require deep
toms of autonomic dysreflexia. suctioning. Autonomic dysreflexia is an
unrelated complication of pneumonia.
The client will have arterial blood
gases (ABGs) within normal limits.
The client will require deep suc-

tioning no more than every 2
hours.
18. When reviewing the medical Compression

record of a client who experienced
a spinal cord injury, the nurse Compression occurs when excessive
notes that the client experienced vertical force is applied to the spinal
the injury while diving into shal- cord, such as in a diving accident. Tran-
9 / 11
low water. Which type of excessive section of the spinal cord occurs when
force does the nurse consider to a force partially or completely sev-
have been placed on the vertebral ers the spinal cord. Excessive force in
column? which the neck is forced backwards is
hyperextension and is seen in whiplash
Compression injuries. Hyperflexion occurs when ex-
cessive force forces the head forward
Hyperextension onto the chest.
Hyperflexion
Transection
19. The nurse is developing a plan of In and out catheterization as indicated

care for a client with urinary re-
tention related to a flaccid blad- Assessing bladder volume
der. Which intervention should the
nurse include? (Select all that ap- Beginning bladder training
ply.)
A client who has a flaccid bladder will
In and out catheterization as indi- need assistance with bladder emptying
cated to avoid bladder overdistention, blad-
der and kidney infection, and the de-
Assessing bladder volume velopment of kidney stones. Bladder
training is possible in many clients de-
Beginning bladder training pending on the level of the injury. Fluid
should not be withheld, as dehydration
Maintaining in semi-Fowler's posi- can lead to other complications. Blad-
tion der volume should be assessed and
catheterization performed as indicated.
Limiting fluid intake Semi-Fowler's position is not indicated.
20. An emergency department nurse Endotracheal intubation

receives a client who reportedly
has a C1 complete spinal cord in- A client with an SCI at level C3 or
jury (SCI). Which collaborative in- higher loses control of all four muscle
tervention should the nurse imme- groups needed for breathing. These in-
diately prepare for the client? dividuals require immediate ventilator
support. Muscle function grading, ASIA
10 / 11
American Spinal Injury Associa- Impairment Scale scoring, and reflex
tion (ASIA) Impairment Scale scor- testing should be done after the client
ing is stabilized.
Reflex testing
Endotracheal intubation
Assessment using the muscle

function grading scale
11 / 11
Spinal injury and ICP Nclex Questions
Study online at https://quizlet.com/_6fqiym
1. A patient with a spinal cord Correct Answer: 2

injury at the T1 level com- Rationale: Autonomic dysreflexia occurs in pa-
plains of a severe headache tients with injury at level T6 or higher, and
and an "anxious feeling." is a life-threatening situation that will require
Which is the most appro- immediate intervention or the patient will die.
priate initial reaction by the The most common cause is an overextend-
nurse? ed bladder or bowel. Symptoms include hy-
1. Try to calm the patient pertension, headache, diaphoresis, bradycar-
and make the environment dia, visual changes, anxiety, and nausea. A
soothing. calm, soothing environment is fine, though not
2. Assess for a full bladder. what the patient needs in this case. The nurse
3. Notify the healthcare should recognize this as an emergency and
provider. proceed accordingly. Once the assessment
4. Prepare the patient for di- has been completed, the findings will need to
agnostic radiography. be communicated to the healthcare provider.
2. A hospitalized patient with Correct Answer: 4

a C7 cord injury begins to Rationale: Spinal shock is a condition almost
yell "I can't feel my legs any- half the people with acute spinal injury ex-
more." Which is the most perience. It is characterized by a temporary
appropriate action by the loss of reflex function below level of injury,
nurse? and includes the following symptomatology:
1. Remind the patient of her flaccid paralysis of skeletal muscles, loss of
injury and try to comfort her. sensation below the injury, and possibly bowel
2. Call the healthcare and bladder dysfunction and loss of ability to
provider and get an order for perspire below the injury level. In this case,
radiologic evaluation. the nurse should explain to the patient what is
3. Prepare the patient for happening.
surgery, as her condition is
worsening.
4. Explain to the patient that
this could be a common,
temporary problem.
3. The nurse is educating a pa- Correct Answer: 2

tient and the family about Rationale: A halo device will allow the pa-
different types of stabiliza- tient to be mobile since it does not require
tion devices. Which state- weights like the Gardner-Wells tongs. The pa-
ment by the patient indi- tient's pain level is not dependant on the type
1 / 26
cates that the patient under- of stabilization device used. The patient does
stands the benefit of using a not have a great risk of infection with the Gar-
halo fixation device instead nder-Wells tongs; both devices require pins to
of Gardner-Wells tongs? be inserted into the skull. The time required for
1. "I will have less pain if I stabilization is not dependant on the type of
use the halo device." stabilization device used.
2. "The halo device will allow
me to get out of bed."
3. "I am less likely to get an
infection with the halo de-
vice."
4. "The halo device does
not have to stay in place as
long."
4. The nurse is caring Correct Answer: 3

for a patient with in- Rationale: Suctioning further increases in-
creased intracranial pres- tracranial pressure; therefore, suctioning
sure (IICP). The nurse re- should be done to maintain a patent airway
alizes that some nursing but not as a matter of routine. Maintaining pa-
actions are contraindicated tient comfort by frequent repositioning as well
with IICP. Which nursing ac- as keeping the head elevated 30 degrees will
tion should be avoided? help to prevent (or even reduce) IICP. Keeping
1. Reposition the patient the patient properly oxygenated may also help
every two hours. to control ICP.
2. Position the patient with
the head elevated 30 de-
grees.
3. Suction the airway every
two hours per standing or-
ders.
4. Provide continuous oxy-
gen as ordered.
5. A patient with a spinal cord Correct Answer: 2,4,5

injury (SCI) is admitted to Rationale: The healthcare provider is respon-
the unit and placed in trac- sible for initial applying of the traction device.
tion. Which of the following The weights on the traction device must not
actions is the nurse respon- be changed without the order of a healthcare
2 / 26
sible for when caring for this provider. When caring for a patient in traction,
patient? the nurse is responsible for assessment and
Select all that apply. care of the skin due to the increased risk of
1. modifying the traction skin breakdown. The patient in traction is likely
weights as needed to experience pain and the nurse is responsi-
2. assessing the patient's ble for assessing this pain and administering
skin integrity the appropriate analgesic as ordered. Passive
3. applying the traction upon range of motion helps prevent contractures;
admission this is often performed by a physical therapist
4. administering pain med- or a nurse.
ication
5. providing passive range
of motion
6. A patient has manifesta- Correct Answer: 2,5

tions of autonomic dysre- Rationale: Autonomic dysreflexia can be
flexia. Which of these as- caused by kinked catheter tubing allowing the
sessments would indicate a bladder to become full, triggering massive
possible cause for this con- vasoconstriction below the injury site, produc-
dition? ing the manifestations of this process. Acute
Select all that apply. symptoms of autonomic dysreflexia, including
1. hypertension a sustained elevated blood pressure, may in-
2. kinked catheter tubing dicate fecal impaction. The other answers will
3. respiratory wheezes and not cause autonomic dysreflexia.
stridor
4. diarrhea
5. fecal impaction
7. An unconscious patient re- Correct Answer: 1,2,5

ceiving emergency care fol- Rationale: In the emergency setting, all pa-
lowing an automobile crash tients who have sustained a trauma to the
accident has a possible head or spine, or are unconscious should be
spinal cord injury. What treated as though they have a spinal cord
guidelines for emergency injury. Immobilizing the neck, maintaining a
care will be followed? supine position and securing the patient's
Select all that apply. head to prevent movement are all basic guide-
1. Immobilize the neck using lines of emergency care. Placement on the
rolled towels or a cervical ventilator and raising the head of the bed will
collar. be considered after admittance to the hospital.
3 / 26
2. The patient will be placed
in a supine position
on a ventilator.
4. The head of the bed will be
elevated.
5. The patient's head will be
secured with a belt or tape
secured to the stretcher.

injury is recovering from Rationale: Be attuned to the prevention of a
spinal shock. The nurse real- distended bladder when caring for spinal cord
izes that the patient should injury (SCI) patients in order to prevent this
not develop a full bladder chain of events that lead to autonomic dysre-
because what emergency flexia. Track urinary output carefully. Routine
condition can occur if it is use of bladder scanning can help prevent the
not corrected quickly? occurrence. Other causes of autonomic dys-
1. autonomic dysreflexia reflexia are impacted stool and skin pressure.
2. autonomic crisis Autonomic crisis, autonomic shutdown, and
3. autonomic shutdown autonomic failure are not terms used to de-
4. autonomic failure scribe common complications of spinal injury
associated with bladder distension.
9. Which patient is at highest Correct Answer: 1

risk for a spinal cord injury? Rationale: The three major risk factors for
1. 18-year-old male with a spinal cord injuries (SCI) are age (young
prior arrest for driving while adults), gender (higher incidence in males),
intoxicated (DWI) and alcohol or drug abuse. Females tend to
2. 20-year-old female with a engage in less risk-taking behavior than young
history of substance abuse men.
3. 50-year-old female with
osteoporosis
4. 35-year-old male who
coaches a soccer team
10. The nurse understands that Correct Answer: 2

when the spinal cord is in- Rationale: Within 24 hours necrosis of both
jured, ischemia results and gray and white matter begins if ischemia has
4 / 26
edema occurs. How should been prolonged and the function of nerves
the nurse explain to the pa- passing through the injured area is lost. Be-
tient the reason that the ex- cause the edema extends above and below
tent of injury cannot be de- the area affected, the extent of injury cannot
termined for several days to be determined until after the edema is con-
a week? trolled. Neurons do not regenerate, and the
1. "Tissue repair does not edema is the factor that limits the ability to
begin for 72 hours." predict extent of injury.
2. "The edema extends the
level of injury for two cord
segments above and below
the affected level."
3. "Neurons need time to re-
generate so stating the in-
jury early is not predictive
of how the patient progress-
es."
4. "Necrosis of gray and
white matter does not occur
until days after the injury."
11. A patient with a spinal Correct Answer: 4

cord injury (SCI) has com- Rationale: Quadriplegia describes complete
plete paralysis of the up- paralysis of the upper extremities and com-
per extremities and complete paralysis of the lower part of the body.
plete paralysis of the lower Hemiplegia describes paralysis on one side of
part of the body. The nurse the body. Paresthesia does not indicate paral-
should use which medical ysis. Paraplegia is paralysis of the lower body.
term to adequately describe
this in documentation?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia
12. Which of the following nurs- Correct Answer: 4

ing actions is appropriate Rationale: A patient who has undergone a
for preventing skin break- laminectomy needs to be turned by log rolling
down in a patient who to prevent pressure on the area of surgery.
5 / 26
has recently undergone a An air mattress will help prevent skin break-
laminectomy? down but the patient still needs to be turned
1. Provide the patient with an frequently. Placing pillows under the patient
air mattress. can help take pressure off of one side but the
2. Place pillows under pa- patient still needs to change positions often.
tient to help patient turn. Teaching the patient to grasp the side rail will
3. Teach the patient to grasp cause the spine to twist, which needs to be
the side rail to turn. avoided.
4. Use the log roll to turn the
patient to the side.
13. The patient is admitted Correct Answer: 2

with injuries that were sus- Rationale: Spinal shock is common in acute
tained in a fall. During spinal cord injuries. In addition to the signs
the nurse's first assess- and symptoms mentioned, the additional sign
ment upon admission, the of absence of the cremasteric reflex is asso-
findings are: blood pres- ciated with spinal shock. Lack of respiratory
sure 90/60 (as compared to effort is generally associated with high cervi-
136/66 in the emergency de- cal injury. The findings describe paralysis that
partment), flaccid paralysis would be associated with spinal shock in an
on the right, absent bowel spinal injured patient. The likely cause of these
sounds, zero urine output, findings is not hypovolemia, but rather spinal
and palpation of a distend- shock.
ed bladder. These signs are
consistent with which of the
following?
1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia
14. While caring for the pa- Correct Answer: 3

tient with spinal cord injury Rationale: Autonomic dysreflexia is an emer-
(SCI), the nurse elevates the gency that requires immediate assessment
head of the bed, removes and intervention to prevent complications of
compression stockings, and extremely high blood pressure. Additional
continues to assess vital nursing assistance will be needed and a col-
signs every two to three league needs to reach the physician stat.
minutes while searching for
6 / 26
the cause in order to prevent
loss of consciousness or
death. By practicing these
interventions, the nurse is
avoiding the most danger-
ous complication of auto-
nomic dysreflexia, which is
which of the following?
1. hypoxia
2. bradycardia
3. elevated blood pressure
4. tachycardia
15. A patient is admitted to D. loss of sympathetic nervous system inner-

the hospital with a CD4 vation resulting in peripheral vasodilation
spinal cord injury after a mo-
torcycle collision. The pa-
tient's BP is 83/49, and his
pulse is 39 beats/min, and
he remains orally intubat-
ed. The nurse identifies this
pathophysiologic response
as caused by
a. increased vasomotor tone
after injury
b. a temporary loss of sen-
sation and flaccid paralysis
below the level of injury
c. loss of parasympathet-
ic nervous system innerva-
tion resulting in vasocon-
striction
d. loss of sympathetic ner-
vous system innervation re-
sulting in peripheral vasodi-
lation
16. A nurse is caring for a client B. sit the client upright in bed
with a spinal cord injury who Rationale: The greatest risk to the client is ex-
7 / 26
reports a severe headache periencing a cerebrovascular accident (stroke)
and is sweating profuse- secondary to elevated BP. The first action by
ly. vital signs include BP the nurse is elevate the head of the bed until
220/110, apical heart rate the client is in an upright position. this will lower
of 54/min. Which of the fol- the BP secondary to postural hypotension.
lowing acctions should the
nurse take first?
a. notify the provider
b. sit the client upright in
bed
c. check the client's urinary
catheter for blockage
d. administer antihyperten-
sive medication
17. Following a T2 spinal cord D. nasogastric suctioning

injury, the patient develops Rationale: During the first 2 to 3 days after a
paralytic ileus. While this spinal cord injury, paralytic ileus may occur,
condition is present, the and NG suction must be used to remove se-
nurse anticipates that the cretions and gas from the GI tract until peri-
patient will need stalsis resumes. IV fluids are used to maintain
a. IV fluids fluid balance but do not specifically relate to
b. tube feedings paralytic ileus. Tube feedings would be used
c. parenteral nutrition only for patients who had difficulty swallowing
d. nasogastric suctioning and not until peristalsis is returned; PN would
be used only if the paralytic ileus was unusally
prolonged.
18. An initial incomplete spinal C. c. infarction and necrosis of the cord caused
cord injury often results in by edema, hemorrhage, and metabolites
complete cord damage be- Rationale: The primary injury of the spinal cord
cause of rarely affects the entire cord, but the patho
a. edematous compression of secondary injury may result in damage
of the cord above the level of that is the same as mechanical severance of
the injury the cord. Complete cord dissolution occurs
b. continued trauma to the through autodestruction of the cord by hemor-
cord resulting from damage rhage, edema, and the presence of metabo-
to stabilizing ligaments lites and norepinephrine. resulting in anoxia
c. infarction and necrosis of and infarction of the cord. Edema resulting
8 / 26
the cord caused by edema, from the inflammatory response may increase
hemorrhage, and metabo- the damage as it extends above and below the
lites injury site.
d. mecheanical transection
of the cord by sharp ver-
tebral bone fragments after
the initial injury
19. Two days following a spinal B. the extent of your injury cannot be deter-
cord injury, a patient asks mined until the secondary injury to the cord is
continually about the extent resolved
of impairment that will result Rationale: Until the edema and necrosis at the
from the injury. The best re- site of the injury are resolved in 72 hours to
sponse by the nurse is, 1 week after the injury, it is not possible to
a. you will have more normal determine how much cord damage is present
function when spinal shock from the initial injury, how much secondary
resolves and the reflex arc injury occurred, or how much the cord was
returns damaged by edema that extended above the
b. the extent of your injury level of the original injury. The return of reflexes
cannot be determined until signals only the end of spinal shock, and the
the secondary injury to the reflexes may be inappropriate and excessive,
cord is resolved causing spasms that complicate rehab.
c. when your condition is
more stable, an MRI will be
done that can reveal the ex-
tent of the cord damage
d. because long-term reha-
bilitation can affect the re-
turn of tunction, it will be
years before we can tell
when the complete effect
will be
20. A week following a spinal B. the could be a really positive finding. can
cord injury at T2, a patient you show me the movement
experiences movement in Rationale: in 1 week following a spinal cord
his leg and tells the nurse he injury, there may be a resolution of the ede-
is recovering some function. ma of the injury and an end to spinal shock.
The nurses' best response When spinal shock ends, reflex movement and
9 / 26
to the patient is, spasms will occur, which may be mistaken
a. it is really still too soon for return of function, but with the resolution
to know if you will have a of edema, some normal function may also
return of function occur. it is important when movement occurs
b. the could be a really pos- to determine whether the movement is volun-
itive finding. can you show tary and can be consciously controlled, which
me the movement would indicate some return of function.
c. that's wonderful. we will
start exercising your legs
more frequently now
d. im sorry, but the move-
ment is only a reflex and
does not indicate normal
function
21. Urinary function during the A. an indwelling catheterization

acute phase of spinal cord
injury is maintained with
a. an indwelling catheter
b. intermittent catheteriza-
tion
c. insertion of a suprapubic
catheter
d. use of incontinent pads to
protect the skin
22. A nurse is caring for a client D. respiratory compromise

who has a C4 spinal cord Rationale: Using the airway, breathing and cir-
injury. which of the follow- culation priority framework, the greatest risk
ing should the nurse recog- to the client with a SCI at the level of C4 is
nize the client as being at respiratory compromise secondary to involve-
the greatest risk for? ment of the phrenic nerve. Maintainance of an
a. neurogenic shock airway and provision of ventilator support as
b. paralytic ileus needed is the priority intervention.
c. stress ulcer
d. respiratory compromise
23. During assessment of a pa- C. assess lungs sounds and respiratory rate
tient with a spinal cord in- and depth
10 / 26
jury, the nurse determines Rationale: Because pneumonia and atelec-
that the patient has a poor tasis are potential problems RT ineffective
cough with diaphragmatic coughing function, the nurse should assess
breathing. Based on this the patient's breath sound and resp function
finding, the nurses' first ac- to determine whether secretions are being re-
tion should be to tained or whether there is progression of resp
a. initiate frequent turning impairment. Suctioning is not indicated unless
and repositioning lung sounds indicate retained secretions: posi-
b. use tracheal suctioning to tion changes will help mobilize secretions. In-
remove secretions tubation and mechanical ventilation are used
c. assess lung sounds and if the patient becomes exhausted from labored
respiratory rate and depth breathing or if ABGs deteriorate.
d. prepare the patient for
endotracheal intubation and
mechanical ventilation
24. The healthcare provider has C. BP of 106/82

ordered IV dopamine (In- Rationale: Dopamine is a vasopressor that is
tropin) for a patient in used to maintain BP during states of hypoten-
the emergency deparement sion that occur during neurogenic shock asso-
with a spinal cord injury. ciated with spinal cord injury. Atropine would
The nurse determines that be used to treat bradycardia. The T reflects
the drug is having the de- some degree of poikilothermism, but this is not
sired effect when assess- treated with medications.
ment findings include
a. pulse rate of 68
b. respiratory rate of 24
c. BP of 106/82
d. temperature of 96.8
25. A patient is admitted to the b. HR of 42 beats/min

emergency department with Rationale: Neurogenic shock associated with
a spinal cord injury at the cord injuries above the level of T6 greatly de-
level of T2. Which of the fol- crease the effect of the sympathetic nervous
lowing findings is of most system, and bradycardia and hypotension oc-
concern to the nurse? cur. A heart rate of 42 is not adequate to meet
a. SpO2 of 92% oxygen needs of the body, and while low, the
b. HR of 42 beats/min BP is not at a critical point. The O2 sat is ok,
c. BP of 88/60 and the motor and sensory loss are expected.
11 / 26
d. loss of motor and sensory
function in arms and legs
26. Without surgical stabiliza- C. skeletal traction with skull tongs

tion, immobilization and Rationale: Cervical injuries usually require
traction of the patient with skeletal traction with the use of Crutchfield,
a cervical spinal cord injury Vinke, or other types of skull tongs to immobi-
most frequently requires the lize the cervical vertebrae, even if fracture has
use of not occurred. Hard cervical collars are used
a. kinetic beds for minor injuries or for stabilization during
b. hard cervical collars emergency transport of the patient. Sandbags
c. skeletal traction with skull are also used temporarily to stabilize the neck
tongs during insertion of tongs or during diagnostic
d. sternal-occipi- testing immediately following the injury. Spe-
tal-mandibular immobilizer cial turning or kinetic beds may be used to
(SOMI) brace turn and mobilize patients who are in cervical
traction.
27. A patient with a spinal cord C. c. resolution of spinal shock is manifested

injury has spinal shock. The by spasticity, hyperreflexia, and reflex empty-
nurse plans care for the pa- ing of the bladder
tient based on the knowl- Rationale: Spinal shock occurs in about half
edge that of all people with acute spinal cord injury. In
a. rehabilitation measures spinal shock, the entire cord below the level of
cannot be initiated until the lesion fails to function, resulting in a flaccid
spinal shock has resolved paralysis and hypomotility of most processes
b. the patient will need con- without any reflex activity. Return of reflex ac-
tinuous monitoring for hy- tivity signals the end of spinal shock. Sympa-
potension, tachycardia, and thetic function is impaired belwo the level of
hypoxemia the injury because sympathetic nerves leave
c. resolution of spinal shock the spinal cord at the thoracic and lumbar ar-
is manifested by spastici- eas, and cranial parasympathetic nerves pre-
ty, hyperreflexia, and reflex dominate in control over respirations, heart,
emptying of the bladder and all vessels and organ below the injury.
d. the patient will have com- Neurogenic shock results from loss of vascular
plete loss of motor and sen- tone caused by the injury and is manifested
sory functions below the by hypotension, peripheral vasodilation, and
level of the injury, but auto- decreased CO. Rehab activities are not con-
traindicated during spainl shock and should
12 / 26
nomic functions are not af- be instituted if the patient's cardiopulmonary
fected status is stable.
28. A patient with a C7 spinal c. Take the patient's BP

cord injury undergoing re-
habilitation tells the nurse
he must have the flu
because he has a bad
headache and nausea. The
initial action of the nurse is
to
a. call the physician
b. check the patient's tem-
perature
c. take the patient's BP
d. elevate the HOB to 90 de-
grees
29. One indication for surgical D. evidence of continued compression of the

therapy of the patient with a cord is apparent
spinal cord injury is when Rationale: Although surgical treatment of
a. there is incomplete cord spinal cord injuries often depends on the pref-
lesion involvement erence of the health care provider, surgery
b. the ligaments that sup- is usually indicated when there is continued
port the spine are torn compression of the cord by extrinsic forces
c. a high cervical injury or when there is evidence of cord compres-
causes loss of respiratory sion. Other indications may include progres-
function sive neurologic deficit, compound fracture of
d. evidence of continued the vertebra, bony fragments, and penetrating
compression of the cord is wounds of the cord.
apparent
30. A patient is admitted to the a. maintaining a patent airway

emergency department with Rationale: The need for a patent airway is the
a possible cervical spinal first priority for any injured patient, and a high
cord injury following an au- cervical injury may decrease the gag reflex
tomobile crash. During the and ability to maintain an airway, as well as the
admission of the patient, the ability to breathe. Maintaining cervical stability
nurse places the highest pri-
13 / 26
ority on is then a consideration, along with assessing
a. maintaining a patent air- for other injuries and the patients neuro status.
way
b. assessing the patient for
head and other injuries
c. maintaining immobiliza-
tion of the cervical spine
d. assessing the patient's
motor and sensory function
31. A nurse is planning care A. prevention of further damage to the spinal

for a client who suffered cord
a spinal cord injury (SCI) Rationale: The greatest risk to the client during
involving a T12 fracture 1 the acute phase of a SCI is further damage
week ago. The client has no to the spinal cord. Therefore, when planning
muscle control of the low- care, the priority should be the prevention of
er limbs, bowel, or blad- further damage to the spinal cord by admin-
der. which of the following istration of corticosteroids, minimizing move-
should be the nurses' great- ment of the client until spinal stabilization is ac-
est priority? complished through either traction or surgery,
a. prevention of further dam- and adequate oxygenation of the client to de-
age to the spinal cord crease ischemia of the spinal cord.
b. prevention of contrac-
tures of the lower extremi-
ties
c. prevention of skin break-
down of areas that lack sen-
sation
d. prevention of postural hy-
potension when placing the
client in a wheelchair
32. Goals of rehabilitation for B, C, D, E

the patient with an injury at
the C6 level include (select
all that apply)
a. stand erect with leg brace
b. feed self with hand de-
vices
14 / 26
c. drive an electric wheel-
chair
d. assist with transfer activi-
ties
e. drive adapted van from
wheelchair
33. A nurse is caring for a client a. condom catheter

who experienced a cervi- Rationale: a client who has a cervical spinal
cal spine injury 3 months cord injury will also have a upper motor neuron
ago. Which of the following injury, which is manifested by a spastic blad-
types of bladder manage- der. because the bladder will empty on its own,
ment methods should the a condom catheter is an appropriate method
nurse use for this client? and is noninvasive.
a. condom catheter B & C are for flaccid bladder.
b. intermittent urinary
catheterization
c. crede's method
d. indwelling urinary
catheter
34. A patient is admitted with B. tetraplegia with total sensory loss

a spinal cord injury at the Rationale: At the C7 level, spinal shock is man-
C7 level. During assessment ifested by tetraplegia and sensory loss. The
the nurse identifies the pres- neurologic loss may be temporary or perma-
ence of spinal shock on find- nent. Paraplegia with sensory loss would oc-
ing cur at the level of T1. A hemiplegia occurs with
a. paraplegia with flaccid central (brain) lesions affecting motor neurons
paralysis and spastic tetraplegia occurs when spinal
b. tetraplegia with total sen- shock resolves.
sory loss
c. total hemiplegia with sen-
sory and motor loss
d. spastic tetraplegia with
loss of pressure sensation
35. During the patient's process A. helps the patient understand that working
of grieving for the losses re- through the grief will be a lifelong process
sulting from spinal cord in-
15 / 26
jury, the nurse
a. helps the patient under-
stand that working through
the grief will be a lifelong
process
b. should assist the patient
to move through all stages
of the mourning process to
acceptance
c. lets the patient know that
anger directed at the staff or
the family is not a positive
coping mechanism
d. facilitates the grieving
process so that it is com-
pleted by the time the pa-
tient is discharged from re-
habilitation
36. In planning community ed- D. adolescent and young adult men

ucation for prevention of Rationale: Spinnal cord injuries are highest in
spinal cord injuries, the young adult men between the ages of 15 and
nurse targets 30 and those who are impulsive or risk takers
a. elderly men in daily living. Other risk factors include alcohol
b. teenage girls and drug abuse as well as participation in
c. elementary school-age sports and occupational exposure to trauma
children or violence.
d. adolescent and young
adult men
37. In counseling patient with D. will probably be unable to have either psy-
spinal cord lesions regard- chogenic or reflexogenic erections with no
ing sexual function, the ejaculation or orgasm
nurse advises a male patient Rationale: Most patients with a complete low-
with a complete lower motor er motor neuron lesion are unable to have
neuron lesion that he either psychogenic or reflexogenic erections,
a. is most likely to have and alterative methods of obtaining sexual sat-
reflexogenic erections and isfaction may be suggested. Patients with in-
may experience orgasm if complete lower motor neuron lesions have the
16 / 26
ejaculation occurs highest possibility of successful psychogenic
b. may have uncontrolled re- erections with ejaculation, whereas patients
flex erections, but that or- with incomplete upper motor neuron lesions
gasm and ejaculation are are more likey to experience reflexogeic erec-
usually not possible tions with ejaculation. Patients with complete
c. has a lesion with the upper motor neuron lesions usually only have
greatest possibility of suc- reflex sexual function with rare ejaculation.
cessful psychogenic erec-
tion with ejaculation and or-
gasm
d. will probably be unable to
have either psychogenic or
reflexogenic erections with
no ejaculation or orgasm
38. A patient with paraplegia B. b. how to perform intermittent self-catheter-

has developed an irritable ization
bladder with reflex empty- Rationale: Intermittent self cath five to six
ing. The nurse teaches the times a day is the recommended method of
patient bladder management for the patient with a
a. hygiene care for an in- spinal cord injury because it more closely mim-
dwelling urinary catheter ics normal emptying and has less potential
b. how to perform intermit- for infectinon. The patient and family should
tent self-catheterization be taught the procedure using clean tech-
c. to empty the bladder nique, and if the patient has use of the arms,
with manual pelvic pressure self-cath is use during the acute phase to pre-
in coordination with reflex vent overdistention of the bladder and surgical
voiding patterns urinary diversions are used if urinary compli-
d. that a urinary diversion, cations occur.
such as an ileal conduit, is
the easiest way to handle
urinary elimination
39. A nurse is caring for a client D. muscle relaxants

who experienced a cervical Rationale: The client will still be in spinal shock
spine injury 24 hours ago. 24 hours following the injury. the client will
which of the following types not experience muscle spasms until after the
of prescribed medications spinal shock has resolved, making muscle re-
should the nurse clarify with laxants unnecessary at this time.
17 / 26
the provider?
a. glucocorticoids
b. plasma expanders
c. H2 antagonists
d. muscle relaxants
40. 27. When caring for a patient Correct Answer: C

who was admitted 24 hours Rationale: Edema around the area of injury
previously with a C5 spinal may lead to damage above the C4 level, so
cord injury, which nursing the highest priority is assessment of the pa-
action has the highest prior- tient's respiratory function. The other actions
ity? are also appropriate but are not as important
a. Continuous cardiac moni- as assessment of respiratory effort.
toring for bradycardia
b. Administration of methyl- Cognitive Level: Application Text Reference: p.
prednisolone (Solu-Medrol) 1602
infusion Nursing Process: Assessment NCLEX: Physi-
c. Assessment of respirato- ological Integrity
ry rate and depth
d. Application of pneumat-
ic compression devices to
both legs
41. 22. A 26-year-old patient Correct Answer: D

with a C8 spinal cord injury Rationale: Maintenance of sexuality is an im-
tells the nurse, "My wife and portant aspect of rehabilitation after spinal
I have always had a very ac- cord injury and should be handled by someone
tive sex life, and I am wor- with expertise in sexual counseling. Although
ried that she may leave me the patient should discuss these issues with
if I cannot function sexual- his wife, open communication about this issue
ly." The most appropriate re- may be difficult without the assistance of a
sponse by the nurse to the counselor. Sildenafil does assist with erectile
patient's comment is to dysfunction after spinal cord injury, but the pa-
a. advise the patient to talk tient's sexuality is not determined solely by the
to his wife to determine how ability to have an erection. Reflex erections are
she feels about his sexual common after upper motor neuron injury, but
function. these erections are uncontrolled and cannot
b. tell the patient that silde- be maintained during coitus.
nafil (Viagra) helps to de-
18 / 26
crease erectile dysfunction Cognitive Level: Application Text Reference: p.
in patients with spinal cord 1608
injury. Nursing Process: Implementation NCLEX:
c. inform the patient that Psychosocial Integrity
most patients with upper
motor neuron injuries have
reflex erections.
d. suggest that the patient
and his wife work with a
nurse specially trained in
sexual counseling.
42. 13. A patient with a neck Correct Answer: D

fracture at the C5 level is Rationale: Clinical manifestations of spinal
admitted to the intensive shock include decreased reflexes, loss of sen-
care unit (ICU) following ini- sation, and flaccid paralysis below the area
tial treatment in the emer- of injury. Hypotension, bradycardia, and warm
gency room. During initial extremities are evidence of neurogenic shock.
assessment of the patient, Involuntary spastic movements and hyperac-
the nurse recognizes the tive reflexes are not seen in the patient at this
presence of spinal shock on stage of spinal cord injury.
finding
a. hypotension, bradycardia, Cognitive Level: Comprehension Text Refer-
and warm extremities. ence: p. 1590
b. involuntary, spastic move- Nursing Process: Assessment NCLEX: Physi-
ments of the arms and legs. ological Integrity
c. the presence of hyperac-
tive reflex activity below the
level of the injury.
d. flaccid paralysis and lack
of sensation below the level
of the injury.
43. MULTIPLE RESPONSE Correct Answer: B, C, E, F

Rationale: The patient is at risk for brady-
1. When caring for a pa- cardia and poikilothermia caused by sympa-
tient who experienced a T1 thetic nervous system dysfunction and should
spinal cord transsection 2 have continuous cardiac monitoring and main-
days ago, which collabora- tenance of a relatively warm room tempera-
19 / 26
tive and nursing actions will ture. Gastrointestinal (GI) motility is decreased
the nurse include in the plan initially and NG suctioning is indicated. To
of care? (Select all that ap- avoid bladder distension, a retention catheter
ply.) is used during this acute phase. Stress ulcers
a. Endotracheal suctioning are a common complication but can be avoid-
b. Continuous cardiac mon- ed through the use of the H2 receptor blockers
itoring such as famotidine.
c. Avoidance of cool room
temperature Cognitive Level: Application Text Reference:
d. Nasogastric tube feeding pp. 1594-1595, 1597, 1603
e. Retention catheter care Nursing Process: Planning NCLEX: Physiolog-
f. Administration of H2 re- ical Integrity
ceptor blockers
44. 16. A patient with a T1 spinal Correct Answer: B

cord injury is admitted to Rationale: The patient with a T1 injury can
the intensive care unit (ICU). expect to retain full motor and sensory function
The nurse will teach the pa- of the arms. Use of only the shoulders is asso-
tient and family that ciated with cervical spine injury. Total loss of
a. use of the shoulders will respiratory function occurs with injuries above
be preserved. the C4 level and is permanent. Bradycardia is
b. full function of the pa- associated with injuries above the T6 level.
tient's arms will be retained.
c. total loss of respirato- Cognitive Level: Application Text Reference: p.
ry function may occur tem- 1594
porarily. Nursing Process: Implementation NCLEX:
d. elevations in heart rate Physiological Integrity
are common with this type
of injury.
45. 1. In which order will the Correct Answer: C, A, B, D

nurse perform the following Rationale: The first action should be to prevent
actions when caring for a further injury by stabilizing the patient's spinal
patient with possible cervi- cord. Maintenance of oxygenation by adminis-
cal spinal cord trauma who tration of 100% O2 is the second priority. Be-
is admitted to the emer- cause neurogenic shock is a possible compli-
gency department? cation, continuous monitoring of heart rhythm
a. Administer O2 using a and BP is indicated. CT scan to determine the
non-rebreathing mask. extent and level of injury is needed once initial
20 / 26
b. Monitor cardiac rhythm assessment and stabilization is accomplished.
and blood pressure.
c. Immobilize the patient's Cognitive Level: Application Text Reference: p.
head, neck, and spine. 1596
d. Transfer the patient to ra- Nursing Process: Implementation NCLEX:
diology for spinal CT. Physiological Integrity
46. 14. When caring for a pa- Correct Answer: B

tient who had a C8 spinal Rationale: The nurse has identified that the
cord injury 10 days ago and cough effort is poor, so the initial action should
has a weak cough effort, be to use assisted coughing techniques to im-
bibasilar crackles, and de- prove the ability to mobilize secretions. Admin-
creased breath sounds, the istration of oxygen will improve oxygenation,
initial intervention by the but the data do not indicate hypoxemia, and
nurse should be to oxygen will not help expel respiratory secre-
a. administer oxygen at 7 to tions. The use of the spirometer may improve
9 L/min with a face mask. respiratory status, but the patient's ability to
b. place the hands on the take deep breaths is limited by the loss of
epigastric area and push intercostal muscle function. Suctioning may be
upward when the patient needed if the patient is unable to expel secre-
coughs. tions by coughing but should not be the nurse's
c. encourage the patient to first action.
use an incentive spirome-
ter every 2 hours during the Cognitive Level: Application Text Reference: p.
day. 1602
d. suction the patient's oral Nursing Process: Implementation NCLEX:
and pharyngeal airway. Physiological Integrity
47. 20. The nurse discusses Correct Answer: D

long-range goals with a pa- Rationale: The patient with a C6 injury will be
tient with a C6 spinal cord in- able to use the hands to push a wheelchair on
jury. An appropriate patient flat, smooth surfaces. Because flexion of the
outcome is thumb and fingers is minimal, the patient will
a. transfers independently not be able to grasp a wheelchair during trans-
to a wheelchair. fer, drive a car with powered hand controls, or
b. drives a car with powered turn independently in bed.
hand controls.
c. turns and repositions self Cognitive Level: Application Text Reference: p.
independently when in bed. 1594
21 / 26
d. pushes a manual wheel- Nursing Process: Planning NCLEX: Physiolog-
chair on flat, smooth sur- ical Integrity
faces.
48. 18. A patient with a para- Correct Answer: A

plegia resulting from a T10 Rationale: Because the patient's bladder is
spinal cord injury has a neu- spastic and will empty in response to over-
rogenic reflex bladder. When stretching of the bladder wall, the most appro-
the nurse develops a plan of priate method is to avoid incontinence by emp-
care for this problem, which tying the bladder at regular intervals through
nursing action will be most intermittent catheterization. Assisting the pa-
appropriate? tient to the toilet will not be helpful because
a. Teaching the patient how the bladder will not empty. The Credé method
to self-catheterize is more appropriate for a bladder that is flac-
b. Assisting the patient to cid, such as occurs with a reflexic neurogenic
the toilet q2-3hr bladder. Catheterization after voiding will not
c. Use of the Credé method resolve the patient's incontinence.
to empty the bladder
d. Catheterization for resid- Cognitive Level: Application Text Reference: p.
ual urine after voiding 1605
Nursing Process: Planning NCLEX: Physiolog-
ical Integrity
49. Which is most important to A. Blood pressure of 88/60 mm Hg, pulse of 56

respond to in a patient pre- beats/minute
senting with a T3 spinal in- Neurogenic shock is a loss of vasomotor tone
jury? caused by injury, and it is characterized by
A. Blood pressure of 88/60 hypotension and bradycardia. The loss of sym-
mm Hg, pulse of 56 pathetic nervous system innervations causes
beats/minute peripheral vasodilation, venous pooling, and a
B. Deep tendon reflexes of decreased cardiac output. The other options
1+, muscle strength of 1+ can be expected findings and are not as signif-
C. Pain rated at 9 icant. Patients in neurogenic shock have pink
D. Warm, dry skin and dry skin, instead of cold and clammy, but
this sign is not as important as the vital signs.
50. The patient arrives in D. Use a logroll technique when moving the
the emergency department patient.
from a motor vehicle acci- When the head hits the windshield with
22 / 26
dent, during which the car enough force to shatter it, you must assume
ran into a tree. The patient neck or cervical spine trauma occurred and
was not wearing a seat belt, you need to maintain spinal precautions. This
and the windshield is shat- includes moving the patient in alignment as a
tered. What action is most unit or using a logroll technique during trans-
important for you to do? fers. The other options are important and are
A. Determine if the patient done after spinal precautions are applied.
lost consciousness.
B. Assess the Glasgow
Coma Scale (GCS) score.
C. Obtain a set of vital signs.
D. Use a logroll technique
when moving the patient.
51. One month after a spinal B. The left calf is 5 cm larger than the right calf.
cord injury, which finding is Deep vein thrombosis is a common prob-
most important for you to lem accompanying spinal cord injury during
monitor? the first 3 months. Pulmonary embolism is
A. Bladder scan indicates one of the leading causes of death. Common
100 mL. signs and symptoms are absent. Assessment
B. The left calf is 5 cm larger includes Doppler examination and measure-
than the right calf. ment of leg girth. The other options are not
C. The heel has a reddened, as urgent to deal with as potential deep vein
nonblanchable area. thrombosis.
D. Reflux bowel emptying.
52. Which clinical manifestation A. Bradycardia

do you interpret as repre- Neurogenic shock results from loss of vaso-
senting neurogenic shock in motor tone caused by injury and is charac-
a patient with acute spinal terized by hypotension and bradycardia. Loss
cord injury? of sympathetic innervation causes peripheral
A. Bradycardia vasodilation, venous pooling, and a decreased
B. Hypertension cardiac output.
C. Neurogenic spasticity
D. Bounding pedal pulses
53. 17. A male client with a 17. Answer D. The most frequent cause of
spinal cord injury is prone autonomic dysreflexia is a distended bladder.
to experiencing automatic Straight catheterization should be done every
23 / 26
dysreflexia. The nurse would 4 to 6 hours, and foley catheters should be
avoid which of the following checked frequently to prevent kinks in the tub-
measures to minimize the ing. Constipation and fecal impaction are oth-
risk of recurrence? er causes, so maintaining bowel regularity is
a. Strict adherence to a bow- important. Other causes include stimulation of
el retraining program the skin from tactile, thermal, or painful stimuli.
b. Keeping the linen wrin- The nurse administers care to minimize risk in
kle-free under the client these areas.
c. Preventing unnecessary
pressure on the lower limbs
d. Limiting bladder catheter-
ization to once every 12
hours
54. 10. For a male client 0. Answer C. The goal of treatment is to pre-
with suspected increased vent acidemia by eliminating carbon dioxide.
intracranial pressure (ICP), That is because an acid environment in the
a most appropriate respira- brain causes cerebral vessels to dilate and
tory goal is to: therefore increases ICP. Preventing respirato-
a. prevent respiratory alka- ry alkalosis and lowering arterial pH may bring
losis. about acidosis, an undesirable condition in this
b. lower arterial pH. case. It isn't necessary to maintain a PaO2 as
c. promote carbon dioxide high as 80 mm Hg; 60 mm Hg will adequately
elimination. oxygenate most clients.
d. maintain partial pressure
of arterial oxygen (PaO2)
above 80 mm Hg
55. 15. The nurse is position- 15. Answer B. The head of the client with in-
ing the female client with creased intracranial pressure should be posi-
increased intracranial pres- tioned so the head is in a neutral midline posi-
sure. Which of the following tion. The nurse should avoid flexing or extend-
positions would the nurse ing the client's neck or turning the head side
avoid? to side. The head of the bed should be raised
a. Head mildline to 30 to 45 degrees. Use of proper positions
b. Head turned to the side promotes venous drainage from the cranium
c. Neck in neutral position to keep intracranial pressure down.
d. Head of bed elevated 30 to
45 degrees
24 / 26
56. 16. A female client has 16. Answer D. Leakage of cerebrospinal fluid
clear fluid leaking from the (CSF) from the ears or nose may accompa-
nose following a basilar ny basilar skull fracture. CSF can be distin-
skull fracture. The nurse as- guished from other body fluids because the
sesses that this is cere- drainage will separate into bloody and yellow
brospinal fluid if the fluid: concentric rings on dressing material, called
a. Is clear and tests negative a halo sign. The fluid also tests positive for
for glucose glucose.
b. Is grossly bloody in ap-
pearance and has a pH of 6
c. Clumps together on the
dressing and has a pH of 7
d. Separates into concentric
rings and test positive of
glucose
57. 5. The nurse is working on 5. Answer A. The client who has had spinal
a surgical floor. The nurse surgery, such as laminectomy, must be
must logroll a male client fol- logrolled to keep the spinal column straight
lowing a: when turning. The client who has had a tho-
a. laminectomy. racotomy or cystectomy may turn himself or
b. thoracotomy. may be assisted into a comfortable position.
c. hemorrhoidectomy. Under normal circumstances, hemorrhoidec-
d. cystectomy. tomy is an outpatient procedure, and the client
may resume normal activities immediately af-
ter surgery.
58. A client with a spinal cord in- 4. limiting bladder cath to once q12h
jury is prone to experiencing (the most frequent cause of autonomic dys-
autonomic dysreflexia. The reflexia is a distended bladder . Straight cath
nurse should avoid which should be performed q4-6 hrs and foley cath
measure to minimize the should be checked frequently for kinks in tub-
risk of recurrence? ing . Constipation and fecal impaction are oth-
1. strict adherence to a bow- er causes, so maintaining bowel irregularity is
el retraining program important .
2. keeping the linen wrinkle
free under the client
3. avoiding unnecessary
25 / 26
4. limiting bladder catheter-
hours
59. A nurse is positioning a B. head turned to the side

client with increased ICP. (The head of a client with increased ICP
Which position would the should be positioned so that the head is in
nurse avoid? a neutral, midline position. The nurse should
A. head midline avoid flexing or extending the neck or turning
B. head turned to the side the head side to side . The head of the bed
C. neck in neutral position should be raised 30-45 degrees . Use of prop-
D. head of bed elevated er position promotes venous drainage from the
30-45 degrees cranium to keep ICP down)
60. A nurse is caring for a client increased temp, decreased pulse, decreasing
with increased intracranial respirations, and increasing bp
pressure (ICP). the nurse (a change in vital signs may be a late sign of
should monitor for what vi- increased ICP)
tal signs that would occur if
ICP is rising
61. A client recovering from D. exhaling during repositioning

a head injury is arous- (activities that increase intra-throacic and in-
able and participating in tra-abdominal pressures cause indirect eleva-
care. The nurse determines tion of the ICP. Exhaling during activities such
that the client understands as repositioning or pulling up in bed opens the
measures to prevent eleva- glottis, which prevents intra-thoracic pressure
tions in intracranial pres- from rising).
sure if the nurse observes
the client doing which of the
following activities?
A. blowing the nose
B. isometric exercises
C. coughing vigorously
D. exhaling during reposi-
tioning
26 / 26
SCI NCLEX style questions
Study online at https://quizlet.com/_5ie6zu
1. A 70-year-old patient is admit- . b. At the C7 level, spinal shock is manifested

ted after falling from his roof. by
He has a spinal cord injury at tetraplegia and sensory loss. The neurologic
the C7 level. What loss may be
findings during the assess- temporary or permanent. Paraplegia with
ment identify the presence of sensory loss
spinal shock? would occur at the level of T1. A hemiplegia
a. Paraplegia with a flaccid occurs with
paralysis central (brain) lesions affecting motor neu-
b. Tetraplegia with total sen- rons and spastic
sory loss tetraplegia occurs when spinal shock re-
c. Total hemiplegia with sen- solves
sory and motor loss
d. Spastic tetraplegia with
2. Which syndrome of incom- . a. In central cord syndrome, motor weak-

plete spinal cord lesion is de- ness and sensory
scribed as cord damage com- loss are present in both upper and lower
mon in the cervical region extremities, with
resulting in greater weakness upper extremities affected more than lower
in upper extremities than low- extremities.
er?
a. Central cord syndrome
b. Anterior cord syndrome
c. Posterior cord syndrome
d. Cauda equina and conus
medullaris syndromes
3. The patient is diagnosed with b. Brown-Séquard syndrome is character-

Brown-Séquard syndrome af- ized by ipsilateral
ter a knife wound to the spine. loss of motor function and position and vibra-
Which description tory sense
accurately describes this syn- and vasomotor paralysis with contralateral
drome? loss of pain
a. Damage to the most distal and temperature sensation below the level of
cord and nerve roots, result- the injury.
ing in flaccid paralysis of the Damage to the most distal cord and nerve
lower limbs and areflexic roots with
1 / 13
bowel and bladder flaccid paralysis of the lower limbs and are-
b. Spinal cord damage result- flexic bowel
ing in ipsilateral motor paral- and bladder is seen with cauda equine syn-
ysis and contralateral loss of drome or conus
pain and sensation below the medullaris syndrome. Posterior cord syn-
level of the lesion drome is rare, with
c. Rare cord damage resulting cord damage resulting in loss of propriocep-
in loss of proprioception be- tion below the
low the lesion level with reten- lesion level but retention of motor control and
tion of motor control and temperature
temperature and pain sensa- and pain sensation. Anterior cord syndrome
tion is often caused
d. Often caused by flexion in- by flexion injury, with acute compression of
jury with acute compression the cord
of cord resulting in complete resulting in complete motor paralysis and
motor paralysis and loss of loss of pain and
pain and temperature sensa- temperature sensation below the level of in-
tion below the level of injury jury but touch,
position, vibration, and motion remaining in-
tact.
4. What causes an initial incom- c. The primary injury of the spinal cord rarely
plete spinal cord injury to re- affects
sult in complete cord dam- the entire cord but the pathophysiology of
age? secondary
a. Edematous compression of injury may result in damage that is the same
the cord above the level of the as
injury mechanical severance of the cord. Complete
b. Continued trauma to the cord
cord resulting from damage dissolution occurs through autodestruction
to stabilizing ligaments of the cord by
c. Infarction and necrosis of hemorrhage, edema, and the presence of
the cord caused by edema, metabolites and
hemorrhage, and metabolites norepinephrine, resulting in anoxia and in-
d. Mechanical transection of farction of the
the cord by sharp vertebral cord. Edema resulting from the inflammatory
bone fragments after the ini- response
tial injury may compress the spinal cord as well as
increase the
2 / 13
damage as it extends above and below the
injury site
5. A patient with a spinal cord c. Spinal shock occurs in about half of all
injury has spinal shock. The people with
nurse plans care for the pa- acute spinal cord injury. In spinal shock, the
tient based on what knowl- entire
edge? cord below the level of the lesion fails to
a. Rehabilitation measures function,
cannot be initiated until resulting in a flaccid paralysis and hypomotil-
spinal shock has resolved. ity of most
b. The patient will need con- processes without any reflex activity. Return
tinuous monitoring for hy- of reflex
potension, tachycardia, and activity, although hyperreflexive and spastic,
hypoxemia. signals
c. Resolution of spinal shock the end of spinal shock. Rehabilitation activ-
is manifested by spasticity, ities are
hyperreflexia, and reflex emp- not contraindicated during spinal shock and
tying of the bladder. should be
d. The patient will have com- instituted if the patient's cardiopulmonary
plete loss of motor and sen- status is stable.
sory functions below the level Neurogenic shock results from loss of vascu-
of the injury but autonomic lar tone caused by the injury and is manifest-
functions are not affected. ed by hypotension,
peripheral vasodilation, and decreased car-
diac output
(CO). Sympathetic function is impaired be-
low the level
of the injury because sympathetic nerves
leave the
spinal cord at the thoracic and lumbar areas
and cranial
parasympathetic nerves predominate in con-
trol over
respirations, heart, and all vessels and or-
gans below the
injury, which includes autonomic functions.
6.
3 / 13
Two days following a spinal b. Until the edema and necrosis at the site of
cord injury, a patient asks the injury
continually about the extent are resolved in 72 hours to 1 week after the
of impairment that will result injury, it
from the injury. What is the is not possible to determine how much cord
best response by the nurse? damage is
a. "You will have more normal present from the initial injury, how much sec-
function when spinal shock ondary injury
resolves and the reflex arc re- occurred, or how much the cord was dam-
turns." aged by edema
b. "The extent of your injury that extended above the level of the original
cannot be determined until injury. The
the secondary injury to the return of reflexes signals only the end of
cord is resolved." spinal shock and
c. "When your condition is the reflexes may be inappropriate and exces-
more stable, MRI will be done sive, causing
to reveal the extent of the cord spasms that complicate rehabilitation.
damage."
d. "Because long-term reha-
bilitation can affect the return
of function, it will be years be-
fore we can tell what the
complete effect will be."
7. Priority Decision: The patient a. Spinal injury below C4 will result in di-
was in a traffic collision and is aphragmatic
experiencing loss of function breathing and usually hypoventilation from
below C4. Which effect decreased
must the nurse be aware of vital capacity and tidal volume from inter-
to provide priority care for the costal muscle
patient? impairment. The nurse's priority actions will
a. Respiratory diaphragmatic be to
breathing monitor rate, rhythm, depth, and effort of
b. Loss of all respiratory mus- breathing to
cle function observe for changes from the baseline and
c. Decreased response of the identify the
sympathetic nervous system need for ventilation assistance. Loss of all
d. GI hypomotility with para- respiratory
muscle function occurs above C4 and the
4 / 13
lytic ileus and gastric disten- patient requires
tion mechanical ventilation to survive. Although
the decreased
sympathetic nervous system response (from
injuries
above T6) and GI hypomotility (paralytic ileus
and gastric
distention) will occur (with injuries above T5),
they are
not the patient's initial priority needs.
8. A patient is admitted to the b. Neurogenic shock associated with cord

emergency department with a injuries
spinal cord injury at the level above the level of T6 greatly decreases the
of T2. Which finding is of effect of
most concern to the nurse? the sympathetic nervous system and brady-
a. SpO2 cardia and
of 92% hypotension occur. A heart rate of 42 bpm is
b. Heart rate of 42 bpm not adequate
c. Blood pressure of 88/60 to meet the oxygen needs of the body. While
mm Hg low, the
d. Loss of motor and sensory blood pressure is not at a critical point. The
function in arms and legs oxygen
saturation is satisfactory and the motor and
sensory losses
are expected.
9. The patient's spinal cord in- c. With the injury at T4, the highest-level re-
jury is at T4. What is the high- alistic goal for
est-level goal of rehabilitation this patient is to be able to be independent in
that is realistic for this patient self-care and
to have? wheelchair use because arm function will not
a. Indoor mobility in manual be affected.
wheelchair Indoor mobility in a manual wheelchair will
b. Ambulate with crutches be achievable
and leg braces but it is not the highest-level goal. Ambulating
c. Be independent in self-care with
and wheelchair use crutches and leg braces can be achieved
d. Completely independent only by patients
5 / 13
ambulation with short leg with injuries in T6-12 area. Independent am-
braces and canes bulation with
short leg braces and canes could occur for a
patient with
an L3-4 injury.
10. What is one indication for ear- d. Although surgical treatment of spinal cord
ly surgical therapy of the pa- injuries often
tient with a spinal cord injury? depends on the preference of the health care
a. There is incomplete cord le- provider,
sion involvement. surgery is usually indicated when there is
b. The ligaments that support continued
the spine are torn. compression of the cord by extrinsic forces
c. A high cervical injury caus- or when there
es loss of respiratory func- is evidence of cord compression. Other indi-
tion. cations may
d. Evidence of continued include progressive neurologic deficit, com-
compression of the cord is pound fracture
apparent. of the vertebra, bony fragments, and pene-
trating wounds
of the cord.
11. Priority Decision: A patient a. The need for a patent airway is the first
is admitted to the emergency priority for any
department with a possible injured patient and a high cervical injury may
cervical spinal cord injury decrease the
following an automobile gag reflex and the ability to maintain an air-
crash. During admission of way as well as
the patient, what is the high- the ability to breathe. Maintaining cervical
est priority for the nurse? stability is then
a. Maintaining a patent airway a consideration, along with assessing for oth-
b. Maintaining immobilization er injuries and
of the cervical spine the patient's neurologic status.
c. Assessing the patient for
d. Assessing the patient's
12.
6 / 13
Without surgical stabilization, c. The development of better surgical stabi-
what method of immobiliza- lization has
tion for the patient with a cer- made surgery the more frequent treatment of
vical spinal cord injury cervical
should the nurse expect to be injuries. However, when surgery cannot be
used? done,
a. Kinetic beds skeletal traction with the use of Crutchfield,
b. Hard cervical collar Vinke, or
c. Skeletal traction with skull other types of skull tongs is required to im-
tongs mobilize
d. Sternal-occipital-mandibu- the cervical vertebrae, even if a fracture has
lar immobilizer brace not
occurred. Hard cervical collars or a ster-
nal-occipitalmandibular
immobilizer brace may be used after cervical
stabilization surgery or for minor injuries or
stabilization
during emergency transport of the patient.
Sandbags
may also be used temporarily to stabilize the
neck
during insertion of tongs or during diagnostic
testing
immediately following the injury. Special turn-
ing or
kinetic beds may be used to turn and mobi-
lize patients
who are in cervical traction.
13. The health care provider has c. Dopamine is a vasopressor that is used to
ordered IV dopamine (In- maintain
tropin) for a patient in the blood pressure during states of hypotension
emergency department with a that occur
spinal cord injury. The nurse during neurogenic shock associated with
determines that the drug is spinal cord
having the desired effect injury. Atropine would be used to treat brady-
when what is observed in pa- cardia. The
tient temperature reflects some degree of poikilo-
assessment?
7 / 13
a. Heart rate of 68 bpm thermism but
b. Respiratory rate of 24 this is not treated with medications.
c. Blood pressure of 106/82
mm Hg
d. Temperature of 96.8°F
(36.0°C)
14. Priority Decision: During as- c. Because pneumonia and atelectasis are
sessment of a patient with a potential
spinal cord injury, the nurse problems related to ineffective coughing and
determines that the patient the loss of
has intercostal and abdominal muscle function,
a poor cough with diaphrag- the nurse
matic breathing. Based on should assess the patient's breath sounds
this finding, what should be and respiratory
the nurse's first action? function to determine whether secretions are
a. Institute frequent turning being retained
and repositioning. or whether there is progression of respiratory
b. Use tracheal suctioning to impairment.
remove secretions. Suctioning is not indicated unless lung
c. Assess lung sounds and sounds indicate
respiratory rate and depth. retained secretions. Position changes will
d. Prepare the patient for en- help to mobilize
dotracheal intubation and me- secretions. Intubation and mechanical venti-
chanical ventilation lation are used
if the patient becomes exhausted from la-
bored breathing or
if arterial blood gases (ABGs) deteriorate.
15. Following a T2 spinal cord in- d. During the first 2 to 3 days after a spinal
jury, the patient develops par- cord injury,
alytic ileus. While this condi- paralytic ileus may occur and nasogastric
tion is present, what should suction must be
the nurse anticipate that the used to remove secretions and gas from the
patient will need? GI tract until
a. IV fluids peristalsis resumes. IV fluids are used to
b. Tube feedings maintain fluid
c. Parenteral nutrition balance but do not specifically relate to par-
d. Nasogastric suctioning alytic ileus.
8 / 13
Tube feedings would be used only for pa-
tients who have
difficulty swallowing and not until peristalsis
returns.
Parenteral nutrition would be used only if the
paralytic
ileus was unusually prolonged.
16. How is urinary function main- a. During the acute phase of spinal cord in-
tained during the acute phase jury, the bladder
of spinal cord injury? is hypotonic, causing urinary retention with
a. An indwelling catheter the risk
b. Intermittent catheterization for reflux into the kidney or rupture of the
c. Insertion of a suprapubic bladder. An
catheter indwelling catheter is used to keep the blad-
d. Use of incontinent pads to der empty and
protect the skin to monitor urinary output. Intermittent
catheterization
or other urinary drainage methods may be
used in longterm
bladder management. Use of incontinent
pads is
inappropriate because they do not help the
bladder to
empty
17. A week following a spinal b. When spinal shock ends, reflex movement
cord injury at T2, a patient and spasms
experiences movement in his will occur, which may be mistaken for return
leg and tells the nurse that he of function;
is however, with the resolution of edema, some
recovering some function. normal
What is the nurse's best re- function may also occur. It is important when
sponse to the patient? movement
a. "It is really still too soon to occurs to determine whether the movement
know if you will have a return is voluntary
of function." and can be consciously controlled, which
b. "That could be a really posi- would indicate
tive finding. Can you show me some return of function.
9 / 13
the movement?"
c. "That's wonderful. We will
more frequently now."
d. "I'm sorry but the move-
ment is only a reflex and does
not indicate normal function."
18. Priority Decision: A patient a. 5; b. 2; c. 6; d. 3; e. 1; f. 4. The patient is

with a spinal cord injury sud- experiencing
denly experiences a throb- autonomic dysreflexia. The initial response
bing headache, flushed skin, by the
and nurse should be to elevate the head of bed
diaphoresis above the level of (HOB) to
injury. After checking the pa- decrease blood pressure (BP) and then to
tient's vital signs and finding remove noxious stimulation. Frequently the
a systolic blood pressure trigger is bladder distention,
of 210 and a heart rate of which can be dealt with quickly. The physi-
48 bpm, number the follow- cian needs
ing nursing actions in order of to be notified as soon as possible and, de-
priority from highest to low- pending on
est the communication system available to the
(begin with number 1 as first nurse, he or
priority). she should have the call placed. Meanwhile,
__________ a. Administer or- the nurse
dered prn nifedipine (Procar- should stay with the patient and loosen any
dia). restrictive
__________ b. Check for blad- clothing. The physician may order an antihy-
der distention. pertensive
__________ c. Document the and documentation should be an accurate
occurrence, treatment, and and thorough
response. description of the entire episode
__________ d. Place call to
physician.
__________ e. Raise the head
of bed (HOB) to 45 degrees or
above.
__________ f. Loosen tight
clothing on the patient.
10 / 13
19. A patient with paraplegia has . b. Intermittent self-catheterization five to six
developed an irritable bladder times a day is
with reflex emptying. What the recommended method of bladder man-
will be most helpful for the agement for the
nurse to teach the patient? patient with a spinal cord injury and reflexic
a. Hygiene care for an in- neurogenic
dwelling urinary catheter bladder because it more closely mimics nor-
b. How to perform intermittent mal emptying
self-catheterization and has less potential for infection. The pa-
c. To empty the bladder with tient and family
manual pelvic pressure in co- should be taught the procedure using clean
ordination with reflex voiding technique
patterns and if the patient has use of the arms,
d. That a urinary diversion, self-catheterization
such as an ileal conduit, is the should be performed. Indwelling catheteriza-
easiest way to handle urinary tion is used
elimination during the acute phase to prevent overdis-
tention of the
bladder and surgical urinary diversions are
used if urinary
complications occur.
20. In counseling patients with d. Most patients with a complete lower motor
spinal cord lesions regarding neuron lesion
sexual function, how should are unable to have either psychogenic or
the nurse advise a male pa- reflexogenic
tient erections and alternative methods of obtain-
with a complete lower motor ing sexual
neuron lesion? satisfaction may be suggested. Patients with
a. He is most likely to have re- incomplete
flexogenic erections and may lower motor neuron lesions have the highest
experience orgasm if ejacula- possibility of
tion occurs. successful psychogenic erections with ejac-
b. He may have uncontrolled ulation whereas
reflex erections but orgasm patients with incomplete upper motor neuron
and ejaculation are usually lesions are
not possible. more likely to experience reflexogenic erec-
c. He has a lesion with the tions with
greatest possibility of suc- ejaculation. Patients with complete upper
11 / 13
cessful psychogenic erection motor neuron
with ejaculation and orgasm. lesions usually have only reflex sexual func-
d. He will probably be unable tion with rare
to have either psychogenic or ejaculation.
reflexogenic erections and no
ejaculation or orgasm
21. During the patient's process a. Working through the grief process is a
of grieving for the losses re- lifelong process
sulting from spinal cord in- that is triggered by new experiences, such as
jury, what should the nurse marriage,
do? child rearing, employment, or illness, which
a. Help the patient to under- the patient
stand that working through must adjust to throughout life within the con-
the grief will be a lifelong text of
process. his or her disability. The goal of recovery is
b. Assist the patient to move related to
through all stages of the adjustment rather than acceptance and
mourning process to accep- many patients do
tance. not experience all components of the grief
c. Let the patient know that process. During
anger directed at the staff or the anger phase, patients should be allowed
the family is not a positive outbursts and
coping mechanism. the nurse may use humor to displace some
d. Facilitate the grieving of the patient's
process so that it is complet- anger.
ed by the time the patient
is discharged from rehabilita-
tion.
22. A patient with a metastatic b. Most metastatic or secondary tumors are

tumor of the spinal cord is extradural
scheduled for removal of the lesions in which treatment, including surgery,
tumor by a laminectomy. In is palliative.
planning postoperative care Primary spinal tumors may be removed with
for the patient, what should the goal of
the nurse recognize? cure. Most tumors of the spinal cord are
a. Most cord tumors cause au- slow-growing, do
todestruction of the cord as in not cause autodestruction, and, if removal is
12 / 13
traumatic injuries. possible, can
b. Metastatic tumors are com- have complete function restored. Radiation
monly extradural lesions that is used to treat
are treated palliatively. metastatic tumors that are sensitive to radia-
c. Radiation therapy is rou- tion and that
tinely administered follow- have caused only minor neurologic deficits in
ing surgery for all malignant the patient.
spinal cord tumors. Radiation is also used as adjuvant therapy to
d. Because complete removal surgery for
of intramedullary tumors is intramedullary tumors
not possible, the surgery is
considered palliative.
13 / 13
Spinal Cord Injury NCLEX Questions
Study online at https://quizlet.com/_brbm4s

2. A hospitalized patient with Correct Answer: 4

a C7 cord injury begins to Rationale: Spinal shock is a condition almost
yell "I can't feel my legs any- half the people with acute spinal injury ex-
more." Which is the most perience. It is characterized by a temporary
appropriate action by the loss of reflex function below level of injury,
nurse? and includes the following symptomatology:
1. Remind the patient of her flaccid paralysis of skeletal muscles, loss of
injury and try to comfort her. sensation below the injury, and possibly bowel
2. Call the healthcare and bladder dysfunction and loss of ability to
provider and get an order for perspire below the injury level. In this case,
radiologic evaluation. the nurse should explain to the patient what is
3. Prepare the patient for happening.
surgery, as her condition is
worsening.
4. Explain to the patient that
this could be a common,
temporary problem.
3. The nurse is caring Correct Answer: 3

for a patient with in- Rationale: Suctioning further increases in-
creased intracranial pres- tracranial pressure; therefore, suctioning
sure (IICP). The nurse re- should be done to maintain a patent airway
alizes that some nursing but not as a matter of routine. Maintaining pa-
1 / 24
actions are contraindicated tient comfort by frequent repositioning as well
with IICP. Which nursing ac- as keeping the head elevated 30 degrees will
tion should be avoided? help to prevent (or even reduce) IICP. Keeping
1. Reposition the patient the patient properly oxygenated may also help
every two hours. to control ICP.
2. Position the patient with
the head elevated 30 de-
grees.
3. Suction the airway every
two hours per standing or-
ders.
4. Provide continuous oxy-
gen as ordered.
4. A patient with a spinal cord Correct Answer: 2,4,5

injury (SCI) is admitted to Rationale: The healthcare provider is respon-
the unit and placed in trac- sible for initial applying of the traction device.
tion. Which of the following The weights on the traction device must not
actions is the nurse respon- be changed without the order of a healthcare
sible for when caring for this provider. When caring for a patient in traction,
patient? the nurse is responsible for assessment and
Select all that apply. care of the skin due to the increased risk of
1. modifying the traction skin breakdown. The patient in traction is likely
weights as needed to experience pain and the nurse is responsi-
2. assessing the patient's ble for assessing this pain and administering
skin integrity the appropriate analgesic as ordered. Passive
3. applying the traction upon range of motion helps prevent contractures;
admission this is often performed by a physical therapist
4. administering pain med- or a nurse.
ication
5. providing passive range
of motion

2 / 24
stridor
4. diarrhea
5. fecal impaction
6. An unconscious patient re- Correct Answer: 1,2,5

ceiving emergency care fol- Rationale: In the emergency setting, all pa-
lowing an automobile crash tients who have sustained a trauma to the
accident has a possible head or spine, or are unconscious should be
spinal cord injury. What treated as though they have a spinal cord
guidelines for emergency injury. Immobilizing the neck, maintaining a
care will be followed? supine position and securing the patient's
Select all that apply. head to prevent movement are all basic guide-
1. Immobilize the neck using lines of emergency care. Placement on the
rolled towels or a cervical ventilator and raising the head of the bed will
collar. be considered after admittance to the hospital.
in a supine position
on a ventilator.
4. The head of the bed will be
elevated.
5. The patient's head will be
secured with a belt or tape
secured to the stretcher.

3 / 24
8. Which patient is at highest Correct Answer: 1

risk for a spinal cord injury? Rationale: The three major risk factors for
1. 18-year-old male with a spinal cord injuries (SCI) are age (young
prior arrest for driving while adults), gender (higher incidence in males),
intoxicated (DWI) and alcohol or drug abuse. Females tend to
2. 20-year-old female with a engage in less risk-taking behavior than young
history of substance abuse men.
3. 50-year-old female with
osteoporosis
4. 35-year-old male who
coaches a soccer team
9. The nurse understands that Correct Answer: 2

when the spinal cord is in- Rationale: Within 24 hours necrosis of both
jured, ischemia results and gray and white matter begins if ischemia has
edema occurs. How should been prolonged and the function of nerves
the nurse explain to the pa- passing through the injured area is lost. Be-
tient the reason that the ex- cause the edema extends above and below
tent of injury cannot be de- the area affected, the extent of injury cannot
termined for several days to be determined until after the edema is con-
a week? trolled. Neurons do not regenerate, and the
1. "Tissue repair does not edema is the factor that limits the ability to
begin for 72 hours." predict extent of injury.
2. "The edema extends the
level of injury for two cord
segments above and below
the affected level."
3. "Neurons need time to re-
generate so stating the in-
jury early is not predictive
of how the patient progress-
es."
4. "Necrosis of gray and
white matter does not occur
until days after the injury."
4 / 24
10. A patient with a spinal Correct Answer: 4
cord injury (SCI) has com- Rationale: Quadriplegia describes complete
plete paralysis of the up- paralysis of the upper extremities and com-
per extremities and complete paralysis of the lower part of the body.
plete paralysis of the lower Hemiplegia describes paralysis on one side of
part of the body. The nurse the body. Paresthesia does not indicate paral-
should use which medical ysis. Paraplegia is paralysis of the lower body.
term to adequately describe
this in documentation?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia
11. Which of the following nurs- Correct Answer: 4

ing actions is appropriate Rationale: A patient who has undergone a
for preventing skin break- laminectomy needs to be turned by log rolling
down in a patient who to prevent pressure on the area of surgery.
has recently undergone a An air mattress will help prevent skin break-
laminectomy? down but the patient still needs to be turned
1. Provide the patient with an frequently. Placing pillows under the patient
air mattress. can help take pressure off of one side but the
2. Place pillows under pa- patient still needs to change positions often.
tient to help patient turn. Teaching the patient to grasp the side rail will
3. Teach the patient to grasp cause the spine to twist, which needs to be
the side rail to turn. avoided.
4. Use the log roll to turn the
patient to the side.

5 / 24
following?
1. paralysis
2. spinal shock
13. While caring for the pa- Correct Answer: 3

tient with spinal cord injury Rationale: Autonomic dysreflexia is an emer-
(SCI), the nurse elevates the gency that requires immediate assessment
head of the bed, removes and intervention to prevent complications of
compression stockings, and extremely high blood pressure. Additional
continues to assess vital nursing assistance will be needed and a col-
signs every two to three league needs to reach the physician stat.
minutes while searching for
the cause in order to prevent
loss of consciousness or
death. By practicing these
interventions, the nurse is
avoiding the most danger-
ous complication of auto-
nomic dysreflexia, which is
1. hypoxia
2. bradycardia
3. elevated blood pressure
4. tachycardia
14. A patient is admitted to D. loss of sympathetic nervous system inner-

the hospital with a CD4 vation resulting in peripheral vasodilation
spinal cord injury after a mo-
torcycle collision. The pa-
tient's BP is 83/49, and his
pulse is 39 beats/min, and
he remains orally intubat-
ed. The nurse identifies this
6 / 24
pathophysiologic response
as caused by
a. increased vasomotor tone
after injury
b. a temporary loss of sen-
sation and flaccid paralysis
below the level of injury
c. loss of parasympathet-
ic nervous system innerva-
tion resulting in vasocon-
striction
d. loss of sympathetic ner-
vous system innervation re-
sulting in peripheral vasodi-
lation
15. A nurse is caring for a client B. sit the client upright in bed
with a spinal cord injury who Rationale: The greatest risk to the client is ex-
reports a severe headache periencing a cerebrovascular accident (stroke)
and is sweating profuse- secondary to elevated BP. The first action by
ly. vital signs include BP the nurse is elevate the head of the bed until
220/110, apical heart rate the client is in an upright position. this will lower
of 54/min. Which of the fol- the BP secondary to postural hypotension.
lowing acctions should the
nurse take first?
a. notify the provider
b. sit the client upright in
bed
c. check the client's urinary
catheter for blockage
d. administer antihyperten-
sive medication
16. Following a T2 spinal cord D. nasogastric suctioning

injury, the patient develops Rationale: During the first 2 to 3 days after a
paralytic ileus. While this spinal cord injury, paralytic ileus may occur,
condition is present, the and NG suction must be used to remove se-
nurse anticipates that the cretions and gas from the GI tract until peri-
patient will need stalsis resumes. IV fluids are used to maintain
7 / 24
a. IV fluids fluid balance but do not specifically relate to
b. tube feedings paralytic ileus. Tube feedings would be used
c. parenteral nutrition only for patients who had difficulty swallowing
d. nasogastric suctioning and not until peristalsis is returned; PN would
be used only if the paralytic ileus was unusally
prolonged.
17. An initial incomplete spinal C. c. infarction and necrosis of the cord caused
cord injury often results in by edema, hemorrhage, and metabolites
complete cord damage be- Rationale: The primary injury of the spinal cord
cause of rarely affects the entire cord, but the patho
a. edematous compression of secondary injury may result in damage
of the cord above the level of that is the same as mechanical severance of
the injury the cord. Complete cord dissolution occurs
b. continued trauma to the through autodestruction of the cord by hemor-
cord resulting from damage rhage, edema, and the presence of metabo-
to stabilizing ligaments lites and norepinephrine. resulting in anoxia
c. infarction and necrosis of and infarction of the cord. Edema resulting
the cord caused by edema, from the inflammatory response may increase
hemorrhage, and metabo- the damage as it extends above and below the
lites injury site.
d. mecheanical transection
of the cord by sharp ver-
tebral bone fragments after
the initial injury
18. Two days following a spinal B. the extent of your injury cannot be deter-
cord injury, a patient asks mined until the secondary injury to the cord is
continually about the extent resolved
of impairment that will result Rationale: Until the edema and necrosis at the
from the injury. The best re- site of the injury are resolved in 72 hours to
sponse by the nurse is, 1 week after the injury, it is not possible to
a. you will have more normal determine how much cord damage is present
function when spinal shock from the initial injury, how much secondary
resolves and the reflex arc injury occurred, or how much the cord was
returns damaged by edema that extended above the
b. the extent of your injury level of the original injury. The return of reflexes
cannot be determined until signals only the end of spinal shock, and the
the secondary injury to the
8 / 24
cord is resolved reflexes may be inappropriate and excessive,
c. when your condition is causing spasms that complicate rehab.
more stable, an MRI will be
done that can reveal the ex-
tent of the cord damage
d. because long-term reha-
bilitation can affect the re-
turn of tunction, it will be
years before we can tell
when the complete effect
will be
19. A week following a spinal B. the could be a really positive finding. can
cord injury at T2, a patient you show me the movement
experiences movement in Rationale: in 1 week following a spinal cord
his leg and tells the nurse he injury, there may be a resolution of the ede-
is recovering some function. ma of the injury and an end to spinal shock.
The nurses' best response When spinal shock ends, reflex movement and
to the patient is, spasms will occur, which may be mistaken
a. it is really still too soon for return of function, but with the resolution
to know if you will have a of edema, some normal function may also
return of function occur. it is important when movement occurs
b. the could be a really pos- to determine whether the movement is volun-
itive finding. can you show tary and can be consciously controlled, which
me the movement would indicate some return of function.
c. that's wonderful. we will
more frequently now
d. im sorry, but the move-
ment is only a reflex and
does not indicate normal
function
20. Urinary function during the A. an indwelling catheterization

acute phase of spinal cord
injury is maintained with
b. intermittent catheteriza-
tion
9 / 24
c. insertion of a suprapubic
catheter
d. use of incontinent pads to
protect the skin

c. stress ulcer
22. During assessment of a pa- C. assess lungs sounds and respiratory rate
tient with a spinal cord in- and depth
jury, the nurse determines Rationale: Because pneumonia and atelec-
that the patient has a poor tasis are potential problems RT ineffective
cough with diaphragmatic coughing function, the nurse should assess
breathing. Based on this the patient's breath sound and resp function
finding, the nurses' first ac- to determine whether secretions are being re-
tion should be to tained or whether there is progression of resp
a. initiate frequent turning impairment. Suctioning is not indicated unless
and repositioning lung sounds indicate retained secretions: posi-
b. use tracheal suctioning to tion changes will help mobilize secretions. In-
remove secretions tubation and mechanical ventilation are used
c. assess lung sounds and if the patient becomes exhausted from labored
respiratory rate and depth breathing or if ABGs deteriorate.
d. prepare the patient for
endotracheal intubation and
mechanical ventilation
23. The healthcare provider has C. BP of 106/82

ordered IV dopamine (In- Rationale: Dopamine is a vasopressor that is
tropin) for a patient in used to maintain BP during states of hypoten-
the emergency deparement sion that occur during neurogenic shock asso-
with a spinal cord injury. ciated with spinal cord injury. Atropine would
10 / 24
The nurse determines that be used to treat bradycardia. The T reflects
the drug is having the de- some degree of poikilothermism, but this is not
sired effect when assess- treated with medications.
ment findings include
a. pulse rate of 68
c. BP of 106/82
d. temperature of 96.8

25. Without surgical stabiliza- C. skeletal traction with skull tongs

tion, immobilization and Rationale: Cervical injuries usually require
traction of the patient with skeletal traction with the use of Crutchfield,
a cervical spinal cord injury Vinke, or other types of skull tongs to immobi-
most frequently requires the lize the cervical vertebrae, even if fracture has
use of not occurred. Hard cervical collars are used
a. kinetic beds for minor injuries or for stabilization during
b. hard cervical collars emergency transport of the patient. Sandbags
c. skeletal traction with skull are also used temporarily to stabilize the neck
tongs during insertion of tongs or during diagnostic
d. sternal-occipi- testing immediately following the injury. Spe-
tal-mandibular immobilizer cial turning or kinetic beds may be used to
(SOMI) brace turn and mobilize patients who are in cervical
traction.
26. A patient with a spinal cord C. c. resolution of spinal shock is manifested

injury has spinal shock. The by spasticity, hyperreflexia, and reflex empty-
nurse plans care for the pa- ing of the bladder
11 / 24
tient based on the knowl- Rationale: Spinal shock occurs in about half
edge that of all people with acute spinal cord injury. In
a. rehabilitation measures spinal shock, the entire cord below the level of
cannot be initiated until the lesion fails to function, resulting in a flaccid
spinal shock has resolved paralysis and hypomotility of most processes
b. the patient will need con- without any reflex activity. Return of reflex ac-
tinuous monitoring for hy- tivity signals the end of spinal shock. Sympa-
potension, tachycardia, and thetic function is impaired belwo the level of
hypoxemia the injury because sympathetic nerves leave
c. resolution of spinal shock the spinal cord at the thoracic and lumbar ar-
is manifested by spastici- eas, and cranial parasympathetic nerves pre-
ty, hyperreflexia, and reflex dominate in control over respirations, heart,
emptying of the bladder and all vessels and organ below the injury.
d. the patient will have com- Neurogenic shock results from loss of vascular
plete loss of motor and sen- tone caused by the injury and is manifested
sory functions below the by hypotension, peripheral vasodilation, and
level of the injury, but auto- decreased CO. Rehab activities are not con-
nomic functions are not af- traindicated during spainl shock and should
fected be instituted if the patient's cardiopulmonary
status is stable.
27. A patient with a C7 spinal c. Take the patient's BP

cord injury undergoing re-
habilitation tells the nurse
he must have the flu
because he has a bad
initial action of the nurse is
to
a. call the physician
perature
c. take the patient's BP
d. elevate the HOB to 90 de-
grees
28. One indication for surgical D. evidence of continued compression of the

therapy of the patient with a cord is apparent
spinal cord injury is when Rationale: Although surgical treatment of
12 / 24
a. there is incomplete cord spinal cord injuries often depends on the pref-
lesion involvement erence of the health care provider, surgery
b. the ligaments that sup- is usually indicated when there is continued
port the spine are torn compression of the cord by extrinsic forces
c. a high cervical injury or when there is evidence of cord compres-
causes loss of respiratory sion. Other indications may include progres-
function sive neurologic deficit, compound fracture of
d. evidence of continued the vertebra, bony fragments, and penetrating
compression of the cord is wounds of the cord.
apparent
29. A patient is admitted to the a. maintaining a patent airway

emergency department with Rationale: The need for a patent airway is the
a possible cervical spinal first priority for any injured patient, and a high
cord injury following an au- cervical injury may decrease the gag reflex
tomobile crash. During the and ability to maintain an airway, as well as the
admission of the patient, the ability to breathe. Maintaining cervical stability
nurse places the highest pri- is then a consideration, along with assessing
ority on for other injuries and the patients neuro status.
a. maintaining a patent air-
way
b. assessing the patient for
c. maintaining immobiliza-
tion of the cervical spine
d. assessing the patient's
30. A nurse is planning care A. prevention of further damage to the spinal

for a client who suffered cord
a spinal cord injury (SCI) Rationale: The greatest risk to the client during
involving a T12 fracture 1 the acute phase of a SCI is further damage
week ago. The client has no to the spinal cord. Therefore, when planning
muscle control of the low- care, the priority should be the prevention of
er limbs, bowel, or blad- further damage to the spinal cord by admin-
der. which of the following istration of corticosteroids, minimizing move-
should be the nurses' great- ment of the client until spinal stabilization is ac-
est priority? complished through either traction or surgery,
a. prevention of further dam-
13 / 24
age to the spinal cord and adequate oxygenation of the client to de-
b. prevention of contrac- crease ischemia of the spinal cord.
tures of the lower extremi-
ties
c. prevention of skin break-
down of areas that lack sen-
sation
d. prevention of postural hy-
potension when placing the
31. Goals of rehabilitation for B, C, D, E

the patient with an injury at
the C6 level include (select
all that apply)
a. stand erect with leg brace
b. feed self with hand de-
vices
c. drive an electric wheel-
chair
d. assist with transfer activi-
ties
e. drive adapted van from
wheelchair
32. A nurse is caring for a client a. condom catheter

who experienced a cervi- Rationale: a client who has a cervical spinal
cal spine injury 3 months cord injury will also have a upper motor neuron
ago. Which of the following injury, which is manifested by a spastic blad-
types of bladder manage- der. because the bladder will empty on its own,
ment methods should the a condom catheter is an appropriate method
nurse use for this client? and is noninvasive.
a. condom catheter B & C are for flaccid bladder.
b. intermittent urinary
catheterization
c. crede's method
d. indwelling urinary
catheter
14 / 24
33. A patient is admitted with B. tetraplegia with total sensory loss
a spinal cord injury at the Rationale: At the C7 level, spinal shock is man-
C7 level. During assessment ifested by tetraplegia and sensory loss. The
the nurse identifies the pres- neurologic loss may be temporary or perma-
ence of spinal shock on find- nent. Paraplegia with sensory loss would oc-
ing cur at the level of T1. A hemiplegia occurs with
a. paraplegia with flaccid central (brain) lesions affecting motor neurons
paralysis and spastic tetraplegia occurs when spinal
b. tetraplegia with total sen- shock resolves.
sory loss
c. total hemiplegia with sen-
sory and motor loss
d. spastic tetraplegia with
34. During the patient's process A. helps the patient understand that working
of grieving for the losses re- through the grief will be a lifelong process
sulting from spinal cord in-
jury, the nurse
a. helps the patient under-
stand that working through
the grief will be a lifelong
process
b. should assist the patient
to move through all stages
of the mourning process to
acceptance
c. lets the patient know that
anger directed at the staff or
the family is not a positive
coping mechanism
d. facilitates the grieving
process so that it is com-
pleted by the time the pa-
tient is discharged from re-
habilitation
35. In planning community ed- D. adolescent and young adult men

ucation for prevention of Rationale: Spinnal cord injuries are highest in
15 / 24
spinal cord injuries, the young adult men between the ages of 15 and
nurse targets 30 and those who are impulsive or risk takers
a. elderly men in daily living. Other risk factors include alcohol
b. teenage girls and drug abuse as well as participation in
c. elementary school-age sports and occupational exposure to trauma
children or violence.
d. adolescent and young
adult men
36. In counseling patient with D. will probably be unable to have either psy-
spinal cord lesions regard- chogenic or reflexogenic erections with no
ing sexual function, the ejaculation or orgasm
nurse advises a male patient Rationale: Most patients with a complete low-
with a complete lower motor er motor neuron lesion are unable to have
neuron lesion that he either psychogenic or reflexogenic erections,
a. is most likely to have and alterative methods of obtaining sexual sat-
reflexogenic erections and isfaction may be suggested. Patients with in-
may experience orgasm if complete lower motor neuron lesions have the
ejaculation occurs highest possibility of successful psychogenic
b. may have uncontrolled re- erections with ejaculation, whereas patients
flex erections, but that or- with incomplete upper motor neuron lesions
gasm and ejaculation are are more likey to experience reflexogeic erec-
usually not possible tions with ejaculation. Patients with complete
c. has a lesion with the upper motor neuron lesions usually only have
greatest possibility of suc- reflex sexual function with rare ejaculation.
cessful psychogenic erec-
tion with ejaculation and or-
gasm
d. will probably be unable to
have either psychogenic or
reflexogenic erections with
no ejaculation or orgasm
37. A patient with paraplegia B. b. how to perform intermittent self-catheter-

has developed an irritable ization
bladder with reflex empty- Rationale: Intermittent self cath five to six
ing. The nurse teaches the times a day is the recommended method of
patient bladder management for the patient with a
a. hygiene care for an in- spinal cord injury because it more closely mim-
16 / 24
dwelling urinary catheter ics normal emptying and has less potential
b. how to perform intermit- for infectinon. The patient and family should
tent self-catheterization be taught the procedure using clean tech-
c. to empty the bladder nique, and if the patient has use of the arms,
with manual pelvic pressure self-cath is use during the acute phase to pre-
in coordination with reflex vent overdistention of the bladder and surgical
voiding patterns urinary diversions are used if urinary compli-
d. that a urinary diversion, cations occur.
such as an ileal conduit, is
the easiest way to handle
urinary elimination
38. A nurse is caring for a client D. muscle relaxants

who experienced a cervical Rationale: The client will still be in spinal shock
spine injury 24 hours ago. 24 hours following the injury. the client will
which of the following types not experience muscle spasms until after the
of prescribed medications spinal shock has resolved, making muscle re-
should the nurse clarify with laxants unnecessary at this time.
the provider?
a. glucocorticoids
b. plasma expanders
c. H2 antagonists
d. muscle relaxants
39. 27. When caring for a patient Correct Answer: C

who was admitted 24 hours Rationale: Edema around the area of injury
previously with a C5 spinal may lead to damage above the C4 level, so
cord injury, which nursing the highest priority is assessment of the pa-
action has the highest prior- tient's respiratory function. The other actions
ity? are also appropriate but are not as important
a. Continuous cardiac moni- as assessment of respiratory effort.
toring for bradycardia
b. Administration of methyl- Cognitive Level: Application Text Reference: p.
prednisolone (Solu-Medrol) 1602
infusion Nursing Process: Assessment NCLEX: Physi-
c. Assessment of respirato- ological Integrity
ry rate and depth
d. Application of pneumat-
17 / 24
ic compression devices to
both legs
40. 22. A 26-year-old patient Correct Answer: D

with a C8 spinal cord injury Rationale: Maintenance of sexuality is an im-
tells the nurse, "My wife and portant aspect of rehabilitation after spinal
I have always had a very ac- cord injury and should be handled by someone
tive sex life, and I am wor- with expertise in sexual counseling. Although
ried that she may leave me the patient should discuss these issues with
if I cannot function sexual- his wife, open communication about this issue
ly." The most appropriate re- may be difficult without the assistance of a
sponse by the nurse to the counselor. Sildenafil does assist with erectile
patient's comment is to dysfunction after spinal cord injury, but the pa-
a. advise the patient to talk tient's sexuality is not determined solely by the
to his wife to determine how ability to have an erection. Reflex erections are
she feels about his sexual common after upper motor neuron injury, but
function. these erections are uncontrolled and cannot
b. tell the patient that silde- be maintained during coitus.
nafil (Viagra) helps to de-
crease erectile dysfunction Cognitive Level: Application Text Reference: p.
in patients with spinal cord 1608
injury. Nursing Process: Implementation NCLEX:
c. inform the patient that Psychosocial Integrity
most patients with upper
motor neuron injuries have
reflex erections.
d. suggest that the patient
and his wife work with a
nurse specially trained in
sexual counseling.
41. 13. A patient with a neck Correct Answer: D

fracture at the C5 level is Rationale: Clinical manifestations of spinal
admitted to the intensive shock include decreased reflexes, loss of sen-
care unit (ICU) following ini- sation, and flaccid paralysis below the area
tial treatment in the emer- of injury. Hypotension, bradycardia, and warm
gency room. During initial extremities are evidence of neurogenic shock.
assessment of the patient, Involuntary spastic movements and hyperac-
the nurse recognizes the tive reflexes are not seen in the patient at this
18 / 24
presence of spinal shock on stage of spinal cord injury.
finding
a. hypotension, bradycardia, Cognitive Level: Comprehension Text Refer-
and warm extremities. ence: p. 1590
b. involuntary, spastic move- Nursing Process: Assessment NCLEX: Physi-
ments of the arms and legs. ological Integrity
c. the presence of hyperac-
tive reflex activity below the
level of the injury.
d. flaccid paralysis and lack
of sensation below the level
of the injury.
42. MULTIPLE RESPONSE Correct Answer: B, C, E, F

Rationale: The patient is at risk for brady-
1. When caring for a pa- cardia and poikilothermia caused by sympa-
tient who experienced a T1 thetic nervous system dysfunction and should
spinal cord transsection 2 have continuous cardiac monitoring and main-
days ago, which collabora- tenance of a relatively warm room tempera-
tive and nursing actions will ture. Gastrointestinal (GI) motility is decreased
the nurse include in the plan initially and NG suctioning is indicated. To
of care? (Select all that ap- avoid bladder distension, a retention catheter
ply.) is used during this acute phase. Stress ulcers
a. Endotracheal suctioning are a common complication but can be avoid-
b. Continuous cardiac mon- ed through the use of the H2 receptor blockers
itoring such as famotidine.
c. Avoidance of cool room
temperature Cognitive Level: Application Text Reference:
d. Nasogastric tube feeding pp. 1594-1595, 1597, 1603
e. Retention catheter care Nursing Process: Planning NCLEX: Physiolog-
f. Administration of H2 re- ical Integrity
ceptor blockers
43. 16. A patient with a T1 spinal Correct Answer: B

cord injury is admitted to Rationale: The patient with a T1 injury can
the intensive care unit (ICU). expect to retain full motor and sensory function
The nurse will teach the pa- of the arms. Use of only the shoulders is asso-
tient and family that ciated with cervical spine injury. Total loss of
a. use of the shoulders will respiratory function occurs with injuries above
19 / 24
be preserved. the C4 level and is permanent. Bradycardia is
b. full function of the pa- associated with injuries above the T6 level.
tient's arms will be retained.
c. total loss of respirato- Cognitive Level: Application Text Reference: p.
ry function may occur tem- 1594
porarily. Nursing Process: Implementation NCLEX:
d. elevations in heart rate Physiological Integrity
are common with this type
of injury.
44. 1. In which order will the Correct Answer: C, A, B, D

nurse perform the following Rationale: The first action should be to prevent
actions when caring for a further injury by stabilizing the patient's spinal
patient with possible cervi- cord. Maintenance of oxygenation by adminis-
cal spinal cord trauma who tration of 100% O2 is the second priority. Be-
is admitted to the emer- cause neurogenic shock is a possible compli-
gency department? cation, continuous monitoring of heart rhythm
a. Administer O2 using a and BP is indicated. CT scan to determine the
non-rebreathing mask. extent and level of injury is needed once initial
b. Monitor cardiac rhythm assessment and stabilization is accomplished.
and blood pressure.
c. Immobilize the patient's Cognitive Level: Application Text Reference: p.
head, neck, and spine. 1596
d. Transfer the patient to ra- Nursing Process: Implementation NCLEX:
diology for spinal CT. Physiological Integrity
45. 14. When caring for a pa- Correct Answer: B

tient who had a C8 spinal Rationale: The nurse has identified that the
cord injury 10 days ago and cough effort is poor, so the initial action should
has a weak cough effort, be to use assisted coughing techniques to im-
bibasilar crackles, and de- prove the ability to mobilize secretions. Admin-
creased breath sounds, the istration of oxygen will improve oxygenation,
initial intervention by the but the data do not indicate hypoxemia, and
nurse should be to oxygen will not help expel respiratory secre-
a. administer oxygen at 7 to tions. The use of the spirometer may improve
9 L/min with a face mask. respiratory status, but the patient's ability to
b. place the hands on the take deep breaths is limited by the loss of
epigastric area and push intercostal muscle function. Suctioning may be
upward when the patient needed if the patient is unable to expel secre-
20 / 24
coughs. tions by coughing but should not be the nurse's
c. encourage the patient to first action.
use an incentive spirome-
ter every 2 hours during the Cognitive Level: Application Text Reference: p.
day. 1602
d. suction the patient's oral Nursing Process: Implementation NCLEX:
and pharyngeal airway. Physiological Integrity
46. 20. The nurse discusses Correct Answer: D

long-range goals with a pa- Rationale: The patient with a C6 injury will be
tient with a C6 spinal cord in- able to use the hands to push a wheelchair on
jury. An appropriate patient flat, smooth surfaces. Because flexion of the
outcome is thumb and fingers is minimal, the patient will
a. transfers independently not be able to grasp a wheelchair during trans-
to a wheelchair. fer, drive a car with powered hand controls, or
b. drives a car with powered turn independently in bed.
hand controls.
c. turns and repositions self Cognitive Level: Application Text Reference: p.
independently when in bed. 1594
d. pushes a manual wheel- Nursing Process: Planning NCLEX: Physiolog-
chair on flat, smooth sur- ical Integrity
faces.

21 / 24
ical Integrity

D. Warm, dry skin and dry skin, instead of cold and clammy, but
49. The patient arrives in D. Use a logroll technique when moving the
the emergency department patient.
from a motor vehicle acci- When the head hits the windshield with
dent, during which the car enough force to shatter it, you must assume
ran into a tree. The patient neck or cervical spine trauma occurred and
was not wearing a seat belt, you need to maintain spinal precautions. This
and the windshield is shat- includes moving the patient in alignment as a
tered. What action is most unit or using a logroll technique during trans-
important for you to do? fers. The other options are important and are
A. Determine if the patient done after spinal precautions are applied.
lost consciousness.
B. Assess the Glasgow
Coma Scale (GCS) score.
C. Obtain a set of vital signs.
D. Use a logroll technique
when moving the patient.
22 / 24

hours
53. A client with a spinal cord in- 4. limiting bladder cath to once q12h
jury is prone to experiencing (the most frequent cause of autonomic dys-
autonomic dysreflexia. The reflexia is a distended bladder . Straight cath
nurse should avoid which should be performed q4-6 hrs and foley cath
measure to minimize the should be checked frequently for kinks in tub-
risk of recurrence? ing . Constipation and fecal impaction are oth-
23 / 24
1. strict adherence to a bow- er causes, so maintaining bowel irregularity is
el retraining program important .
2. keeping the linen wrinkle
free under the client
3. avoiding unnecessary
4. limiting bladder catheter-
hours
24 / 24
Spinal Cord Injury NCLEX Lewis
Study online at https://quizlet.com/_7pwuw2
1. 3. A patient with spinal c. Flexion-rotation

cord injury is experiencing
severe neurologic deficits.
What is the most likely
mechanism of injury for
this patient?
a. Compression
b. Hyperextension
c. Flexion-rotation
d. Extension-rotation
2. 1. During rehabilitation, a a. L1-2

patient with spinal cord
injury begins to ambu-
late with long leg braces.
Which level of injury does
the nurse associate with
this degree of recovery?
a. L1-2
b. T6-7
c. T1-2
d. C7-8
3. 2. A patient with a T4 b. Hypotension

spinal cord injury expe-
riences neurogenic shock
as a result of sympathetic
nervous system dysfunc-
tion. What would the nurse
recognize as characteris-
tic of this condition?
a. Tachycardia
b. Hypotension
c. Increased cardiac output
d. Peripheral vasoconstric-
tion
4. 4. A patient with a C7 c. take the patient's blood pressure.

spinal cord injury under-
1/7
going rehabilitation tells
the nurse he must have the
flu because he has a bad
nurse's first priority is to
a. call the HCP.
perature.
c. take the patient's blood
pressure.
d. elevate the head of the
bed to 90 degrees.
5. 5. For a 65-year-old woman a. A mammogram is needed every year.

who has lived with a T1
spinal cord injury for 20
years, which health teach-
ing instructions should the
nurse emphasize?
a. A mammogram is need-
ed every year.
b. Bladder function tends
to improve with age.
c. Heart disease is not
common in people with
spinal cord injury.
d. As a person ages, the
need to change body posi-
tion is less important.
6. 6. The most common early b. back pain that worsens with activity.
symptom of a spinal cord
tumor is
a. urinary incontinence.
b. back pain that worsens
with activity.
c. paralysis below the level
of involvement.
d. impaired sensation of
2/7
pain, temperature, and
light touch.
7. 7. During assessment of a. inspect all aspects of the mouth and teeth.

the patient with trigemi- d. test for temperature and sensation perception
nal neuralgia, the nurse on the face.
should (select all that ap- e. ask the patient to describe factors that initiate
ply) an episode.
a. inspect all aspects of the
mouth and teeth.
b. assess the gag reflex
and respiratory rate and
depth.
c. lightly palpate the affect-
ed side of the face for ede-
ma.
d. test for temperature and
sensation perception on
the face.
e. ask the patient to de-
scribe factors that initiate
an episode.
8. 8. During routine assess- d. paralysis ascending to the nerves that stimu-

ment of a patient with Guil- late the thoracic area
lain-Barré syndrome, the
nurse finds the patient is
short of breath. The pa-
tient's respiratory distress
is caused by
a. elevated protein in the
CSF.
b. immobility resulting
from ascending paralysis.
c. degeneration of motor
neurons in the brainstem
and spinal cord.
d. paralysis ascending to
3/7
the nerves that stimulate
the thoracic area
9. 9. A nurse is car- b. "Maintenance therapy will be needed to pre-

ing for a patient new- vent relapse."
ly diagnosed with chronic
inflammatory demyelinat-
ing polyneuropathy (CIDP).
Which statement can the
nurse accurately use to
teach the patient about
CIDP?
a. "Corticosteroids have
little effect on this dis-
ease."
b. "Maintenance therapy
will be needed to prevent
relapse."
c. "You will go into remis-
sion in approximately eight
weeks."
d. "You should be able to
walk without help within
three months."
10. 1. A patient has a spinal d. neurogenic shock from massive vasodilation.

cord injury at T4. Vital
signs include falling blood
pressure with bradycardia.
The nurse recognizes that
the patient is experiencing
a. a relative hypervolemia.
b. an absolute hypov-
olemia.
c. neurogenic shock from
low blood flow.
d. neurogenic shock from
massive vasodilation.
4/7
11. A patient has been admit- a, b, c
ted to the hospital with Rationale
a T3-level complete spinal The patient with a T3-level spinal cord injury will
cord injury. The nurse has have full innervation of the upper extremities,
to plan the home-based re- back, essential intrinsic muscles of the hands,
habilitation for this patient. full strength and dexterity of grasp, decreased
When creating the care trunk stability, and decreased respiratory re-
plan, the nurse considers serve. Therefore, the patient may have the fol-
the activities that the pa- lowing potentials: full independence in self-care
tient is able to do inde- and in a wheelchair, ability to drive a car with
pendently. What activities hand controls, independent standing in a stand-
should the nurse consid- ing frame. Abdominal muscles are affected, so
er to make maximum use the ability to cough is lost. The patient may also
of patient's abilities? Se- not be able to climb stars due to the injury.
lect all that apply.
A. Independent self-care is
possible.
B. Independent wheelchair
mobility is possible.
C. Patient may be able to
drive with hand controls.
D. Patient will be able to
climb stairs independently.
E. Patient will be able to
have effective coughing
ability.
12. A patient has been admit- B, D

ted to the hospital with Rationale
a spinal cord injury. Fol- An injury above T12 leads to development of
lowing the assessment, a reflexic bowel, wherein nervous interactions
the health care provider between the colon (large intestine) and the brain
concludes that the injury are interrupted. As a result, the person may not
is above T12. What signs feel the need to have a bowel movement. How-
and symptoms related to ever, stool is still building up in the rectum. The
the gastrointestinal sys- build-up triggers a reflex, causing the rectum
tem would indicate an in- and colon to react, leading to a bowel movement
jury above T12? Select all without warning. When the sensation of a full
5/7
that apply. bowel is perceived by the patient and the patient
has fecal incontinence, it is a lower-level spinal
A. The patient has an ab- cord injury (below T12). In spinal cord injury, it is
sence of bowel sounds. usually incontinence that occurs. When the in-
B. There is excess gastric jury is above T5, paralytic ileus may be present
distention, and the stom- and bowel sounds may be absent.
ach is hard.
C. The patient is consti-
pated and is passing hard
stools with straining.
D. The sensation of a full
bowel is perceived by the
patient, and fecal inconti-
nence is present.
E. The sensation of a full
bowel is not perceived by
the patient, and fecal in-
continence is present.
13. A nurse is assessing a pa- B. Monitor blood pressure regularly.

tient with a T2-level spinal D. Notify the primary health care provider.
cord injury. The nurse no- E. Check for the presence of bowel impaction.
tices that there is a kink F. Remove the kink in the catheter and drain the
in the catheter, the blad- bladder.
der is distended, and the
blood pressure is 220/100 Rationale
mm Hg. What nursing inter- A sudden rise in blood pressure for a spinal
ventions would be appro- cord injury patient above the level of T6 is gen-
priate for this patient if the
erally indicative of autonomic dysreflexia. Nurs-
nurse suspects autonomic ing interventions in a serious emergency like
dysreflexia? Select all that autonomic dysreflexia include notifying the pri-
apply. mary health care provider and determining the
cause. The blood pressure should be regularly
A. Lower the head of the monitored; administration of an alpha-adrener-
bed. gic blocker or an arteriolar vasodilator is re-
B. Monitor blood pressure quired. Contractions of the rectum are also a
regularly. cause; therefore, the nurse should check for
C. Make the patient lie flat bowel impaction and treat it accordingly. The
on the bed. most common cause is bladder distension. If a
6/7
D. Notify the primary catheter is present, the presence of any kinks
health care provider. or folds should be checked. However, the most
E. Check for the presence important nursing intervention in this case is
of bowel impaction. elevating the head of the bed 45 degrees or
F. Remove the kink in higher to make the patient sit upright; this would
the catheter and drain the lower the blood pressure.
bladder.
p. 1431
14. While assessing a pa- B. Ability to drive an electric wheelchair

tient's level of spinal injury, Rationale
the nurse observes that A patient with sensation and movement in the
the patient has sensation neck and the region above the neck can drive
and movement in the neck an electric wheelchair by using chin control of a
and the region above, and mouth stick. Self-feeding is not possible for the
can breathe without a ven- patient because the ability of movement is lim-
tilator. What is the potential ited to the neck. The patient requires complete
for rehabilitation that the assistance with daily living activities; therefore
nurse can expect? attendant care is required 24 hours a day. Due
to paralysis in the arms and hands, the patient
A. Ability to feed self with can access the computer only with the help of a
setup mouth stick and head wand. Hence independent
B. Ability to drive an elec- use of a computer is not possible.
tric wheelchair
C. Attendant care required
for 10 hours in a day
D. Independent computer
use with adaptive equip-
ment
15. What type of blunt trauma b. Diving accident

can lead to a spinal cord
injury? Rationale
A diving accident is a blunt trauma caused by a
A. Stab wound physical injury that can lead to spinal cord injury.
B. Diving accident Stab wound, gunshot wounds, and a torn spinal
C. Gunshot wound cord are instances of penetrating traumas that
D. Torn spinal cord can injure the spinal cord.
7/7
Spinal Cord Injury NCLEX
Study online at https://quizlet.com/_7lwdzt
1. The nurse is caring for a patient admit- Correct Answer(s): D

ted 1 week ago with an acute spinal Autonomic dysreflexia is related to
cord injury. Which of the following reflex stimulation of the sympathet-
assessment findings would alert the ic nervous system reflected by hy-
nurse to the presence of autonomic pertension, bradycardia, throbbing
dysreflexia? headache, and diaphoresis.
A) Tachycardia
B) Hypotension
C) Hot, dry skin
D) Throbbing headache
2. When planning care for a patient with Correct Answer(s): D

a C5 spinal cord injury, which nursing Maintaining a patent airway is the
diagnosis is the highest priority? most important goal for a patient
A) Risk for impairment of tissue in- with a high cervical fracture. Al-
tegrity caused by paralysis though all of these are appropri-
B) Altered patterns of urinary elimina- ate nursing diagnoses for a patient
tion caused by quadriplegia with a spinal cord injury, respiratory
C) Altered family and individual cop- needs are always the highest prior-
ing caused by the extent of trauma ity. Remember the ABCs.
D) Ineffective airway clearance caused
by high cervical spinal cord injury
3. Which of the following signs and Correct Answer(s): A

symptoms in a patient with a T4 spinal Among the manifestations of auto-
cord injury should alert the nurse to nomic dysreflexia are hypertension
the possibility of autonomic dysreflex- (up to 300 mm Hg systolic) and
ia? a throbbing headache. Respiratory
A) Headache and rising blood pres- manifestations, decreased level of
sure consciousness, and gastrointesti-
B) Irregular respirations and short- nal manifestations are not charac-
ness of breath teristic.
C) Decreased level of consciousness
or hallucinations
D) Abdominal distention and absence
of bowel sounds
4. Which of the following interventions Correct Answer(s): A

should the nurse perform in the acute Because the most common cause
1/9
care of a patient with autonomic dys- of autonomic dysreflexia is blad-
reflexia? der irritation, immediate catheter-
A) Urinary catheterization ization to relieve bladder disten-
B) Administration of benzodiazepines tion may be necessary. The patient
C) Suctioning of the patient's upper should be positioned upright. Ben-
airway zodiazepines are contraindicated
D) Placement of the patient in the Tren- and suctioning is likely unneces-
delenburg position sary.
5. Nurse is assessing a patient who has Correct Answer (s): a, c, d, e

a spinal cord injury?Which should the the assessment to determine the
nurse include in the nervous system level of spinal cord injury includes
assessment to determine the extent of analyzing the -vital sign, plantar re-
the patient's injury? flexes, bilatereal hand grasp, de-
select all that apply. scription of trauma.
a. vital sign Romberg test must be performed
b. romberg test while standing therefore not suit-
c. plantar reflexes able for unstable patient
d. bilatereal hand grasps
e. description of trauma
6. A patient has impairments from a SCI Answer is B

at C4 classified as incomplete C on A patient who has a SCI has neu-
the American Spinal Injury Associa- rologic impairment to all extremities
tion, (ASIA) Impairment Sclae. Which and the diaphragm. However, be-
patient assessment is the nurse likely cause the injury is C on the ASIA
to observe in this patient? impairment Scale, sensory function
A. poor propricopetor in the legs can be intact but motor function
B. poor peristalsis in the intestines will be impaired significantly or ab-
C. Absent gag and blinking reflexes sent.the patient can lose moder-
D. Absent bladder fulness sensation ate to complete peristatlic action in
the intestines but should reatine the
ability to sense bladder fulnessand
the position of the legs.
7. The nurse admnisters methyl- Correct Answer(s): B

prenisone(Solu-Medrol) as a conti- the nurse should adminster PPI
nous IV fusion to a male patient who because they are at high risk for
has fractures of the cervical vertebrae.
2/9
Which intervention would prevent or Gi erosion and bleeding. from the
detect adverse effects of the medica- steroid.
tion?
A. record pt baseline weight
B. adminster PPI( proton pump in-
hibitor)
C. Check the hear rate for bradycardia
D. suction the patient's oropharynx
8. A male patient has a pinal cord injury Correct Answer(s) : C

at L 1-2 . Which clinical manifestation during spinal shock neuromuscular
of the patient's injury is the nurse like- function is lost below the level of the
ly to observe before spinal shock re- injury along with hyporeflexia and
solves? loss of sensation. So the pt will not
A. opoiod analgesic Iv for foot pain be able to sit until the pinal shock
B. able to blance in sitting position resolves.
C. unresponsive quadriceps muscle
D. requites asssist control ventilation
9. A female nurse is injured in an automo- Correct C. Hospital case manage-

bile accident and suffers acute comment(s)
presssion of the anterior apinal cord at the nurse in most likely to have an
T8-10 Which nursing rols is a potential anterior cord syndrome resulting in
source of employment for the patients the loss of neuromuscular and pain
after completing rehabilitation ? and temp sensation below t8. Pt will
A. Certified nurse practioner have full use of upper extremities ,
B. Community health nursing upper back, and resp muscles.thus
C. Hospital case mangement she will be in a wheel chair.
D. Inpatient behavioral health
10. A 70 yr old patient who has a spinal Correct Answer(s): D

cord injury at C8 resulting in central Weakness of thoracic muscle is
cord syndrome. Which effect of the pa- most likely to cause life-threatening
tient's most likely to be life threatening complications because affects pa-
after completeing rehabiliation? tients oxygentation and ventilation.
A. increased bone density loss
B. higher tisk for tissue hpoxia
C. vasomotor compensation lost
D. Weakness of thoracic muscles
3/9
11. A patient with a neck fracture at the C5 Correct Answer(s): D
level is admitted to the intensive care Rationale: Clinical manifestations
unit (ICU) following initial treatment in of spinal shock include decreased
the emergency room. During initial as- reflexes, loss of sensation, and
sessment of the patient, the nurse rec- flaccid paralysis below the area
ognizes the presence of spinal shock of injury. Hypotension, bradycardia,
on finding and warm extremities are evidence
a. hypotension, bradycardia, and of neurogenic shock. Involuntary
warm extremities. spastic movements and hyperac-
b. involuntary, spastic movements of tive reflexes are not seen in the
the arms and legs. patient at this stage of spinal cord
c. the presence of hyperactive reflex injury.
activity below the level of the injury.
d. flaccid paralysis and lack of sensa-
tion below the level of the injury.
12. When caring for a patient who had a C8 Correct Answer(s): B

spinal cord injury 10 days ago and has Rationale: The nurse has identi-
a weak cough effort, bibasilar crack- fied that the cough effort is poor,
les, and decreased breath sounds, the so the initial action should be to
initial intervention by the nurse should use assisted coughing techniques
be to to improve the ability to mobilize
a. administer oxygen at 7 to 9 L/min secretions. Administration of oxy-
with a face mask. gen will improve oxygenation, but
b. place the hands on the epigastric the data do not indicate hypoxemia,
area and push upward when the pa- and oxygen will not help expel res-
tient coughs. piratory secretions. The use of the
c. encourage the patient to use an in- spirometer may improve respirato-
centive spirometer every 2 hours dur- ry status, but the patient's ability to
ing the day. take deep breaths is limited by the
d. suction the patient's oral and pha- loss of intercostal muscle function.
ryngeal airway. Suctioning may be needed if the
patient is unable to expel secre-
tions by coughing but should not be
the nurse's first action.
13. A patient with a T1 spinal cord injury Correct Answer(s): B

is admitted to the intensive care unit Rationale: The patient with a T1
(ICU). The nurse will teach the patient injury can expect to retain full motor
4/9
and family that and sensory function of the arms.
a. use of the shoulders will be pre- Use of only the shoulders is associ-
served. ated with cervical spine injury. Total
b. full function of the patient's arms loss of respiratory function occurs
will be retained. with injuries above the C4 level and
c. total loss of respiratory function is permanent. Bradycardia is asso-
may occur temporarily. ciated with injuries above the T6
d. elevations in heart rate are common level.
with this type of injury.
14. The health care provider orders ad- Correct Answer(s): C

ministration of IV methylprednisolone Rationale: The purpose of methyl-
(Solu-Medrol) for the first 24 hours to a prednisolone administration is to
patient who experienced a spinal cord help preserve neurologic function;
injury at the T10 level 3 hours ago. therefore, the nurse will assess this
When evaluating the effectiveness of patient for lower-extremity function.
the medication the nurse will assess Sympathetic nervous system dys-
a. blood pressure and heart rate. function occurs with injuries at or
b. respiratory effort and O2 saturation. above T6, so monitoring of BP
c. motor and sensory function of the and heart rate will not be useful
legs. in determining the effectiveness of
d. bowel sounds and abdominal dis- the medication. Respiratory and GI
tension. function will not be impaired by
a T10 injury, so assessments of
these systems will not provide in-
formation about whether the med-
ication is effective.
15. A patient with a paraplegia resulting Correct Answer(s): A

from a T10 spinal cord injury has a neu- Rationale: Because the patient's
rogenic reflex bladder. When the nurse bladder is spastic and will emp-
develops a plan of care for this prob- ty in response to overstretching of
lem, which nursing action will be most the bladder wall, the most appropri-
appropriate? ate method is to avoid incontinence
a. Teaching the patient how to by emptying the bladder at reg-
self-catheterize ular intervals through intermittent
b. Assisting the patient to the toilet catheterization. Assisting the pa-
q2-3hr tient to the toilet will not be helpful
c. Use of the Credé method to empty because the bladder will not empty.
5/9
the bladder The Credé method is more appro-
d. Catheterization for residual urine priate for a bladder that is flaccid,
after voiding such as occurs with a reflexic neu-
rogenic bladder. Catheterization af-
ter voiding will not resolve the pa-
tient's incontinence.
16. A patient with a history of a T2 spinal Correct Answer(s): B

cord tells the nurse, "I feel awful today. Rationale: The BP should be as-
My head is throbbing, and I feel sick to sessed immediately in a patient
my stomach." Which action should the with an injury at the T6 level or high-
nurse take first? er who complains of a headache
a. Notify the patient's health care to determine whether autonomic
provider. dysreflexia is causing the symp-
b. Check the blood pressure (BP). toms, including hypertension. Noti-
c. Give the ordered antiemetic. fication of the patient's health care
d. Assess for a fecal impaction. provider is appropriate after the
BP is obtained. Administration of
an antiemetic is indicated after au-
tonomic dysreflexia is ruled out
as the cause of the nausea. The
nurse may assess for a fecal im-
paction, but this should be done
after checking the BP and lidocaine
jelly should be used to prevent fur-
ther increases in the BP.
17. The nurse discusses long-range goals Correct Answer(s): D

with a patient with a C6 spinal cord Rationale: The patient with a C6 in-
injury. An appropriate patient outcome jury will be able to use the hands to
is push a wheelchair on flat, smooth
a. transfers independently to a wheel- surfaces. Because flexion of the
chair. thumb and fingers is minimal, the
b. drives a car with powered hand con- patient will not be able to grasp a
trols. wheelchair during transfer, drive a
c. turns and repositions self indepen- car with powered hand controls, or
dently when in bed. turn independently in bed.
d. pushes a manual wheelchair on flat,
smooth surfaces.
6/9
18. A patient who sustained a T1 spinal Correct Answer(s): A
cord injury a week ago refuses to dis- Rationale: The patient is demon-
cuss the injury and becomes verbal- strating behaviors consistent with
ly abusive to the nurses and other the anger phase of the mourning
staff. The patient demands to be trans- process, and the nurse should al-
ferred to another hospital, where "they low expression of anger and seek
know what they are doing." The best the patient's input into care. Ex-
response by the nurse to the patient's pression of anger is appropriate
behavior is to at this stage and should be toler-
a. ask for the patient's input into the ated by the nurse. Refusal to ac-
plan for care. knowledge the patient's anger by
b. clarify that abusive behavior will not telling the patient that the anger is
be tolerated. just a phase is inappropriate. Con-
c. reassure the patient that the anger tinuing to perform needed assess-
will pass and rehabilitation will then ments and care is appropriate, but
progress. the nurse should seek the patient's
d. ignore the patient's anger and con- input into what care is needed.
tinue to perform needed assessments
and care.
19. A 26-year-old patient with a C8 spinal Correct Answer(s): D

cord injury tells the nurse, "My wife Rationale: Maintenance of sexu-
and I have always had a very active ality is an important aspect of re-
sex life, and I am worried that she may habilitation after spinal cord injury
leave me if I cannot function sexually." and should be handled by some-
The most appropriate response by the one with expertise in sexual coun-
nurse to the patient's comment is to seling. Although the patient should
a. advise the patient to talk to his wife discuss these issues with his wife,
to determine how she feels about his open communication about this is-
sexual function. sue may be difficult without the
b. tell the patient that sildenafil (Vi- assistance of a counselor. Silde-
agra) helps to decrease erectile dys- nafil does assist with erectile dys-
function in patients with spinal cord function after spinal cord injury, but
injury. the patient's sexuality is not deter-
c. inform the patient that most patients mined solely by the ability to have
with upper motor neuron injuries have an erection. Reflex erections are
reflex erections. common after upper motor neu-
d. suggest that the patient and his wife ron injury, but these erections are
7/9
work with a nurse specially trained in uncontrolled and cannot be main-
sexual counseling. tained during coitus.
20. A 25-year-old patient has returned Correct Answer((s): D

home following extensive rehabilita- Rationale: The best action by the
tion for a C8 spinal cord injury. The nurse will be to involve all the par-
home care nurse visits and notices ties in developing an optimal plan
that the patient's spouse and parents of care. Because family members
are performing many of the activities who will be assisting with the pa-
of daily living (ADLs) that the patient tient's ongoing care need to feel
had been managing during rehabilita- that their input is important, telling
tion. The most appropriate action by the family that the patient can per-
the nurse at this time is to form ADLs independently is not the
a. tell the family members that the pa- best choice. Reminding the patient
tient can perform ADLs independently. about the importance of indepen-
b. remind the patient about the impor- dence may not change the behav-
tance of independence in daily activi- iors of the family members. Sup-
ties. porting the activities of the spouse
c. recognize that it is important for the and parents will lead to ongoing de-
patient's family to be involved in the pendency by the patient.
patient's care and support their activi-
ties.
d. develop a plan to increase the pa-
tient's independence in consultation
with the with the patient, spouse, and
parents.
21. When caring for a patient who was ad- Correct Answer(s): C
mitted 24 hours previously with a C5 Rationale: Edema around the area
spinal cord injury, which nursing ac- of injury may lead to damage above
tion has the highest priority? the C4 level, so the highest priority
a. Continuous cardiac monitoring for is assessment of the patient's res-
bradycardia piratory function. The other actions
b. Administration of methylpred- are also appropriate but are not as
nisolone (Solu-Medrol) infusion important as assessment of respi-
c. Assessment of respiratory rate and ratory effort.
depth
d. Application of pneumatic compres-
sion devices to both legs
8/9
22. In which order will the nurse perform Correct Answer(s): C, A, B, D
the following actions when caring for Rationale: The first action should
a patient with possible cervical spinal be to prevent further injury by sta-
cord trauma who is admitted to the bilizing the patient's spinal cord.
emergency department? Maintenance of oxygenation by ad-
a. Administer O2 using a non-re- ministration of 100% O2 is the
breathing mask. second priority. Because neuro-
b. Monitor cardiac rhythm and blood genic shock is a possible complica-
pressure. tion, continuous monitoring of heart
c. Immobilize the patient's head, neck, rhythm and BP is indicated. CT
and spine. scan to determine the extent and
d. Transfer the patient to radiology for level of injury is needed once initial
spinal CT. assessment and stabilization is ac-
complished.
23. The nurse is caring for a man who Correct Answer(s: ) C

has experienced a spinal cord injury. Having a bowel movement is a
Throughout his recovery, the client ex- spinal reflex requiring intact nerve
pects to gain control of his bowels. The fibers. Yours are not intact
nurse's best response to this client The act of defecation is a spinal
would be which of the following? reflex involving the parasympathet-
a. "Over time, the nerve fibers will ic nerve fibers. Normally, the ex-
regrow new tracts, and you can have ternal anal sphincter is maintained
bowel movements again." in a state of tonic contraction. With
b. "Wearing an undergarment will be- a spinal cord injury, the client no
come more comfortable over time." longer has this nervous system
c "Having a bowel movement is a control and is often incontinent.
spinal reflex requiring intact nerve
fibers. Yours are not intact."
d "It is not going to happen. Your nerve
cells are too damaged."
9/9
Study online at https://quizlet.com/_95lssl


stridor
4. diarrhea
5. fecal impaction

1/5

following?
1. paralysis
2. spinal shock

c. stress ulcer

2/5

ical Integrity

D. Warm, dry skin
3/5
and dry skin, instead of cold and clammy, but

4/5
hours
5/5
Study online at https://quizlet.com/_33wtuf
1. The nurse is caring for a patient ad- Correct Answer(s): B

mitted with a spinal cord injury follow- About 50% of people with acute
ing a motor vehicle accident. The pa- spinal cord injury experience a tem-
tient exhibits a complete loss of motor, porary loss of reflexes, sensation,
sensory, and reflex activity below the and motor activity that is known
injury level. The nurse recognizes this as spinal shock. Central cord syn-
condition as which of the following? drome is manifested by motor and
A) Central cord syndrome sensory loss greater in the upper
B) Spinal shock syndrome extremities than the lower extremi-
C) Anterior cord syndrome ties. Anterior cord syndrome results
D) Brown-Séquard in motor and sensory loss but not
reflexes. Brown-Séquard syndrome
is characterized by ipsilateral loss
of motor function and contralateral
loss of sensory function.
2. Which of the following clinical man- Correct Answer(s): A

ifestations would the nurse interpret Neurogenic shock is due to the loss
as representing neurogenic shock in a of vasomotor tone caused by injury
patient with acute spinal cord injury? and is characterized by hypoten-
A) Bradycardia sion and bradycardia. Loss of sym-
B) Hypertension pathetic innervation causes periph-
C) Neurogenic spasticity eral vasodilation, venous pooling,
D) Bounding pedal pulses and a decreased cardiac output.
3. The nurse is caring for a patient admit- Correct Answer(s): D

ted 1 week ago with an acute spinal Autonomic dysreflexia is related to
cord injury. Which of the following reflex stimulation of the sympathet-
assessment findings would alert the ic nervous system reflected by hy-
nurse to the presence of autonomic pertension, bradycardia, throbbing
dysreflexia? headache, and diaphoresis.
A) Tachycardia
B) Hypotension
C) Hot, dry skin
D) Throbbing headache
4. When planning care for a patient with Correct Answer(s): D

a C5 spinal cord injury, which nursing Maintaining a patent airway is the
diagnosis is the highest priority? most important goal for a patient
1 / 10
A) Risk for impairment of tissue in- with a high cervical fracture. Al-
tegrity caused by paralysis though all of these are appropri-
B) Altered patterns of urinary elimina- ate nursing diagnoses for a patient
tion caused by quadriplegia with a spinal cord injury, respiratory
C) Altered family and individual cop- needs are always the highest prior-
ing caused by the extent of trauma ity. Remember the ABCs.
D) Ineffective airway clearance caused
by high cervical spinal cord injury
5. Which of the following signs and Correct Answer(s): A

symptoms in a patient with a T4 spinal Among the manifestations of auto-
cord injury should alert the nurse to nomic dysreflexia are hypertension
the possibility of autonomic dysreflex- (up to 300 mm Hg systolic) and
ia? a throbbing headache. Respiratory
A) Headache and rising blood pres- manifestations, decreased level of
sure consciousness, and gastrointesti-
B) Irregular respirations and short- nal manifestations are not charac-
ness of breath teristic.
C) Decreased level of consciousness
or hallucinations
D) Abdominal distention and absence
of bowel sounds
6. Which of the following interventions Correct Answer(s): A

should the nurse perform in the acute Because the most common cause
care of a patient with autonomic dys- of autonomic dysreflexia is blad-
reflexia? der irritation, immediate catheter-
A) Urinary catheterization ization to relieve bladder disten-
B) Administration of benzodiazepines tion may be necessary. The patient
C) Suctioning of the patient's upper should be positioned upright. Ben-
airway zodiazepines are contraindicated
D) Placement of the patient in the Tren- and suctioning is likely unneces-
delenburg position sary.
7. Nurse is assessing a patient who has Correct Answer (s): a, c, d, e

a spinal cord injury?Which should the the assessment to determine the
nurse include in the nervous system level of spinal cord injury includes
assessment to determine the extent of analyzing the -vital sign, plantar re-
the patient's injury? flexes, bilatereal hand grasp, de-
2 / 10
select all that apply. scription of trauma.
a. vital sign Romberg test must be performed
b. romberg test while standing therefore not suit-
c. plantar reflexes able for unstable patient
d. bilatereal hand grasps
e. description of trauma
8. A patient has impairments from a SCI Answer is B

at C4 classified as incomplete C on A patient who has a SCI has neu-
the American Spinal Injury Associa- rologic impairment to all extremities
tion, (ASIA) Impairment Sclae. Which and the diaphragm. However, be-
patient assessment is the nurse likely cause the injury is C on the ASIA
to observe in this patient? impairment Scale, sensory function
A. poor propricopetor in the legs can be intact but motor function
B. poor peristalsis in the intestines will be impaired significantly or ab-
C. Absent gag and blinking reflexes sent.the patient can lose moder-
D. Absent bladder fulness sensation ate to complete peristatlic action in
the intestines but should reatine the
ability to sense bladder fulnessand
the position of the legs.
9. The nurse admnisters methyl- Correct Answer(s): B

prenisone(Solu-Medrol) as a conti- the nurse should adminster PPI
nous IV fusion to a male patient who because they are at high risk for
has fractures of the cervical vertebrae. Gi erosion and bleeding. from the
Which intervention would prevent or steroid.
detect adverse effects of the medica-
tion?
A. record pt baseline weight
B. adminster PPI( proton pump in-
hibitor)
C. Check the hear rate for bradycardia
D. suction the patient's oropharynx
10. A male patient has a pinal cord injury Correct Answer(s) : C

at L 1-2 . Which clinical manifestation during spinal shock neuromuscular
of the patient's injury is the nurse like- function is lost below the level of the
ly to observe before spinal shock re- injury along with hyporeflexia and
solves? loss of sensation. So the pt will not
3 / 10
A. opoiod analgesic Iv for foot pain be able to sit until the pinal shock
B. able to blance in sitting position resolves.
C. unresponsive quadriceps muscle
D. requites asssist control ventilation
11. A female nurse is injured in an automo- Correct C. Hospital case manage-

bile accident and suffers acute comment(s)
presssion of the anterior apinal cord at the nurse in most likely to have an
T8-10 Which nursing rols is a potential anterior cord syndrome resulting in
source of employment for the patients the loss of neuromuscular and pain
after completing rehabilitation ? and temp sensation below t8. Pt will
A. Certified nurse practioner have full use of upper extremities ,
B. Community health nursing upper back, and resp muscles.thus
C. Hospital case mangement she will be in a wheel chair.
D. Inpatient behavioral health
12. A 25-yr old male pt who is a pro- Correct answer(s) B

fessional motorcross racer has ante- The pt is at high risk for depression
rior spinal cord syndrome at T10. His and self-injury because he is likely
history includes tobacco use, alcohol to lose function below the umblicus
abuse, marijuana abuse. What is the . resulting in loss motor function.
nurse's priority during rehabilation? In addition he will need to be in a
A. Monitor the patient 4 times an hour wheelchair, impaired sexual func-
B. Encourage him to verbalize feeling. tion, and can not use tobacco, al-
C. Prevent urniary tract infection cohol, marijuana abuse for coping.
D. Teach about using gastrocolic reflex
13. A 70 yr old patient who has a spinal Correct Answer(s): D

cord injury at C8 resulting in central Weakness of thoracic muscle is
cord syndrome. Which effect of the pa- most likely to cause life-threatening
tient's most likely to be life threatening complications because affects pa-
after completeing rehabiliation? tients oxygentation and ventilation.
A. increased bone density loss
B. higher tisk for tissue hpoxia
C. vasomotor compensation lost
D. Weakness of thoracic muscles
14. A patient with a neck fracture at the C5 Correct Answer(s): D

level is admitted to the intensive care Rationale: Clinical manifestations
unit (ICU) following initial treatment in of spinal shock include decreased
4 / 10
the emergency room. During initial as- reflexes, loss of sensation, and
sessment of the patient, the nurse rec- flaccid paralysis below the area
ognizes the presence of spinal shock of injury. Hypotension, bradycardia,
on finding and warm extremities are evidence
a. hypotension, bradycardia, and of neurogenic shock. Involuntary
warm extremities. spastic movements and hyperac-
b. involuntary, spastic movements of tive reflexes are not seen in the
the arms and legs. patient at this stage of spinal cord
c. the presence of hyperactive reflex injury.
activity below the level of the injury.
d. flaccid paralysis and lack of sensa-
tion below the level of the injury.
15. When caring for a patient who had a C8 Correct Answer(s): B

spinal cord injury 10 days ago and has Rationale: The nurse has identi-
a weak cough effort, bibasilar crack- fied that the cough effort is poor,
les, and decreased breath sounds, the so the initial action should be to
initial intervention by the nurse should use assisted coughing techniques
be to to improve the ability to mobilize
a. administer oxygen at 7 to 9 L/min secretions. Administration of oxy-
with a face mask. gen will improve oxygenation, but
b. place the hands on the epigastric the data do not indicate hypoxemia,
area and push upward when the pa- and oxygen will not help expel res-
tient coughs. piratory secretions. The use of the
c. encourage the patient to use an in- spirometer may improve respirato-
centive spirometer every 2 hours dur- ry status, but the patient's ability to
ing the day. take deep breaths is limited by the
d. suction the patient's oral and pha- loss of intercostal muscle function.
ryngeal airway. Suctioning may be needed if the
patient is unable to expel secre-
tions by coughing but should not be
the nurse's first action.
16. A patient with a T1 spinal cord injury Correct Answer(s): B

is admitted to the intensive care unit Rationale: The patient with a T1
(ICU). The nurse will teach the patient injury can expect to retain full motor
and family that and sensory function of the arms.
a. use of the shoulders will be pre- Use of only the shoulders is associ-
served. ated with cervical spine injury. Total
5 / 10
b. full function of the patient's arms loss of respiratory function occurs
will be retained. with injuries above the C4 level and
c. total loss of respiratory function is permanent. Bradycardia is asso-
may occur temporarily. ciated with injuries above the T6
d. elevations in heart rate are common level.
with this type of injury.
17. The health care provider orders ad- Correct Answer(s): C

ministration of IV methylprednisolone Rationale: The purpose of methyl-
(Solu-Medrol) for the first 24 hours to a prednisolone administration is to
patient who experienced a spinal cord help preserve neurologic function;
injury at the T10 level 3 hours ago. therefore, the nurse will assess this
When evaluating the effectiveness of patient for lower-extremity function.
the medication the nurse will assess Sympathetic nervous system dys-
a. blood pressure and heart rate. function occurs with injuries at or
b. respiratory effort and O2 saturation. above T6, so monitoring of BP
c. motor and sensory function of the and heart rate will not be useful
legs. in determining the effectiveness of
d. bowel sounds and abdominal dis- the medication. Respiratory and GI
tension. function will not be impaired by
a T10 injury, so assessments of
these systems will not provide in-
formation about whether the med-
ication is effective.
18. A patient with a paraplegia resulting Correct Answer(s): A

from a T10 spinal cord injury has a neu- Rationale: Because the patient's
rogenic reflex bladder. When the nurse bladder is spastic and will emp-
develops a plan of care for this prob- ty in response to overstretching of
lem, which nursing action will be most the bladder wall, the most appropri-
appropriate? ate method is to avoid incontinence
a. Teaching the patient how to by emptying the bladder at reg-
self-catheterize ular intervals through intermittent
b. Assisting the patient to the toilet catheterization. Assisting the pa-
q2-3hr tient to the toilet will not be helpful
c. Use of the Credé method to empty because the bladder will not empty.
the bladder The Credé method is more appro-
d. Catheterization for residual urine priate for a bladder that is flaccid,
after voiding such as occurs with a reflexic neu-
6 / 10
rogenic bladder. Catheterization af-
ter voiding will not resolve the pa-
tient's incontinence.
19. A patient with a history of a T2 spinal Correct Answer(s): B

cord tells the nurse, "I feel awful today. Rationale: The BP should be as-
My head is throbbing, and I feel sick to sessed immediately in a patient
my stomach." Which action should the with an injury at the T6 level or high-
nurse take first? er who complains of a headache
a. Notify the patient's health care to determine whether autonomic
provider. dysreflexia is causing the symp-
b. Check the blood pressure (BP). toms, including hypertension. Noti-
c. Give the ordered antiemetic. fication of the patient's health care
d. Assess for a fecal impaction. provider is appropriate after the
BP is obtained. Administration of
an antiemetic is indicated after au-
tonomic dysreflexia is ruled out
as the cause of the nausea. The
nurse may assess for a fecal im-
paction, but this should be done
after checking the BP and lidocaine
jelly should be used to prevent fur-
ther increases in the BP.
20. The nurse discusses long-range goals Correct Answer(s): D

with a patient with a C6 spinal cord Rationale: The patient with a C6 in-
injury. An appropriate patient outcome jury will be able to use the hands to
is push a wheelchair on flat, smooth
a. transfers independently to a wheel- surfaces. Because flexion of the
chair. thumb and fingers is minimal, the
b. drives a car with powered hand con- patient will not be able to grasp a
trols. wheelchair during transfer, drive a
c. turns and repositions self indepen- car with powered hand controls, or
dently when in bed. turn independently in bed.
d. pushes a manual wheelchair on flat,
smooth surfaces.
21. A patient who sustained a T1 spinal Correct Answer(s): A

cord injury a week ago refuses to dis- Rationale: The patient is demon-
7 / 10
cuss the injury and becomes verbal- strating behaviors consistent with
ly abusive to the nurses and other the anger phase of the mourning
staff. The patient demands to be trans- process, and the nurse should al-
ferred to another hospital, where "they low expression of anger and seek
know what they are doing." The best the patient's input into care. Ex-
response by the nurse to the patient's pression of anger is appropriate
behavior is to at this stage and should be toler-
a. ask for the patient's input into the ated by the nurse. Refusal to ac-
plan for care. knowledge the patient's anger by
b. clarify that abusive behavior will not telling the patient that the anger is
be tolerated. just a phase is inappropriate. Con-
c. reassure the patient that the anger tinuing to perform needed assess-
will pass and rehabilitation will then ments and care is appropriate, but
progress. the nurse should seek the patient's
d. ignore the patient's anger and con- input into what care is needed.
tinue to perform needed assessments
and care.
22. A 26-year-old patient with a C8 spinal Correct Answer(s): D

cord injury tells the nurse, "My wife Rationale: Maintenance of sexu-
and I have always had a very active ality is an important aspect of re-
sex life, and I am worried that she may habilitation after spinal cord injury
leave me if I cannot function sexually." and should be handled by some-
The most appropriate response by the one with expertise in sexual coun-
nurse to the patient's comment is to seling. Although the patient should
a. advise the patient to talk to his wife discuss these issues with his wife,
to determine how she feels about his open communication about this is-
sexual function. sue may be difficult without the
b. tell the patient that sildenafil (Vi- assistance of a counselor. Silde-
agra) helps to decrease erectile dys- nafil does assist with erectile dys-
function in patients with spinal cord function after spinal cord injury, but
injury. the patient's sexuality is not deter-
c. inform the patient that most patients mined solely by the ability to have
with upper motor neuron injuries have an erection. Reflex erections are
reflex erections. common after upper motor neu-
d. suggest that the patient and his wife ron injury, but these erections are
work with a nurse specially trained in uncontrolled and cannot be main-
sexual counseling. tained during coitus.
8 / 10
23. A 25-year-old patient has returned Correct Answer((s): D
home following extensive rehabilita- Rationale: The best action by the
tion for a C8 spinal cord injury. The nurse will be to involve all the par-
home care nurse visits and notices ties in developing an optimal plan
that the patient's spouse and parents of care. Because family members
are performing many of the activities who will be assisting with the pa-
of daily living (ADLs) that the patient tient's ongoing care need to feel
had been managing during rehabilita- that their input is important, telling
tion. The most appropriate action by the family that the patient can per-
the nurse at this time is to form ADLs independently is not the
a. tell the family members that the pa- best choice. Reminding the patient
tient can perform ADLs independently. about the importance of indepen-
b. remind the patient about the impor- dence may not change the behav-
tance of independence in daily activi- iors of the family members. Sup-
ties. porting the activities of the spouse
c. recognize that it is important for the and parents will lead to ongoing de-
patient's family to be involved in the pendency by the patient.
patient's care and support their activi-
ties.
d. develop a plan to increase the pa-
tient's independence in consultation
with the with the patient, spouse, and
parents.
24. When caring for a patient who was ad- Correct Answer(s): C
mitted 24 hours previously with a C5 Rationale: Edema around the area
spinal cord injury, which nursing ac- of injury may lead to damage above
tion has the highest priority? the C4 level, so the highest priority
a. Continuous cardiac monitoring for is assessment of the patient's res-
bradycardia piratory function. The other actions
b. Administration of methylpred- are also appropriate but are not as
nisolone (Solu-Medrol) infusion important as assessment of respi-
c. Assessment of respiratory rate and ratory effort.
depth
d. Application of pneumatic compres-
sion devices to both legs
25. In which order will the nurse perform Correct Answer(s): C, A, B, D

the following actions when caring for Rationale: The first action should
9 / 10
a patient with possible cervical spinal be to prevent further injury by sta-
cord trauma who is admitted to the bilizing the patient's spinal cord.
emergency department? Maintenance of oxygenation by ad-
a. Administer O2 using a non-re- ministration of 100% O2 is the
breathing mask. second priority. Because neuro-
b. Monitor cardiac rhythm and blood genic shock is a possible complica-
pressure. tion, continuous monitoring of heart
c. Immobilize the patient's head, neck, rhythm and BP is indicated. CT
and spine. scan to determine the extent and
d. Transfer the patient to radiology for level of injury is needed once initial
spinal CT. assessment and stabilization is ac-
complished.
26. The nurse is caring for a man who Correct Answer(s: ) C

has experienced a spinal cord injury. Having a bowel movement is a
Throughout his recovery, the client ex- spinal reflex requiring intact nerve
pects to gain control of his bowels. The fibers. Yours are not intact
nurse's best response to this client The act of defecation is a spinal
would be which of the following? reflex involving the parasympathet-
a. "Over time, the nerve fibers will ic nerve fibers. Normally, the ex-
regrow new tracts, and you can have ternal anal sphincter is maintained
bowel movements again." in a state of tonic contraction. With
b. "Wearing an undergarment will be- a spinal cord injury, the client no
come more comfortable over time." longer has this nervous system
c "Having a bowel movement is a control and is often incontinent.
spinal reflex requiring intact nerve
fibers. Yours are not intact."
d "It is not going to happen. Your nerve
cells are too damaged."
10 / 10
Exam 3: Spinal Cord Injury NCLEX Questions
Study online at https://quizlet.com/_8qvc36
1. a During rehabilitation, a patient with spinal cord injury be-

gins to ambulate with long leg braces. Which level of injury
does the nurse associate with this degree of recovery?
a. L1-2
b. T6-7
c. T1-2
d. C7-8
2. b A patient with a T4 spinal cord injury experiences neuro-

genic shock as a result of SNS dysfunction. What would
the nurse recognize as characteristic of this condition?
a. Tachycardia
b. Hypotension
c. Increased urine output
d. Peripheral vasoconstriction
3. c A patient with spinal cord injury is experiencing severe

neurologic deficits. What is the most likely mechanism of
injury for this patient?
a. compression
b. hyperextension
c. flexion-rotation
d. extension-rotation
4. c A patient with a C7 SCI undergoing rehabilitation tells

the nurse he must have the flu because he has a bad
headache and nausea. The nurse's first priority is to
a. call the HCP

b. check the patient's temperature
c. take the patient's blood pressure
d. elevate the HOB to 90 degrees
5. a The nurse is caring for a patient with a halo vest after

cervical spine injury. Which care instructions should the
nurse include in the patient's discharge plan?
1 / 14
a. Keep a wrench close or attached to the vest.

b. Use the frame and vest to assist in positioning.
c. Clean around the pins using betadine swab sticks.
d. Loosen both sides of the vest to provide skin care
6. a The nurse performs discharge teaching for a 34-yr-old

male patient with a thoracic spinal cord injury (T2) from a
construction accident. Which patient statement indicates
teaching about autonomic dysreflexia is successful?
a. "I will perform self-catheterization at least six times per

day."
b. "A reflex erection may cause an unsafe drop in blood
pressure."
c. "If I develop a severe headache, I will lie down for 15 to
20 minutes."
d. "I can avoid this problem by taking medications to pre-
vent leg spasms."
7. c A 22-yr-old woman with paraplegia after a spinal cord

injury tells the home care nurse she experiences bowel
incontinence two or three times each day. Which action by
the nurse is most appropriate?
a. Insert a rectal stimulant suppository.

b. Teach the patient to gradually increase intake of
high-fiber foods.
c. Assess bowel movements for frequency, consistency,
and volume.
d. Instruct the patient to avoid all caffeinated and carbon-
ated beverages.
8. b The nurse is caring for a patient admitted with a spinal cord

injury after a motor vehicle accident. The patient exhibits a
complete loss of motor, sensory, and reflex activity below
the injury level. The nurse recognizes this condition as
2 / 14
a. Central cord syndrome
b. Spinal shock syndrome
c. Anterior cord syndrome
d. Brown-Séquard syndrome
9. a Which clinical manifestation would the nurse interpret as a

manifestation of neurogenic shock in a patient with acute
spinal cord injury?
a. Bradycardia
b. Hypertension
c. Neurogenic spasticity
d. Bounding pedal pulses
10. d When planning care for a patient with a cervical spinal

cord injury (C5), which nursing diagnosis has the highest
priority?
a. Impaired urinary elimination related to tetraplegia

b. Risk for impaired tissue integrity related to paralysis
c. Disabled family coping related to the extent of trauma
d. Ineffective airway clearance related to cervical spinal
cord injury
11. a Which manifestations in a patient with a thoracic spinal

cord injury (T4) should alert the nurse to possible auto-
nomic dysreflexia?
a. Headache and rising blood pressure

b. Irregular respirations and shortness of breath
c. Decreased level of consciousness or hallucinations
d. Abdominal distention and absence of bowel sounds
12. c Which intervention should the nurse perform first in the

acute care of a patient with autonomic dysreflexia?
a. Urinary catheterization
b. Check for bowel impaction
c. Elevate the head of the bed
d. Administer intravenous hydralazine
3 / 14
13. c A 25-yr-old male patient who is a professional motocross

racer has anterior spinal cord syndrome at T10. His history
is significant for tobacco, alcohol, and marijuana use. What
is the nurse's priority when planning for rehabilitation?
a. Prevent urinary tract infection.

b. Monitor the patient every 15 minutes.
c. Encourage him to verbalize his feelings.
d. Teach him about using the gastrocolic reflex.
14. b A client with a spinal cord injury (SCI) reports sudden

severe throbbing headache that started a short time ago.
Assessment of the client reveals increased blood pressure
(168/94 mm Hg) and decreased heart rate (48 beats/min),
diaphoresis, and flushing of the face and neck. What action
should the nurse take first?
a. Administer the ordered acetaminophen.

b. Check the Foley tubing for kinks or obstruction.
c. Adjust the temperature in the client's room.
d. Notify the health care provider about the change in
status.
15. a The nurse is helping a client with a spinal cord injury to

b establish a bladder retraining program. Which strategies
d may stimulate the client to void? Select all that apply.
e
a. Stroking the client's inner thigh
b. Pulling on the client's pubic hair
c. Initiating intermittent straight catheterization
d. Pouring warm water over the client's perineum
e. Tapping the bladder to stimulate the detrusor muscle
f. Reminding the client to void in a urinal every hour while
awake
16. d A client with a spinal cord injury at level C3 to C4 is being

cared for by the nurse in the emergency department (ED).
What is the priority nursing assessment?
4 / 14
a. Determine the level at which the client has intact sen-
sation.
b. Assess the level at which the client has retained mobility.
c. Check blood pressure and pulse for signs of spinal
shock.
d. Monitor respiratory effort and oxygen saturation level.
17. d Which nursing action will the home health nurse include
in the plan of care for a patient with paraplegia in order to
prevent autonomic dysreflexia?
a. Assist with selection of a high protein diet.

b. Use quad coughing to assist cough effort.
c. Discuss options for sexuality and fertility.
d. Teach the purpose of a prescribed bowel program.
18. a A patient with a neck fracture at the C5 level is admitted

to the intensive care unit. During initial assessment of the
patient, the nurse recognizes the presence of neurogenic
shock on finding
a. hypotension, bradycardia, and warm extremities.

b. involuntary, spastic movements of the arms and legs.
c. hyperactive reflex activity below the level of the injury.
d. lack of movement or sensation below the level of the
injury.
19. b A patient with a T1 spinal cord injury is admitted to the

intensive care unit. The nurse will teach the patient and
family that
a. use of the shoulders will be preserved.

b. full function of the patients arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of
injury.
20. b A patient with paraplegia resulting from a T10 spinal cord

injury has a neurogenic reflex bladder. Which action will
the nurse include in the plan of care?
5 / 14
a. Educate on the use of the Cred method.

b. Teach the patient how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the patient to the toilet every 2 hours.
21. d When the nurse is developing a rehabilitation plan for a

patient with a C6 spinal cord injury, an appropriate patient
goal is that the patient will be able to
a. transfer independently to a wheelchair.

b. drive a car with powered hand controls.
c. turn and reposition independently when in bed.
d. push a manual wheelchair on flat, smooth surfaces.
22. a A patient who sustained a spinal cord injury a week ago

becomes angry, telling the nurse I want to be transferred
to a hospital where the nurses know what they are doing!
Which reaction by the nurse is best?
a. Ask for the patients input into the plan for care.
b. Clarify that abusive behavior will not be tolerated.
c. Reassure the patient about the competence of the nurs-
ing staff.
d. Continue to perform care without responding to the
patients comments.
23. c After a 25-year-old patient has returned home following

rehabilitation for a spinal cord injury, the home care nurse
notes that the spouse is performing many of the activities
that the patient had been managing during rehabilitation.
The most appropriate action by the nurse at this time is to
a. tell the spouse that the patient can perform activities

independently.
b. remind the patient about the importance of indepen-
dence in daily activities.
c. develop a plan to increase the patients independence in
consultation with the patient and the spouse.
6 / 14
d. recognize that it is important for the spouse to be
involved in the patients care and support the spouses
participation.
24. a When caring for a patient who was admitted 24 hours

previously with a C5 spinal cord injury, which nursing
action has the highest priority?
a. Assessment of respiratory rate and depth

b. Continuous cardiac monitoring for bradycardia
c. Application of pneumatic compression devices to both
legs
d. Administration of methylprednisolone (Solu-Medrol) in-
fusion
25. c When caring for a patient who had a C8 spinal cord

injury 10 days ago and has a weak cough effort and
loose-sounding secretions, the initial intervention by the
nurse should be to
a. suction the patients oral and pharyngeal airway.

b. administer oxygen at 7 to 9 L/min with a face mask.
c. place the hands on the epigastric area and push upward
when the patient coughs.
d. encourage the patient to use an incentive spirometer
every 2 hours during the day.
26. c A patient with a history of a T2 spinal cord injury tells the

nurse, I feel awful today. My head is throbbing, and I feel
sick to my stomach. Which action should the nurse take
first?
a. Assess for a fecal impaction.

b. Give the prescribed antiemetic.
c. Check the blood pressure (BP).
d. Notify the health care provider.
27. c A 26-year-old patient with a T3 spinal cord injury asks the

nurse about whether he will be able to be sexually active.
Which initial response by the nurse is best?
7 / 14
a. Reflex erections frequently occur, but orgasm may not

be possible.
b. Sildenafil (Viagra) is used by many patients with spinal
cord injury.
c. Multiple options are available to maintain sexuality after
spinal cord injury.
d. Penile injection, prostheses, or vacuum suction devices
are possible options.
28. a When caring for a patient who experienced a T1 spinal

c cord transsection 2 days ago, which collaborative and
d nursing actions will the nurse include in the plan of care?
e Select all that apply
a. Urinary catheter care

b. Nasogastric (NG) tube feeding
c. Continuous cardiac monitoring
d. Avoidance of cool room temperature
e. Administration of H2 receptor blockers
29. a A 70 year old patient is admitted after falling from his

roof. He has a spinal cord injury at the C7 level. What
findings during the assessment identify the presence of
spinal shock?
a. paraplegia with a flaccid paralysis

b. tetraplegia with total sensory loss
c. total hemiplegia with sensory and motor loss
d. spastic tetraplegia with loss of pressure sensation
30. c What causes an initial SCI to result in complete cord

damage?
a. edematous compression of the cord above the level of

injury
b. continued trauma to the cord resulting from damage to
stabilizing ligaments
c. infarction and necrosis of the cord caused by edema,
8 / 14
hemorrhage, and metabolites
d. mechanical transection of the cord by sharp vertebral
bone fragments after the initial injury
31. c A patient with SCI has spinal shock. The nurse plans care
for the patient based on what knowledge?
a. rehabilitation measures cannot be initiated until spinal

shock has resolved
b. the patient will need continuous monitoring for hypoten-
sion, tachycardia, and hypoxemia
c. resolution of spinal shock is manifested by spasticity,
reflex return, and neurogenic bladder
d. patient will have complete loss of motor and sensory
functions below the level of the injury, but autonomic func-
tions are not affected
32. b Two days following SCI, a patient asks continually about

the extent of impairment that will result from the injury.
What is the best response by the nurse?
a. "you will have more normal function when spinal shock

resolves and the reflux arc returns"
b. "the extent of your injury cannot be determined until the
secondary injury to the cord is resolved"
c. "when your condition is more stable, MRI will be done
to reveal the extent of the cord damage"
d. "because long-term rehabilitation can affect the return
of function, it will be years before we can tell what the
complete affect will be"
33. a The patient was in a traffic collision and is experiencing

loss of function below C4. Which effect must the nurse be
aware of to provide priority care for the patient?
a. respiratory diaphragmatic breathing

b. loss of all respiratory muscle function
c. decreased response of the SNS
9 / 14
d. GI hypomobility with paralytic ileus and gastric disten-
tion
34. b A patient is admitted to the ED with SCI at the level of T2.

Which clinical finding is of most concern by the nurse?
a. SpO2 of 92%
b. heart rate of 42 bpm
c. BP of 88/60
d. loss of motor and sensory function in the arms and legs
35. d What is one indication for early surgical therapy of the

patient with SCI?
a. there is incomplete cord lesion involvement

b. the ligaments that support the spine are torn
c. a high cervical causes loss of respiratory function
d. evidence of continued compression of the cord is appar-
ent
36. a A patient is admitted to the ED with a possible cervical

SCI following an automobile crash. During admission of
the patient, what is the highest priority for the nurse?
a. maintaining a patent airway

b. assessing the patient for head and other injuries
c. maintaining immobilization of the cervical spine
d. assessing the patient's motor and sensory function
37. c Before surgical stabilization, what method of immobiliza-

tion for the patient with a cervical SCI should the nurse
expect to be used?
a. kinetic beds
b. hard cervical collar
c. skeletal traction with skull tongs
d. sternal-occipital-mandibular immobilizer brace
38. d The HCP has prescribed IV norepinephrine for the patient

in the ED with SCI. The nurse determines that the drug is
10 / 14
having the desired effect when what is observed in patient
assessment?
a. HR of 68 bpm
c. temperature of 96.8
d. BP 106/82
39. c During assessment of the patient with SCI, the nurse de-
termines that the patient has a poor cough with diaphrag-
matic breathing. Based on this finding, what should be the
nurse's first action?
a. institute frequent turning and repositioning

b. use tracheal suctioning to remove secretions
c. assess lung sounds and respiratory rate and depth
d. prepare the patient for ET intubation and mechanical
ventilation
40. d Following a T2 SCI, the patient develops paralytic ileus.

While this condition is present, what should the nurse
anticipate that the patient will need?
a. IV fluids
b. tube feedings
c. parenteral nutrition
d. nasogastric suctioning
41. a How is urinary function maintained during the acute phase

of SCI?
b. intermittent catheterization
c. insertion of a suprapubic catheter
d. use of incontinent pads to protect the skin
42. b A week following SCI at T2, a patient experiences move-

ment in his legs and tells the nurse that he is recovering
some function. What is the nurse's best response?
11 / 14
a. "it is really still too soon to know if you will have a return
of function"
b. "that could be a really positive finding. Can you show me
the movement?"
c. "that's wonderful. We will start exercising your legs more
frequently now"
d. "I'm sorry but the movement is only a reflex and does
not indicate normal function"
43. b A patient with paraplegia has developed an irritable blad-

der with reflux emptying. Along with possible use of med-
ications, what will be most helpful for the nurse to teach
the patient?
a. hygiene care for an indwelling urinary catheter

b. how to perform intermittent self-catheterization
c. to empty the bladder with manual pelvic pressure in
coordination with reflex voiding patterns
d. that a urinary diversion, such as an ileal conduit, is the
easiest way to handle urinary elimination
44. b In counseling patients with SCI regarding sexual function,

how should the nurse advise a male patient with a com-
plete lower motor neuron lesion?
a. he may have uncontrolled reflex erections, but orgasm

and ejaculation are usually not possible
b. he is most likely to have reflex erections and may expe-
rience orgasm if S2-S4 nerve pathways are intact
c. he has a lesion with the greatest possibility of successful
pyschogenic erection with ejaculation and orgasm
d. he will probably be unable to have either psychogenic
or reflexogenic erections and no ejaculation or orgasm
45. a During the patient's process of grieving for the losses

resulting from SCI, what should the nurse do?
a. help the patient to understand that working through the

grief will be a lifelong process
12 / 14
b. assist the patient to move through all stages of the
mourning and grief process to acceptance
c. let the patient know that anger directed at the staff or the
family is not a positive coping mechanism
d. facilitate the grieving process so that it is completed by
the time the patient is discharged from rehabilitation
46. a A nurse is planning care for a client who has a SCI involv-
ing a T12 fracture 1 week ago. The client has no muscle
control of the lower limbs, bowel, or bladder. Which of the
following should be the nurse's highest priority?
a. prevention of further damage to the spinal cord

b. prevention of contractures of the lower extremities
c. prevention of skin breakdown of areas that lack sensa-
tion
d. prevention of postural hypotension when placing the
47. b A nurse is caring for a client who has a SCI who reports
severe headache and is sweating profusely. Vital signs
include BP 220/110 and apical HR of 54. Which of the
following actions should the nurse take first?
a. examine the skin for irritation or pressure

b. sit the client upright in bed
c. check the urinary catheter for blockage
d. administer antihypertensive medication
48. d A nurse is caring for a client who has a C4 SCI. The nurse
should recognize the client is at greatest risk for which of
the following complications?
a. neurogenic shock
b. paralytic ileus
c. stress ulcer
49. d A nurse is caring for a client who experiences a cervical

spine injury 24 hours ago. Which of the following prescrip-
13 / 14
tions should the nurse clarify with the provider?
a. anticoagulant
b. plasma expanders
c. H2 antagonists
d. muscle relaxants
50. a A nurse is caring for a client who experienced a cervical

spine injury 3 months ago. The nurse should plan to imple-
ment which of the following types of bladder management
methods?
a. condom catheter
b. intermittent urinary catheterization
c. Crede's method
d. indwelling urinary catheter
51. a A client with a SCI is prone to experiencing autonomic

b dysreflexia. The nurse should include which measures in
d the plan of care to minimize the risk of this occurrence?
Select all that apply
a. keeping the linens wrinkle-free under the client

b. preventing unnecessary pressure on the lower limbs
c. limiting bladder catheterization to once every 12 hours
d. turning and repositioning the client at least every 2 hours
e. ensuring that the client has a bowel movement at least
once a week
52. c The nurse is evaluating the neurologic signs of a client in

spinal shock following SCI. Which observation indicates
that spinal shock persists?
a. hyperreflexia
b. positive reflexes
c. flaccid paralysis
d. reflex emptying of the bladder
14 / 14
Trauma/SCI/TBI/ICP NCLEX Questions
Study online at https://quizlet.com/_1g2dcp
1. You are working in the triage area of an ED, and 2.) B A D C

four patients approach the triage desk at the same
time. List the order in which you will assess these Rationale:
patients: An irritable infant with
fever and petechi-
a. An ambulatory, dazed 25-year-old male with a ae should be further
bandaged head wound assessed for other
b. An irritable infant with a fever, petechiae, and meningeal signs. The
nuchal rigidity patient with the head
c. A 35-year-old jogger with a twisted ankle, having wound needs addition-
pedal pulse and no deformity al history and assess-
d. A 50-year-old female with moderate abdominal ment for intracranial
pain and occasional vomiting. pressure. The patient
with moderate abdom-
1.) A B D C inal pain is uncomfort-
2.) B A D C able, but not unstable
3.) C D B A at this point. For the
4.) C B A D ankle injury, medical
evaluation can be de-
layed 24 - 48 hours if
necessary.
2. In conducting a primary survey on a trauma pa- c.) Brief neurologic as-

tient, which of the following is considered one of sessment
the priority elements of the primary survey?
Rationale:
a.) Complete set of vital signs A brief neurologic as-
b.) Palpation and auscultation of the abdomen sessment to deter-
c.) Brief neurologic assessment mine level of con-
d.) Initiation of pulse oximetry sciousness and pupil
reaction is part of the
primary survey. Vital
signs, assessment of
the abdomen, and initi-
ation of pulse oximetry
are considered part of
the secondary survey.
3.
1 / 20
You respond to a call for help from the ED waiting 2.) B D A C E
room. There is an elderly patient lying on the floor.
List the order for the actions that you must per- Rationale:
form. Establish unrespon-
siveness first. (The pa-
a. Perform the chin lift or jaw thrust maneuver. tient may have fallen
b. Establish unresponsiveness. and sustained a minor
c. Initiate cardiopulmonary resuscitation (CPR). injury.) If the patient
d. Call for help and activate the code team. is unresponsive, get
e. Instruct a nursing assistant to get the crash cart. help and have some-
one initiate the code.
1.) A B C E D Performing the chin lift
2.) B D A C E or jaw thrust maneuver
3.) C A B E D opens the airway. The
4.) D C B E A nurse is then respon-
5.) E C D B A sible for starting CPR.
CPR should not be in-
terrupted until the pa-
tient recovers or it is
determined that heroic
efforts have been ex-
hausted. A crash cart
should be at the site
when the code team
arrives; however, basic
CPR can be effective-
ly performed until the
team arrives.
4. A client with trauma to the chest develops a ten- a.) an increase in

sion pneumothorax. After a needle thorocostomy blood pressure.
is performed the nurse would expect:
Rationale:
a.) an increase in blood pressure. Clients presenting with
b.) a decrease in blood pressure. tension pneumothorax
c.) an increase in jugular venous distension. would exhibit hypoten-
d.) a decrease in level of consciousness. sion, jugular venous
distension, and de-
creasing level of con-
2 / 20
sciousness. An in-
crease in blood pres-
sure should result after
a thoracostomy is per-
formed.
5. A pediatric client is admitted to the neuro ICU with d.) Deceleration

a closed-head injury sustained after falling out of
a tree house. The mechanisms of injury this young Rationale:
client most likely sustained would be: Deceleration injury oc-
curs when the brain
a.) Acceleration stops rapidly in the
b.) Penetrating cranial vault. As the
c.) Rotational skull ceases move-
d.) Deceleration ment, the brain con-
tinues to move until it
hits the skull. The force
of deceleration caus-
es injury at the site of
impact. An example of
this is a victim of a fall.
6. A client who has had a plaster of Paris cast applied D.) Evaluate the re-
to his forearm is receiving pain medication. To sponse to analgesics
detect early manifestations of compartment syn-
drome, which of these assessments should the
nurse make?
A.) Observe the color of the fingers

B.) Palpate the radial pulse under the cast
C.) Check the cast for odor and drainage
D.) Evaluate the response to analgesics
7. A client presents in the emergency department C.) The affected ex-

after falling from a roof. A fracture of the femoral tremity is shortened,
neck is suspected. Which of these assessments adducted, and ex-
best support this diagnosis? tremely rotated
A.) The client reports pain in the affected leg
3 / 20
B.) A large hematoma is visible in the affected
extremity
C.) The affected extremity is shortened, adducted,
and extremely rotated
D.) The affected extremity is edematous
8. When admitting a client with a fractured extremity, c.) The area distal to
the nurse would focus the assessment on which the fracture
of the following first?
a.) The area proximal to the fracture

b.) The actual fracture site
c.) The area distal to the fracture
d.) The opposite extremity for baseline compari-
son
9. Which of the following would lead the nurse to a.) Acute respiratory
suspect that a client with a fracture of the right distress syndrome
femur may be developing a fat embolus?
a.) Acute respiratory distress syndrome

b.) Migraine like headaches
c.) Numbness in the right leg
d.) Muscle spasms in the right thigh
10. Following x-rays of an injured wrist, the patient is c.) use pillows to
informed that it is badly sprained. In teaching the keep the arm elevated
patient to care for the injury, the nurse tells the above the heart.
patient to
Rationale:
a.) apply a heating pad to reduce muscle spasms. Elevation of the arm
b.) wear an elastic compression bandage continu- will reduce the amount
ously. of swelling and pain.
c.) use pillows to keep the arm elevated above the For the first 24 to
heart. 48 hours, cold packs
d.) gently exercise the joint to prevent muscle are used to reduce
shortening. swelling. Compression
bandages are not left
on continuously. The
4 / 20
wrist should be rest-
ed and kept immo-
bile to prevent further
swelling or injury.
11. A patient with a fractured pelvis is initially treated d.) pinpoint red areas
with bed rest with no turning from side to side on the upper chest.
permitted. The second day after admission, the
patient develops chest pain, tachypnea, and tachy- Rationale:
cardia. The nurse determines that the patient's The presence of pe-
symptoms are most likely related to fat embolism techiae helps distin-
when assessment of the patient reveals guish fat embolism
from other problems.
a.) a blood pressure of 100/65 mm Hg. The other symptoms
b.) anxiety, restlessness, and confusion. might occur with fat
c.) warm, reddened areas in the calf. embolism but could
d.) pinpoint red areas on the upper chest. also occur with other
postoperative compli-
cations such as bleed-
ing, myocardial infarc-
tion, venous thrombo-
sis, or hypoxemia.
12. Based on the nurse's understanding of the phys- a. fracture of the mid-
iology of bone and cartilage, the injury that the humerus.
nurse would expect to heal most rapidly is a:
Rationale:
a. fracture of the midhumerus. Bone is dynamic tis-
b. torn knee cruciate ligament. sue that is continual-
c. fractured nose. ly growing. Nasal frac-
d. severely sprained ankle. ture, sprains, and liga-
ment tears injure car-
tilage, tendons, and
ligaments, which are
slower to heal.
13. When the health care provider tells a patient that b. a small, fluid-filled
the pain in the patient's knee is caused by bursitis, sac found at many
the patient asks the nurse to explain just what joints.
5 / 20
bursitis is. The nurse's best response would be to
tell the patient bursitis is an inflammation of Rationale:
Bursae are fluid-filled
a. the fibrocartilage that acts as a shock absorber sacs that cushion
in the knee joint. joints and bony promi-
b. a small, fluid-filled sac found at many joints. nences. Fibrocartilage
c. any connective tissue that is found supporting is a solid tissue that
the joints of the body. cushions some joints.
d. the synovial membrane that lines the area be- Bursae are a spe-
tween two bones of a joint. cific type of connec-
tive tissue. The syn-
ovial membrane lines
many joints but is not a
bursa.
14. A client admitted to the hospital with a sub- b.) Intracranial pres-
arachnoid hemorrhage has complaints of severe sure (ICP) is increased
headache, nuchal rigidity, and projectile vomiting.
The nurse knows lumbar puncture (LP) would be Rationale:
contraindicated in this client in which of the fol- Sudden removal of
lowing circumstances? CSF results in pres-
sures lower in the lum-
a.) Vomiting continues bar area than the brain
b.) Intracranial pressure (ICP) is increased and favors herniation
c.) The client needs mechanical ventilation of the brain; there-
d.) Blood is anticipated in the cerebralspinal fluid fore, LP is contraindi-
(CSF) cated with increased
ICP. Vomiting may be
caused by reasons
other than increased
ICP; therefore, LP isn't
strictly contraindicat-
ed. An LP may be
preformed on clients
needing mechanical
ventilation. Blood in
the CSF is diagnos-
tic for subarachnoid
hemorrhage and was
6 / 20
obtained before signs
and symptoms of ICP.
15. A client with a subdural hematoma becomes rest- c.) To promote osmot-
less and confused, with dilation of the ipsilateral ic diuresis to decrease
pupil. The physician orders mannitol for which of ICP
the following reasons?
Rationale:
a.) To reduce intraocular pressure Mannitol promotes os-
b.) To prevent acute tubular necrosis motic diuresis by in-
c.) To promote osmotic diuresis to decrease ICP creasing the pressure
d.) To draw water into the vascular system to in- gradient, drawing flu-
crease blood pressure id from intracellular to
intravascular spaces.
Although mannitol is
used for all the rea-
sons described, the re-
duction of ICP in this
client is a concern.
16. A client with subdural hematoma was given a.) Urine output in-
mannitol to decrease intracranial pressure (ICP). creases
Which of the following results would best show
the mannitol was effective? Rationale:
Mannitol promotes os-
a.) Urine output increases motic diuresis by in-
b.) Pupils are 8 mm and nonreactive creasing the pressure
c.) Systolic blood pressure remains at 150 mm Hg gradient in the renal
d.) BUN and creatinine levels return to normal tubes. Fixed and dilat-
ed pupils are symp-
toms of increased ICP
or cranial nerve dam-
age. No information
is given about abnor-
mal BUN and crea-
tinine levels or that
mannitol is being given
for renal dysfunction or
7 / 20
blood pressure main-
tenance.
17. Which of the following signs and symptoms of in- c.) Restlessness and
creased ICP after head trauma would appear first? confusion
a.) Bradycardia Rationale:

b.) Large amounts of very dilute urine The earliest symptom
c.) Restlessness and confusion of elevated ICP is
d.) Widened pulse pressure a change in men-
tal status. Bradycar-
dia, widened pulse
pressure, and bradyp-
nea occur later. The
client may void large
amounts of very dilute
urine if there's damage
to the posterior pitu-
itary.
18. Problems with memory and learning would relate d.) Temporal
to which of the following lobes?
Rationale:
a.) Frontal The temporal lobe
b.) Occipital functions to regulate
c.) Parietal memory and learn-
d.) Temporal ing problems because
of the integration of
the hippocampus. The
frontal lobe primari-
ly functions to regu-
late thinking, planning,
and judgment. The oc-
cipital lobe functions
regulate vision. The
parietal lobe primarily
functions with sensory
function.
8 / 20
19. While cooking, your client couldn't feel the temper- c.) Parietal
ature of a hot oven. Which lobe could be dysfunc-
tional? Rationale:
The parietal lobe regu-
a.) Frontal lates sensory function,
b.) Occipital which would include
c.) Parietal the ability to sense hot
d.) Temporal or cold objects. The
frontal lobe regulates
thinking, planning, and
judgment, and the oc-
cipital lobe is primarily
responsible for vision
function. The temporal
lobe regulates memo-
ry.
20. The nurse is assessing the motor function of an d.) Nail bed pressure
unconscious client. The nurse would plan to use
which of the following to test the client's peripher- Rationale:
al response to pain? Motor testing on the
unconscious client can
a.) Sternal rub be done only by test-
b.) Pressure on the orbital rim ing response to painful
c.) Squeezing the sternocleidomastoid muscle stimuli. Nailbed pres-
d.) Nail bed pressure sure tests a basic
peripheral response.
Cerebral responses to
pain are testing using
sternal rub, placing up-
ward pressure on the
orbital rim, or squeez-
ing the clavicle or ster-
nocleidomastoid mus-
cle.
21. A nurse is assisting with caloric testing of the c.) An intact brainstem
oculovestibular reflex of an unconscious client.
Cold water is injected into the left auditory canal. Rationale:
9 / 20
The client exhibits eye conjugate movements to- Caloric testing pro-
ward the left followed by a rapid nystagmus to- vides information
ward the right. The nurse understands that this about differentiating
indicates the client has: between cerebellar
and brainstem lesions.
a.) A cerebral lesion After determining pa-
b.) A temporal lesion tency of the ear canal,
c.) An intact brainstem cold or warm water
d.) Brain death is injected in the au-
ditory canal. A nor-
mal response that in-
dicates intact function
of cranial nerves III,
IV, and VIII is conju-
gate eye movements
toward the side be-
ing irrigated, followed
by rapid nystagmus to
the opposite side. Ab-
sent or dysconjugate
eye movements indi-
cate brainstem dam-
age.
22. The nurse is caring for the client with increased b.) Increasing tem-
intracranial pressure. The nurse would note which perature, decreasing
of the following trends in vital signs if the ICP is pulse, decreasing res-
rising? pirations, increasing
blood pressure.
a.) Increasing temperature, increasing pulse, in-
creasing respirations, decreasing blood pressure. Rationale:
A change in vital signs
b.) Increasing temperature, decreasing pulse, de- may be a late sign of
creasing respirations, increasing blood pressure. increased intracranial
pressure. Trends in-
c.) Decreasing temperature, decreasing pulse, include increasing tem-
creasing respirations, decreasing blood pressure. perature and blood
pressure and decreas-
ing pulse and respi-
10 / 20
d.) Decreasing temperature, increasing pulse, de- rations. Respiratory ir-
creasing respirations, increasing blood pressure. regularities also may
arise.
23. Which of the following would lead the nurse to a.) Hemorrhagic skin
suspect that a child with meningitis has developed rash
disseminated intravascular coagulation (DIC)?
Rationale:
a.) Hemorrhagic skin rash DIC is characterized
b.) Edema by skin petechiae and
c.) Cyanosis a purpuric skin rash
d.) Dyspnea on exertion caused by sponta-
neous bleeding into
the tissues. An abnor-
mal coagulation phe-
nomenon causes the
condition.
24. A nurse is planning care for a child with acute c.) Maintain respira-
bacterial meningitis. Based on the mode of trans- tory isolation precau-
mission of this infection, which of the following tions for at least 24
would be included in the plan of care? hours after the initia-
tion of antibiotics
a.) No precautions are required as long as antibi-
otics have been started Rationale:
A major priority of
b.) Maintain enteric precautions nursing care for a child
suspected of having
c.) Maintain respiratory isolation precautions for meningitis is to admin-
at least 24 hours after the initiation of antibiotics ister the prescribed
antibiotic as soon as
d.) Maintain neutropenic precautions it is ordered. The child
is also placed on res-
piratory isolation for at
least 24 hours while
culture results are ob-
tained and the antibiot-
ic is having an effect.
11 / 20
25. The nurse is evaluating the status of a client who a.) A positive Brudzin-
had a craniotomy 3 days ago. The nurse would ski's sign
suspect the client is developing meningitis as a
complication of surgery if the client exhibits: Rationale:
Signs of meningeal
a.) A positive Brudzinski's sign irritation compatible
b.) A negative Kernig's sign with meningitis include
c.) Absence of nuchal rigidity nuchal rigidity, posi-
d.) A Glascow Coma Scale score of 15 tive Brudzinski's sign,
and positive Kernig's
sign. Nuchal rigidity is
characterized by a stiff
neck and soreness,
which is especially no-
ticeable when the neck
is fixed. Kernig's sign
is positive when the
client feels pain and
spasm of the ham-
string muscles when
the knee and thigh
are extended from a
flexed-right angle posi-
tion. 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. A
Glascow Coma Scale
of 15 is a perfect score
and indicates the client
is awake and alert
with no neurological
deficits.
26. A client with a head injury is being monitored for a.) 52 mm Hg

increased intracranial pressure (ICP). His blood
12 / 20
pressure is 90/60 mmHG and the ICP is 18 mmHg; Rationale:
therefore his cerebral perfusion pressure (CPP) MAP=Systolic+Dias-
is: tolic(x2)/3
90+60(2)=210
a.) 52 mm Hg 90+120=210
b.) 88 mm Hg 210/3=70
c.) 48 mm Hg MAP=70
d.) 68 mm Hg CCP=MAP-ICP
70-18=52
CCP=52
27. For a male client with suspected increased in- c.) Promote carbon
tracranial pressure (ICP), a most appropriate res- dioxide elimination.
piratory goal is to:
Rationale:
a.) Prevent respiratory alkalosis. The goal in treatment
b.) Lower arterial pH. is to prevent acidemia
c.) Promote carbon dioxide elimination. by eliminating carbon
d.) Maintain partial pressure of arterial oxygen dioxide.
(PaO2) above 80 mm Hg
28. A client who was in a motor vehicle accident a few a.) Central cord syn-
days ago is now complaining of progressive weak- drome
ness in his arms and upper body while the func-
tioning of his lower limbs is unchanged. Which of Rationale:
the following might this client be experiencing? In central cord syn-
drome, motor and sen-
a.) Central cord syndrome sory function of the up-
b.) Whiplash syndrome per extremities is lost
c.) Anterior cord syndrome while the functioning of
d.) Brown-Sequard syndrome the lower extremities
stays intact.
29. A client with a spinal cord injury is exhibiting c.) Keep client warm
poikilothermia. Which of the following would be with extra blankets.
appropriate to include in this client's plan of care?
Rationale:
a.) Provide good perineal care. Poikilothermia is a loss
b.) Pass nasogastric tube to decompress stom- of temperature control
13 / 20
ach. and is dangerous be-
c.) Keep client warm with extra blankets. cause the client's body
d) Stimulate the anal-rectal reflex. temperature will de-
pend upon the temper-
ature in the environ-
ment. The client needs
to be kept warm and
monitored carefully to
avoid thermal injuries
from passive warming
devices.
30. During an assessment of a patient's motor sta- c.) 3

tus with the Glasgow Coma scale, the patient as-
sumes a posture of abnormal flexion. The nurse
would document this finding as:
a.) 5
b.) 4
c.) 3
d.) 2
31. A patient is admitted with a subacute subdur- b.) Elective draining of

al hematoma. The nurse realizes this patient will the hematoma.
most likely be treated with:
a.) Emergency craniotomy.

b.) Elective draining of the hematoma.
c.) Burr holes to remove the hematoma.
d.) Removal of the affected cranial lobe.
32. A patient with a traumatic brain injury is in need a.) Normal saline.
of fluid replacement therapy to maintain a systole
blood pressure of at least 90 mm Hg. The nurse Rationale:
realizes that the best fluid replacement for this A systolic blood pres-
patient would be: sure less than 90 mm
Hg in a patient with
a.) Normal saline. a traumatic brain in-
b.) D5W jury is a predictor of
a poor outcome. Ini-
14 / 20
c.) D5 1/2 0.9% NS tial management usu-
d.) 0.45% NS ally involves assuring
that the patient is hy-
drated. Isotonic crys-
talloids such as 0.9%
saline or Ringer's so-
lution are most com-
monly used. Normal
Saline is preferred be-
cause it is inexpen-
sive, iso-osmolar and
has no free water.
#2 and #4 are not
correct. In general,
the use of hypoton-
ic crystalloids, such as
D5W or 0.45% normal
saline is avoided be-
cause of the potential
for worsening cerebral
edema.
#3 is not correct.
D51/2 NS is hyperton-
ic and will draw fluid
from the cells & inters-
tial tissue into the vas-
cular space. This could
worsen cerebral ede-
ma.
33. The client with an old C6 spinal cord injury com- b.) blood pressure
plains of suddenly being too warm, with nasal
congestion and a very red face. What is your next Rationale:
assessment? This is autonomic dys-
reflexia and is usually
a.) temperature associated with hyper-
b.) blood pressure tension. Sit them up
c.) input and output for previous 8 hours quickly.
d.) bowel for impaction
15 / 20
34. The nurse is caring for a client with a closed head a.) hypoventilation
injury. Which of the following would contribute to
intracrainal hypertension? Rationale:
Hypoventilation leads
a.) hypoventilation to vasodilation and
b.) elevating the head of the bed increased intracranial
c.) hypernatremia pressure.
d.) quiet darkened environnent
35. A client with head trauma develops a urine out- a.) Evaluate urine spe-
put of 300 ml/hr, dry skin, and dry mucous mem- cific gravity
branes. Which of the following nursing interven-
tions is the most appropriate to perform initially? Rationale:
Urine output of 300
a.) Evaluate urine specific gravity ml/hr may indicate dia-
b.) Anticipate treatment for renal failure betes insipidus, which
c.) Provide emollients to the skin to prevent break- is a failure of the
down pituitary to produce
d.) Slow down the IV fluids and notify the physi- anti-diuretic hormone.
cian This may occur with
increased intracranial
pressure and head
trauma; the nurse eval-
uates for low urine
specific gravity, in-
creased serum osmo-
larity, and dehydration.
There's no evidence
that the client is ex-
periencing renal fail-
ure. Providing emol-
lients to prevent skin
breakdown is impor-
tant, but doesn't need
to be performed im-
mediately. Slowing the
rate of IV fluid would
contribute to dehydra-
16 / 20
tion when polyuria is
present.
36. When evaluating an ABG from a client with a sub- a.) Appropriate; low-
dural hematoma, the nurse notes the PaCO2 is ering carbon diox-
30 mm Hg. Which of the following responses best ide (CO2) reduces
describes this result? intracranial pressure
(ICP).
a.) Appropriate; lowering carbon dioxide (CO2) re-
duces intracranial pressure (ICP). Rationale:
b.) Emergent; the client is poorly oxygenated. A normal PaCO2 val-
c.) Normal ue is 35 to 45
d.) Significant; the client has alveolar hypoventila- mm Hg. CO2 has
tion. vasodilating proper-
ties; therefore, lower-
ing PaCO2 through hy-
perventilation will low-
er ICP caused by di-
lated cerebral vessels.
Oxygenation is eval-
uated through PaO2
and oxygen satura-
tion. Alveolar hypoven-
tilation would be re-
flected in an increased
PaCO2.
37. A client with a C4 spinal injury would most likely d.) Tetraplegia
have which of the following symptoms?
Rationale:
a.) Aphasia Tetraplegia occurs as
b.) Hemiparesis a result of cervical
c.) Paraplegia spine injuries. Paraple-
d.) Tetraplegia gia occurs as a result
of injury to the thoracic
cord and below.
38. A 22-year-old client with quadriplegia is apprehen- d.) Raise the head of
sive and flushed, with a blood pressure of 210/100 the bed immediately to
17 / 20
and a heart rate of 50 bpm. Which of the following 90 degrees
nursing interventions should be done first?
Rationale:
a.) Place the client flat in bed Anxiety, flushing
b.) Assess patency of the indwelling urinary above the level
catheter of the lesion, pi-
c.) Give one SL nitroglycerin tablet loerection, hyperten-
d.) Raise the head of the bed immediately to 90 sion, and bradycardia
degrees are symptoms of auto-
nomic dysreflexia, typ-
ically caused by such
noxious stimuli such
as a full bladder, fe-
cal impaction, or de-
cubitus ulcer. Putting
the client flat will cause
the blood pressure to
increase even more.
The indwelling urinary
catheter should be
assessed immediate-
ly after the HOB is
raised. Nitroglycerin is
given to reduce chest
pain and reduce pre-
load; it isn't used for
hypertension or dysre-
flexia.
39. A client is admitted to the ER for head trauma a.) Laceration of

is diagnosed with an epidural hematoma. The un- the middle meningeal
derlying cause of epidural hematoma is usually artery
related to which of the following conditions?
Rationale:
a.) Laceration of the middle meningeal artery Epidural hematoma or
b.) Rupture of the carotid artery extradural hematoma
c.) Thromboembolism from a carotid artery is usually caused by
d.) Venous bleeding from the arachnoid space laceration of the mid-
dle meningeal artery.
18 / 20
An embolic stroke
is a thromboembolism
from a carotid artery
that ruptures. Venous
bleeding from the
arachnoid space is
usually observed with
subdural hematoma
40. When discharging a client from the ER after a c.) An interval when
head trauma, the nurse teaches the guardian to the client is orient-
observe for a lucid interval. Which of the following ed but then becomes
statements best described a lucid interval? somnolent
a.) An interval when the client's speech is garbled Rationale:

b.) An interval when the client is alert but can't A lucid interval is de-
recall recent events scribed as a brief pe-
c.) An interval when the client is oriented but then riod of unconscious-
becomes somnolent ness followed by alert-
d.) An interval when the client has a "warning" ness; after several
symptom, such as an odor or visual disturbance. hours, the client again
loses consciousness.
Garbled speech is
known as dysarthria.
An interval in which
the client is alert
but can't recall re-
cent events is known
as amnesia. Warning
symptoms or auras
typically occur before
seizures.
41. Which of the following conditions indicates that b.) Spasticity

spinal shock is resolving in a client with C7 quad-
riplegia? Rationale:
Spasticity, the return of
a.) Absence of pain sensation in chest reflexes, is a sign of re-
b.) Spasticity solving shock. Spinal
19 / 20
c.) Spontaneous respirations or neurogenic shock
d.) Urinary continence is characterized by hy-
potension, bradycar-
dia, dry skin, flaccid
paralysis, or the ab-
sence of reflexes be-
low the level of in-
jury. The absence of
pain sensation in the
chest doesn't apply to
spinal shock. Spinal
shock descends from
the injury, and respi-
ratory difficulties occur
at C4 and above.
20 / 20
Increased Intracranial Pressure (ICP) NCLEX Q registerednurseRN.com
site
Study online at https://quizlet.com/_4zzjk7
1. 1. Select the main structures below A. Brain

that play a role with altering intracra- C. Cerebrospinal Fluid
nial pressure: D. Blood
A. Brain The answers are A, C, and D. Inside
B. Neurons the skull are three structures that can
C. Cerebrospinal Fluid alter intracranial pressure. They are
D. Blood the brain, cerebrospinal fluid (CSF),
E. Periosteum and blood.
F. Dura mater
2. 2. The Monro-Kellie hypothesis ex- B. Vasodilation of cerebral vessels

plains the compensatory relation- D. Leaking proteins into the brain bar-
ship among the structures in the rier
skull that play a role with intracra- The answers are B and D. These are
nial pressure. Which of the following NOT compensatory mechanisms, but
are NOT compensatory mechanisms actions that will actually increase in-
performed by the body to decrease tracranial pressure. Vasoconstriction
intracranial pressure naturally? Se- (not dilation) decreases blood flow
lect all that apply: and helps lower ICP. Leaking of pro-
A. Shifting cerebrospinal fluid to tein actually leads to more swelling
other areas of the brain and spinal of the brain tissue. Remember water
cord is attracted to protein (oncotic pres-
B. Vasodilation of cerebral vessels sure).
C. Decreasing cerebrospinal fluid
production
D. Leaking proteins into the brain
barrier
3. 3. A patient is being treated A. Coughing

for increased intracranial pressure. B. Sneezing
Which activities below should the D. Valsalva maneuver
patient avoid performing? The answers are A, B, D, and E.
A. Coughing These activities can increase ICP.
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed be-
tween 30- 35 degrees
1/7
site
4. 4. A patient is experiencing hyper- C. cause vasodilation and increase

ventilation and has a PaCO2 level the ICP
of 52. The patient has an ICP of 20 The answer is C. An elevated car-
mmHg. As the nurse you know that bon dioxide level (52 is high...normal
the PaCO2 level will? 35-45) in the blood will cause va-
A. cause vasoconstriction and de- sodilation (NOT constriction), which
crease the ICP will increase ICP (normal ICP 5 to
B. promote diuresis and decrease 15 mmHg). Therefore, many patients
the ICP with severe ICP may need to be
C. cause vasodilation and increase mechanical ventilated so PaCO2 lev-
the ICP els can be lowered (30-35), which
D. cause vasodilation and decrease will lead to vasoconstriction and de-
the ICP crease ICP (with constriction there
is less blood volume and flow go-
ing to the brain and this helps de-
crease pressure)....remember Mon-
ro-Kellie hypothesis.
5. 5. You're providing education to a B. 60-100 mmHg

group of nursing students about ICP. The answer is B. This is a normal
You explain that when cerebral per- CPP. Option A represents a normal
fusion pressure falls too low the intracranial pressure.
brain is not properly perfused and
brain tissue dies. A student asks,
"What is a normal cerebral perfusion
pressure level?" Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg
6. 6. Which patient below is at MOST B. A patient who is admitted with a

risk for increased intracranial pres- traumatic brain injury.
sure? The answer is B. Remember
A. A patient who is experiencing se- head trauma, cerebral hemorrhage,
vere hypotension. hematoma, hydrocephalus, tumor,
B. A patient who is admitted with a encephalitis etc. can all increase ICP.
traumatic brain injury.
2/7
site
C. A patient who recently experi-
enced a myocardial infarction.
D. A patient post-op from eye
surgery.
7. 7. A patient with increased ICP has C. Remove extra blankets and give
the following vital signs: blood pres- the patient a cool bath
sure 99/60, HR 65, Temperature 101.6 The answer is C. It is important to
'F, respirations 14, oxygen satura- monitor the patient for hyperthermia
tion of 95%. ICP reading is 21 mmHg. (a fever). A fever increases ICP and
Based on these findings you would? cerebral blood volume, and metabolic
A. Administered PRN dose of a vaso- needs of the patient. The nurse can
pressor administer antipyretics per MD or-
B. Administer 2 L of oxygen der, remove extra blankets, decrease
C. Remove extra blankets and give room temperature, give a cool bath or
the patient a cool bath use a cooling system. Remember it
D. Perform suctioning is important to prevent shivering (this
also increases metabolic needs and
ICP).
8. 8. A patient has a ventriculostomy. C. ICP 24 mmHg

Which finding would you immediate- The answer is C. A ventriculostomy
ly report to the doctor? is a catheter inserted in the area of
A. Temperature 98.4 'F the lateral ventricle to assess ICP. It
B. CPP 70 mmHg will help drain CSF during increase
C. ICP 24 mmHg pressure readings and measure ICP.
D. PaCO2 35 The nurse must monitor for ICP levels
greater than 20 mmHg and report it to
the doctor.
9. 9. External ventricular drains moni- B. Lateral Ventricle

tor ICP and are inserted where? The answer is B. External ventricular
A. Subarachnoid space drains (also called ventriculostomy)
B. Lateral Ventricle are inserted in the lateral ventricle.
C. Epidural space
D. Right Ventricle
10. 10. Which of the following is con- A. Lumbar puncture

traindicated in a patient with in- The answer is A. LPs are avoided in
3/7
site
creased ICP? patients with ICP because they can
A. Lumbar puncture lead to possible brain herniation.
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications
11. 11. You're collecting vital signs on A. Rectal

a patient with ICP. The patient has The answer is A. This GCS rating
a Glascoma Scale rating of 4. How demonstrates the patient is uncon-
will you assess the patient's temper- scious. If a patient is unconscious the
ature? nurse should take the patient's tem-
A. Rectal perature either via the rectal, tympan-
B. Oral ic, or temporal method. Oral and axil-
C. Axillary lary are not reliable.
12. 12. A patient who experienced a C. Restlessness

cerebral hemorrhage is at risk for The answer is C. Mental status
developing increased ICP. Which changes are the earliest indicator a
sign and symptom below is the EAR- patient is experiencing increased ICP.
LIEST indicator the patient is having All the other signs and symptoms list-
this complication? ed happen later.
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size
13. 13. Select all the signs and symp- A. Decorticate posturing
toms that occur with increased ICP: D. Cheyne-stokes
A. Decorticate posturing E. Hemiplegia
B. Tachycardia The answers are A, D, E, and F. Op-
C. Decrease in pulse pressure tion B is wrong because bradycardia
D. Cheyne-stokes (not tachycardia) happens in the late
E. Hemiplegia stage along with an INCREASE (not
F. Decerebrate posturing decrease) in pulse pressure.
14. 14. You're maintaining an external A. 5 to 15 mmHg

ventricular drain. The ICP readings The answer is A. Normal ICP should
should be? be 5 to 15 mmHg.
A. 5 to 15 mmHg
4/7
site
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg
15. 15. Which patient below with ICP is C. BP 200/60, HR 50, RR 8

experiencing Cushing's Triad? A pa- The answer is C. These vital signs
tient with the following: represent Cushing's triad. There is
A. BP 150/112, HR 110, RR 8 an increase in the systolic pres-
B. BP 90/60, HR 80, RR 22 sure, widening pulse pressure of
C. BP 200/60, HR 50, RR 8 140 (200-60=140), bradycardia, and
D. BP 80/40, HR 49, RR 12 bradypnea.
16. 16. The patient has a blood pres- A. 90 mmHg, normal

sure of 130/88 and ICP reading of 12. The answer is A. CPP is calculated by
What is the patient's cerebral perfu- the following formula: CPP=MAP-ICP.
sion pressure, and how do you inter- The patient's CPP is 90 and this
pret this as the nurse? is normal. A normal CPP is 60-100
A. 90 mmHg, normal mmHg.
B. 62 mmHg, abnormal
C. 36 mmHg, abnormal
D. 56 mmHg, normal
17. 17. According to question 16, the C. 102

patient's blood pressure is 130/88. The answer is C. MAP is calculated by
What is the patient's mean arterial taking the DBP (88) and multiplying it
pressure (MAP)? by 2. This equals 176. Then take this
A. 42 number and add the SBP (130). This
B. 74 equals 306. Then take this number
C. 102 and divide by 3, which equal 102.
D. 88
18. 18. During the assessment of a pa- B. Decerebrate posturing

tient with increased ICP, you note
that the patient's arms are extended
straight out and toes pointed down-
ward. You will document this as:
A. Decorticate posturing
C. Flaccid posturing
5/7
site
19. 19. While positioning a patient in bed D. Flexion of the hips

with increased ICP, it important to The answer is D. Avoid flexing the hips
avoid?* because this can increase intra-ab-
A. Midline positioning of the head dominal/thoracic pressure, which will
B. Placing the HOB at 30-35 degrees increase ICP.
C. Preventing flexion of the neck
D. Flexion of the hips
20. 20. During the eye assessment of a D. The eyes will be in a fixed position
patient with increased ICP, you need as the head is moved side to side.
to assess the oculocephalic reflex. If The answer is D. This is known as
the patient has brain stem damage a negative doll's eye and represents
what response will you find?* brain stem damage. It is a very bad
A. The eyes will move in the same sign.
direction as the head is moved side
to side.
B. The eyes will move in the opposite
direction as the head is moved side
to side.
C. The eyes will roll back as the head
is moved side to side.
D. The eyes will be in a fixed position
as the head is moved side to side.
21. 21. A patient is receiving Mannitol B. Mannitol will cause water and
for increased ICP. Which statement electrolyte reabsorption in the renal
is INCORRECT about this medica- tubules.
tion?* The answer is B. All the other op-
A. Mannitol will remove water from tions are correct. Mannitol will PRE-
the brain and place it in the blood to VENT (not cause) water and elec-
be removed from the body. trolytes (specifically sodium and chlo-
B. Mannitol will cause water and ride) from being reabsorbed....hence
electrolyte reabsorption in the renal it will leave the body as urine.
tubules.
C. When a patient receives Mannitol
the nurse must monitor the patient
for both fluid volume overload and
depletion.
6/7
site
D. Mannitol is not for patients who
are experiencing anuria.
22. 22. What assessment finding re- B. Crackles throughout lung fields
quires immediate intervention if The answer is B. Mannitol can cause
found while a patient is receiving fluid volume overload that leads to
Mannitol?* heart failure and pulmonary edema.
A. An ICP of 10 mmHg Crackles in the lung fields represent
B. Crackles throughout lung fields pulmonary edema and requires im-
C. BP 110/72 mediate intervention. Option A is a
D. Patient complains of dry mouth normal ICP reading and shows the
and thirst mannitol is being effective. BP is with-
in normal limits, and dry mouth/thirst
will occur with this medication be-
cause remember we are trying to de-
hydrate the brain to keep edema and
intracranial pressure decreased.
7/7
NCLEX Intracranial pressure questions
Study online at https://quizlet.com/_7lyejz
1. The nurse is assessing the motor b. nail bed pressure

function of an unconscious client. * motor testing on the unconscious
The nurse would plan to use which client can be done only by testing re-
of the following to test the client's sponse to painful stimuli. *Nail bed
peripheral response to pain: pressure tests peripheral response
a. pressure on the orbital rim to pain. *Cerebral responses to pain
b. nail bed pressure are tested using sternal rub, plac-
c. sternal rub ing upward pressure on the orbital
d. squeezing the sternocleidomas- rim, squeezing the sternocleidomas-
toid muscle toid muscle.
2. While cooking your client could not d. parietal

feel the temperature of the oven. *The parietal lobe controls / regulates
Which lobe of the brain could be sensory function...including the ability
dysfunctional? to feel hot and cold.
a. occipital *The frontal lobe regulates thinking,
b. temporal planning and judgement. *The occipi-
c. frontal tal lobe is primarily responsible for vi-
d. parietal sion function. *The temporal lobe reg-
ulates memory.
3. The nurse is positioning the client b. head turned to the side

with increased intracranial pres- *The head of the client with increased
sure. Which of the following posi- cranial pressure should be positioned
tions would the nurse avoid? so the head is in a neutral midline po-
a. neck in neutral position sition. *The nurse should avoid flexing
b. head turned to the side or extending the clients neck, or turn-
c. head of bed elevated 30 to 45 de- ing the head side to side. *The head
grees of the bed should be raised to 30 to
d. head midline 45 degrees. **Use of proper positions
promotes venous drainage from the
cranium to keep intracranial pressure
balanced.
4. The female client admitted to an c. lidocaine (Xylocaine)

acute care facility after a car acci- *Administering lidocaine (Xylocaine)
dent develops signs and symptoms via endotracheal tube may minimize
of increased intracranial pressure elevations in ICP caused by suction-
(ICP). The client is intubated and ing. Although mannitol and furosemide
1/8
placed on mechanical ventilation to may be given to reduce ICP, they're
help reduce ICP. To prevent a fur- administered parenterally, not endo-
ther rise in ICP caused by suction- tracheally. *Phenytoin does not reduce
ing, the nurse anticipates admin- ICP directly, but may be used to abol-
istering which drug endotracheally ish seizures, which can increase ICP.
before suctioning? *Phenytoin is not administered endo-
a. phenytoin (Dilantin) tracheally.
b. mannitrol (Osmitrol)
c. lidocaine (Xylocaine)
d. furosemide (Lasix)
5. Later signs of intracranial pressure b. projectile vomiting

(ICP) include which of the follow- *Projectile vomiting may occur with in-
ing? creased pressure on the reflex center
a. increased pulse rate in the medulla.
b. projectile vomiting
c. decreased blood pressure
d. narrowed pulse pressure
6. A nurse is assisting with caloric c. an intact brain stem

testing of the oculovestibular re- *Caloric testing provides information
flex of an unconscious client. Cold about differentiating between cerebel-
water is injected into the left audi- lar and brain stem lesions. *After de-
tory canal. The client exhibits eye termining patency of the ear canal,
conjugate movements toward the cold or warm water is injected in the
left followed by a rapid nystagmus auditory canal. A normal response
toward the right. The nurse under- that indicates intact function of cranial
stands that this indicates the client nerves III, IV and VIII is conjugate eye
has: movements toward the side being ir-
a. a temporal lesion rigated, followed by rapid nystagmus
b. brain death toward the opposite side. **Absence or
c. an intact brain stem dysconjugate eye movements indicate
d. a cerebral lesion brain stem damage.
7. Which of the following signs of in- d. restlessness and confusion

creased intracranial pressure (ICP) *The earliest sign of increased ICP is a
would appear first after head trau- change in mental status. *Bradycardia
ma? and widened pulse pressure occur lat-
a. widened pulse pressure er. *The patient may void a lot of very
2/8
b. large amounts of very dilute urine dilute urine if his posterior pituitary is
c. bradycardia damaged.
d. restlessness and confusion
8. Which of the following symptoms a. ataxia and confusion

may occur with phenytoin level of *A therapeutic phenytoin level is
32 mg/dl? 10-20mg/dl. A level of 32 mg/dl is a
a. ataxia and confusion toxic level. Symptoms of toxicity in-
b. tonic-clonic seizure clude ataxia and confusion. Inconti-
c. urinary incontinence nence may occur during or after a
d. sodium depletion seizure.
9. A nurse in the emergency depart- a. repeated vomiting

ment is observing a 4 year old child *Increased pressure caused by bleed-
for signs of increased intracranial ing or swelling within the skull can
pressure after a fall from a bicy- damage delicate brain tissue and may
cle which resulted in a head trau- become life threatening. *Repeated
ma. Which of the following signs or vomiting can be an early sign of pres-
symptoms would be cause for con- sure stimulating the vomiting center in
cern? the medulla. The fontanel is closed in a
a. repeated vomiting four year old. Inability to read and signs
b. bulging anterior fontanel of sleepiness would be an expected
c. inability to read short words from finding for a four year old.
a distance of 18 inches
d. signs of sleepiness at 10 pm
10. For an adult client with a suspect- d. promote CO2 elimination

ed increased intracranial pressure *The goal of treatment would be to
(ICP), a most appropriate respirato- prevent acidemia by eliminating CO2.
ry goal would be: *That is because an acid environment
a. lower arterial pH in the brain causes cerebral vessels
b. maintain partial pressure of arte- to dilate and therefore increases ICP.
rial oxygen, PaO2, above 80 mm/Hg *Preventing respiratory alkalosis and
c. prevent respiratory alkalosis lowering arterial pH could raise acid
d. promote CO2 elimination levels. *A minimum 60 mm/hg can oxy-
genate most clients.
11. A nurse is teaching family members d. headache and vomiting

of a client with a concussion about *Headache and vomiting are early
the early signs of increased cranial signs of increased ICP. *Decreases
3/8
pressure, ICP. Which of the follow- systolic blood pressure, inability to
ing would the nurse cite as early wake a patient with noxious stimuli,
signs of ICP? and dilated pupils that don't react to
a. decreased systolic blood pres- light are late signs of increased ICP.
sure
b. inability to wake the patient with
noxious stimuli
c. dilated pupils that don't react to
light
d. headache and vomiting
12. A client with a subdural hematoma a. to promote osmotic diuresis to re-

(a collection of blood on the brain's duce ICP
surface beneath the skull) becomes *Mannitol promotes osmotic diuresis
restless and confused, with dilation by increasing the pressure gradient,
of the ipsilateral pupil. The physi- drawing fluid from intracellular to in-
cian orders mannitol for which of travascular spaces. **Although Manni-
the following reasons? tol is used for all the other reasons, the
a. to promote osmotic diuresis to primary reason it is used in the given
reduce ICP case is to reduce ICP.
b. to reduce intraocular pressure
c. to prevent acute tubular necrosis
d. to draw water into the vascular
system to increase blood pressure
13. Which of the following types of b. barbiturates

drugs might be given to regulate in- *Barbiturates may be given to induce a
creased intracranial pressure, ICP ? coma in a patient with increased ICP.
a. carbonic anhydrase inhibitors *This decreases cortical activity and
b. barbiturates cerebral metabolism, reduces cere-
c. anticholinergics bral blood volume, decreases cerebral
d. histamine receptor blockers edema, and reduces the brain's need
for glucose and oxygen. **Carbonic
anhydrase inhibitors are used to de-
crease ocular pressure or to decrease
serum pH in a client with metabolic
alkalosis. **Anticholinergics are used
for many things, such as controlling GI
spasms. **Histamine receptor block-
4/8
ers are used to decrease stomach
acidity.
14. Which of the following values is d. 0-15 mm/Hg

considered normal for ICP?
a. 35-45 mm/Hg
b. 120/80 mm/Hg
c. 25 mm/Hg
d. 0-15 mm/Hg
15. Which of the following signs and a. restlessness and confusion

symptoms of increased intracranial *The earliest symptom of increased
pressure, ICP, would occur first af- ICP is a change in mental status.
ter a head injury? **Bradycardia, widened pulse pres-
a. restlessness and confusion sure, and bradypnea occur as late
b. bradycardia symptoms. Voiding large amounts of
c. large amounts of very dilute urine very dilute urine typically occurs with
d. widened pulse pressure damage to the posterior pituitary.
16. An adult client with a severe head c. Increased restlessness

injury is being monitored by the **Restlessness indicates a lack of oxy-
nurse for increase intracranial pres- gen to the brain stem which impairs
sure, ICP. Which finding would be the reticular activating system.
the most indicative indication of in-
creased ICP?
a. intermittent tachycardia
b. polydipsia
c. increased restlessness
d. Tachypnea
17. An adult client is brought to the a. client is oriented when aroused from
emergency department due to a sleep and goes back to sleep immedi-
motor vehicle accident. While mon- ately.
itoring the client, the nurse begins **This behavior indicates a decrease
to suspect increased intracranial in level of consciousness, which is the
pressure, ICP, when: primary sign of increased ICP.
a. client is orientated when aroused
from sleep, and goes back to sleep
immediately
b. blood pressure is decreased from
5/8
160/90 to 110/70
c. client refuses dinner due to
anorexia
d. pulse is increased from 88 to 96
with occasional skipped beat
18. The nurse is caring for a client c. increasing temperature, decreas-

with increased intracranial pres- ing pulse, decreasing respirations, in-
sure, ICP. The nurse would note creasing blood pressure
which of the following trends in vital **A change in vital signs may be a
signs if the ICP is rising? late sign of increased ICP. *Trends
a. decreasing temperature, increas- include increasing temperature and
ing pulse, decreasing respirations, blood pressure, and decreased pulse
increasing blood pressure and respirations. Respiratory irregu-
b. decreasing temperature, de- larities may also arise.
creasing pulse, increasing respira-
tions, decreasing blood pressure
c. increasing temperature, decreas-
ing pulse, decreasing respirations,
increasing blood pressure
d. increasing temperature, increas-
ing pulse, increasing respirations,
decreasing blood pressure
19. A client admitted to the hospital c. intracranial pressure is increased

with a subarachnoid hemorrhage **Sudden removal of CSF results in
has complaints of severe headache, pressures lower in the lumbar region
nuchal rigidity ( inability to flex the than the brain and favors herniation of
neck forward due to rigidity of the the brain; therefore, LP is contraindi-
neck muscles), and projectile vom- cated with increased ICP. **Vomiting
iting. The nurse knows that lumbar may be caused by reasons other than
puncture (LP) would be contraindi- ICP, so LP is not strictly contraindi-
cated in this client in which of the cated. **LP may be performed on
following circumstances? a client needing mechanical ventila-
a. the client needs mechanical vention.**Blood in the CSF is diagnos-
tilation tic for subarachnoid hemorrhage, and
b. vomiting continues was obtained before signs and symp-
c. intracranial pressure, ICP, is in- toms of increased ICP.
creased
6/8
d. blood is anticipated in the cere-
bral spinal fluid (CSF)
20. A client with a head injury is being c. 52 mm Hg

monitored for increased intracra- **Looking for explanation
nial pressure, ICP, His blood pres-
sure is 90/60 mm Hg and the ICP
is 15 mm Hg; therefore his cerebral
perfusion pressure (CPP) is :
a. 68 mm Hg
b. 88 mm Hg
c. 52 mm Hg
d. 48 mm Hg
21. Problems with memory and learn- c. temporal

ing would relate to which of the fol- **The temporal lobe functions to reg-
lowing lobes? ulate memory and learning problems
a. Parietal because of the integration of the hip-
b. Frontal pocampus. **The frontal lobe primari-
c. Temporal ly functions to regulate thinking, plan-
d. Occipital ning, and judgement. **The occipital
lobe functions to regulate vision. **The
parietal lobe functions with sensory
functions.
22. Whether Mr. Synder's tumor is be- d. increased pulse rate, drop in blood
nign or malignant, it will eventual- pressure
ly cause an increase in intracranial **As ICP increases, pulse rate de-
pressure (ICP). Signs and symp- creases, and blood pressure increas-
toms of increasing ICP include ALL es. **As ICP continues to increase, vi-
of the following EXCEPT: tal signs vary considerably.
a. papilledema, dizziness, mental
status changes
b. headache, nausea, vomiting
c. obvious motor deficits
d. increased pulse rate, drop in
blood pressure
23. The client is having a lumbar a. side lying, with legs pulled up and
puncture (LP) performed. The nurse head bent down onto the chest.
7/8
would plan to place the client in **This position helps to open the
which position? spaces between the vertebrae.
a. side lying, with legs pulled up and
head bent down onto the chest.
b. side lying with a pillow under the
hip
c. prone, in a slight Trendelenburg's
position
d. prone, with a pillow under the ab-
domen
24. A client with a subdural hematoma d. urine output increases

was given mannitol to decrease in- **Mannitol promotes osmotic diuresis
tracranial pressure (ICP). Which of by increasing the pressure gradient in
the following results would best the renal tubes.
show the mannitol was effective? *Fixed and dilated pupils are symp-
a. Systolic blood pressure remains toms of ICP or cranial nerve damage.
at 150 mm Hg **No information is given about BUN
b. Pupils are 8mm and non reactive and creatinine levels or that mannitol is
c. BUN and creatinine levels return being given to treat renal dysfunction
to normal or blood pressure.
d. urine output increases
8/8
TBI/ICP NCLEX Questions
Study online at https://quizlet.com/_7j0y47
1. In conducting a primary survey c.) Brief neurologic assessment

on a trauma patient, which of
the following is considered one Rationale:
of the priority elements of the A brief neurologic assessment to deter-
primary survey? mine level of consciousness and pupil re-
action is part of the primary survey. Vital
a.) Complete set of vital signs signs, assessment of the abdomen, and
b.) Palpation and auscultation initiation of pulse oximetry are considered
of the abdomen part of the secondary survey.
c.) Brief neurologic assessment
d.) Initiation of pulse oximetry
2. A pediatric client is admit- d.) Deceleration

ted to the neuro ICU with a
closed-head injury sustained af- Rationale:
ter falling out of a tree house. Deceleration injury occurs when the brain
The mechanisms of injury this stops rapidly in the cranial vault. As the
young client most likely sus- skull ceases movement, the brain contin-
tained would be: ues to move until it hits the skull. The force
of deceleration causes injury at the site of
a.) Acceleration impact. An example of this is a victim of a
b.) Penetrating fall.
c.) Rotational
d.) Deceleration
3. A client who has had a plaster of D.) Evaluate the response to analgesics
Paris cast applied to his forearm
is receiving pain medication. To
detect early manifestations of
compartment syndrome, which
of these assessments should
the nurse make?
A.) Observe the color of the fin-

gers
B.) Palpate the radial pulse un-
der the cast
C.) Check the cast for odor and
drainage
1/9
D.) Evaluate the response to
analgesics
4. A client admitted to the hospi- b.) Intracranial pressure (ICP) is increased

tal with a subarachnoid hem-
orrhage has complaints of se- Rationale:
vere headache, nuchal rigidi- Sudden removal of CSF results in pres-
ty, and projectile vomiting. The sures lower in the lumbar area than the
nurse knows lumbar puncture brain and favors herniation of the brain;
(LP) would be contraindicated therefore, LP is contraindicated with in-
in this client in which of the fol- creased ICP. Vomiting may be caused by
lowing circumstances? reasons other than increased ICP; there-
fore, LP isn't strictly contraindicated. An
a.) Vomiting continues LP may be preformed on clients needing
b.) Intracranial pressure (ICP) is mechanical ventilation. Blood in the CSF is
increased diagnostic for subarachnoid hemorrhage
c.) The client needs mechanical and was obtained before signs and symp-
ventilation toms of ICP.
d.) Blood is anticipated in the
cerebralspinal fluid (CSF)
5. A client with a subdural c.) To promote osmotic diuresis to de-

hematoma becomes restless crease ICP
and confused, with dilation of
the ipsilateral pupil. The physi- Rationale:
cian orders mannitol for which Mannitol promotes osmotic diuresis by
of the following reasons? increasing the pressure gradient, draw-
ing fluid from intracellular to intravascular
a.) To reduce intraocular pres- spaces. Although mannitol is used for all
sure the reasons described, the reduction of
b.) To prevent acute tubular ICP in this client is a concern.
necrosis
c.) To promote osmotic diuresis
to decrease ICP
d.) To draw water into the vas-
cular system to increase blood
pressure
6.
2/9
A client with subdural a.) Urine output increases
hematoma was given mannitol
to decrease intracranial pres- Rationale:
sure (ICP). Which of the follow- Mannitol promotes osmotic diuresis by in-
ing results would best show the creasing the pressure gradient in the renal
mannitol was effective? tubes. Fixed and dilated pupils are symp-
toms of increased ICP or cranial nerve
a.) Urine output increases damage. No information is given about ab-
b.) Pupils are 8 mm and nonre- normal BUN and creatinine levels or that
active mannitol is being given for renal dysfunc-
c.) Systolic blood pressure re- tion or blood pressure maintenance.
mains at 150 mm Hg
d.) BUN and creatinine levels re-
turn to normal
7. Which of the following signs c.) Restlessness and confusion

and symptoms of increased ICP
after head trauma would appear Rationale:
first? The earliest symptom of elevated ICP
is a change in mental status. Bradycar-
a.) Bradycardia dia, widened pulse pressure, and bradyp-
b.) Large amounts of very dilute nea occur later. The client may void large
urine amounts of very dilute urine if there's dam-
c.) Restlessness and confusion age to the posterior pituitary.
d.) Widened pulse pressure
8. Problems with memory and d.) Temporal

learning would relate to which
of the following lobes? Rationale:
The temporal lobe functions to regulate
a.) Frontal memory and learning problems because
b.) Occipital of the integration of the hippocampus. The
c.) Parietal frontal lobe primarily functions to regulate
d.) Temporal thinking, planning, and judgment. The oc-
cipital lobe functions regulate vision. The
parietal lobe primarily functions with sen-
sory function.
9.
3/9
While cooking, your client c.) Parietal
couldn't feel the temperature of
a hot oven. Which lobe could be Rationale:
dysfunctional? The parietal lobe regulates sensory func-
tion, which would include the ability to
a.) Frontal sense hot or cold objects. The frontal lobe
b.) Occipital regulates thinking, planning, and judg-
c.) Parietal ment, and the occipital lobe is primarily re-
d.) Temporal sponsible for vision function. The temporal
lobe regulates memory.
10. The nurse is assessing the mo- d.) Nail bed pressure
tor function of an unconscious
client. The nurse would plan toRationale:
use which of the following to Motor testing on the unconscious client
test the client's peripheral re-
can be done only by testing response to
sponse to pain? painful stimuli. Nailbed pressure tests a
basic peripheral response. Cerebral re-
a.) Sternal rub sponses to pain are testing using sternal
b.) Pressure on the orbital rim rub, placing upward pressure on the orbital
c.) Squeezing the sternocleido- rim, or squeezing the clavicle or sternoclei-
mastoid muscle domastoid muscle.
d.) Nail bed pressure
11. A nurse is assisting with caloric c.) An intact brainstem

testing of the oculovestibular
reflex of an unconscious client. Rationale:
Cold water is injected into the Caloric testing provides information about
left auditory canal. The client differentiating between cerebellar and
exhibits eye conjugate move- brainstem lesions. After determining pa-
ments toward the left followed tency of the ear canal, cold or warm water
by a rapid nystagmus toward is injected in the auditory canal. A normal
the right. The nurse under- response that indicates intact function of
stands that this indicates the cranial nerves III, IV, and VIII is conjugate
client has: eye movements toward the side being irri-
gated, followed by rapid nystagmus to the
a.) A cerebral lesion opposite side. Absent or dysconjugate eye
b.) A temporal lesion movements indicate brainstem damage.
4/9
c.) An intact brainstem
d.) Brain death
12. The nurse is caring for the b.) Increasing temperature, decreasing
client with increased intracra- pulse, decreasing respirations, increasing
nial pressure. The nurse would blood pressure.
note which of the following
trends in vital signs if the ICP is
Rationale:
rising? A change in vital signs may be a late sign
of increased intracranial pressure. Trends
a.) Increasing temperature, in- include increasing temperature and blood
creasing pulse, increasing res- pressure and decreasing pulse and respi-
pirations, decreasing blood rations. Respiratory irregularities also may
pressure. arise.
b.) Increasing temperature, de-

creasing 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.
13. The nurse is evaluating the sta- a.) A positive Brudzinski's sign
tus of a client who had a cran-
iotomy 3 days ago. The nurse Rationale:
would suspect the client is de- Signs of meningeal irritation compatible
veloping meningitis as a com- with meningitis include nuchal rigidity,
plication of surgery if the client
positive Brudzinski's sign, and positive
exhibits: Kernig's sign. Nuchal rigidity is character-
ized by a stiff neck and soreness, which
a.) A positive Brudzinski's sign is especially noticeable when the neck is
5/9
b.) A negative Kernig's sign fixed. Kernig's sign is positive when the
c.) Absence of nuchal rigidity client feels pain and spasm of the ham-
d.) A Glascow Coma Scale string muscles when the knee and thigh
score of 15 are extended from a flexed-right angle po-
sition. 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. A Glascow
Coma Scale of 15 is a perfect score and
indicates the client is awake and alert with
no neurological deficits.
14. A client with a head injury is a.) 52 mm Hg

being monitored for increased
intracranial pressure (ICP). His Rationale:
mean arterial pressure (MAP) is CCP=MAP-ICP
70 and the ICP is 18 mmHg; 70-18=52
therefore his cerebral perfusion CCP=52
pressure (CPP) is:
CCP is maintained above 60 mm Hg
a.) 52 mm Hg
b.) 88 mm Hg
c.) 48 mm Hg
d.) 68 mm Hg
15. For a male client with suspected c.) Promote carbon dioxide elimination.
increased intracranial pressure
(ICP), a most appropriate respi- Rationale:
ratory goal is to: The goal in treatment is to prevent
acidemia by eliminating carbon dioxide.
a.) Prevent respiratory alkalo-
sis.
b.) Lower arterial pH.
c.) Promote carbon dioxide
elimination.
d.) Maintain partial pressure of
arterial oxygen (PaO2) above 80
mm Hg
6/9
16. A patient is admitted with a sub- b.) Elective draining of the hematoma.
acute subdural hematoma. The
nurse realizes this patient will
most likely be treated with:
a.) Emergency craniotomy.

b.) Elective draining of the
hematoma.
c.) Burr holes to remove the
hematoma.
d.) Removal of the affected cra-
nial lobe.
17. A patient with a traumatic brain a.) Normal saline.

injury is in need of fluid replace-
ment therapy to maintain a sys- Rationale:
tole blood pressure of at least A systolic blood pressure less than 90 mm
90 mm Hg. The nurse realizes Hg in a patient with a traumatic brain in-
that the best fluid replacement jury is a predictor of a poor outcome. Ini-
for this patient would be: tial management usually involves assuring
that the patient is hydrated. Isotonic crys-
a.) Normal saline. talloids such as 0.9% saline or Ringer's
b.) D5W solution are most commonly used. Normal
c.) D5 1/2 0.9% NS Saline is preferred because it is inexpen-
d.) 0.45% NS sive, iso-osmolar and has no free water.
#2 and #4 are not correct. In general,
the use of hypotonic crystalloids, such as
D5W or 0.45% normal saline is avoid-
ed because of the potential for worsening
cerebral edema.
#3 is not correct. D51/2 NS is hypertonic
and will draw fluid from the cells & interstial
tissue into the vascular space. This could
worsen cerebral edema.
18. The nurse is caring for a client a.) hypoventilation

with a closed head injury. Which
of the following would con- Rationale:
tribute to intracranial hyperten-
7/9
sion? Hypoventilation leads to vasodilation and
increased intracranial pressure.
a.) hypoventilation
b.) elevating the head of the bed
c.) hypernatremia
d.) quiet darkened environnent
19. A client with head trauma de- a.) Evaluate urine specific gravity
velops a urine output of 300
ml/hr, dry skin, and dry mucous Rationale:
membranes. Which of the fol- Urine output of 300 ml/hr may indicate
lowing nursing interventions is diabetes insipidus, which is a failure of
the most appropriate to perform the pituitary to produce anti-diuretic hor-
initially? mone. This may occur with increased in-
tracranial pressure and head trauma; the
a.) Evaluate urine specific grav- nurse evaluates for low urine specific grav-
ity ity, increased serum osmolarity, and de-
b.) Anticipate treatment for re- hydration. There's no evidence that the
nal failure client is experiencing renal failure. Provid-
c.) Provide emollients to the ing emollients to prevent skin breakdown
skin to prevent breakdown is important, but doesn't need to be per-
d.) Slow down the IV fluids and formed immediately. Slowing the rate of IV
notify the physician fluid would contribute to dehydration when
polyuria is present.
20. When evaluating an ABG from a.) Appropriate; lowering carbon dioxide
a client with a subdural (CO2) reduces intracranial pressure (ICP).
hematoma, the nurse notes the
PaCO2 is 30 mm Hg. Which of Rationale:
the following responses best A normal PaCO2 value is 35 to 45 mm Hg.
describes this result? CO2 has vasodilating properties; there-
fore, lowering PaCO2 through hyperven-
a.) Appropriate; lowering car- tilation will lower ICP caused by dilated
bon dioxide (CO2) reduces in- cerebral vessels. Oxygenation is evaluat-
tracranial pressure (ICP). ed through PaO2 and oxygen saturation.
b.) Emergent; the client is poor- Alveolar hypoventilation would be reflect-
ly oxygenated. ed in an increased PaCO2.
c.) Normal
8/9
d.) Significant; the client has
alveolar hypoventilation.
21. A client is admitted to the ER a.) Laceration of the middle meningeal

for head trauma is diagnosed artery
with an epidural hematoma. The
underlying cause of epidural Rationale:
hematoma is usually related to Epidural hematoma or extradural
which of the following condi- hematoma is usually caused by laceration
tions? of the middle meningeal artery. An em-
bolic stroke is a thromboembolism from a
a.) Laceration of the middle carotid artery that ruptures. Venous bleed-
meningeal artery ing from the arachnoid space is usually
b.) Rupture of the carotid artery observed with subdural hematoma
c.) Thromboembolism from a
carotid artery
d.) Venous bleeding from the
arachnoid space
22. When discharging a client from c.) An interval when the client is oriented
the ER after a head trauma, but then becomes somnolent
the nurse teaches the guardian
to observe for a lucid interval. Rationale:
Which of the following state- A lucid interval is described as a brief pe-
ments best described a lucid in- riod of unconsciousness followed by alert-
terval? ness; after several hours, the client again
loses consciousness. Garbled speech is
a.) An interval when the client's known as dysarthria. An interval in which
speech is garbled the client is alert but can't recall recent
b.) An interval when the client events is known as amnesia. Warning
is alert but can't recall recent symptoms or auras typically occur before
events seizures.
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 distur-
bance.
9/9
Adult Health 2 - Increased ICP NCLEX
Study online at https://quizlet.com/_7epdr0
1. The nurse is caring for a pa- Correct Answer: C

tient with increased intracra- Rationale: If the drainage is cerebrospinal
nial pressure (IICP). The nurse fluid (CSF) leakage from a dural tear, glu-
realizes that some nursing ac- cose will be present. Fluid leaking from the
tions are contraindicated with nose will have normal nasal flora, so culture
IICP. Which nursing action and sensitivity will not be useful. A dural
should be avoided? tear does increase the risk for infections
1. Reposition the patient every such as meningitis, but the nurse should
two hours. first determine whether the clear drainage
2. Position the patient with the is CSF. Blowing the nose is avoided to pre-
head elevated 30 degrees. vent CSF leakage.
3. Suction the airway every two
hours per standing orders.
4. Provide continuous oxygen
as ordered.
2. A patient admitted with a Correct Answer: C

head injury has admission vi- Rationale: Systolic hypertension with
tal signs of temperature 98.6° F widening pulse pressure, bradycardia, and
(37° C), blood pressure 128/68, respiratory changes represent Cushing's
pulse 110, and respirations 26. triad and indicate that the ICP has in-
Which of these vital signs, if creased and brain herniation may be im-
taken 1 hour after admission, minent unless immediate action is taken to
will be of most concern to the reduce ICP. The other vital signs may indi-
nurse? cate the need for changes in treatment, but
a. Blood pressure 130/72, pulse they are not indicative of an immediately
90, respirations 32 life-threatening process.
b. Blood pressure 148/78, pulse
112, respirations 28
c. Blood pressure 156/60, pulse
60, respirations 14
d. Blood pressure 110/70, pulse
120, respirations 30
3. When assessing a patient with Correct Answer: C

a head injury, the nurse rec- Rationale: LOC is the most sensitive in-
ognizes that the earliest indi- dicator of the patient's neurologic status
cation of increased intracranial and possible changes in ICP. Vomiting and
pressure (ICP) is sluggish pupil response to light are later
1/8
a. vomiting. signs of increased ICP. A headache can
b. headache. be caused by compression of intracranial
c. change in level of conscious- structures as the brain swells, but it is not
ness (LOC). unexpected after a head injury.
d. sluggish pupil response to
light.
4. When the nurse applies a Correct Answer: A

painful stimulus to the nailbeds Rationale: Internal rotation, adduction, and
of an unconscious patient, the flexion of the arms in an unconscious pa-
patient responds with internal tient is documented as decorticate postur-
rotation, adduction, and flexion ing. Extension of the arms and legs is de-
of the arms. The nurse docu- cerebrate posturing. Because the flexion is
ments this as general, it does not indicate localization of
a. decorticate posturing. pain or flexion withdrawal.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal.
5. A patient has ICP monitor- A. Aseptic technique to prevent infection

ing with an intraventricular
catheter. A priority nursing in- An intraventricular catheter is a fluid cou-
tervention for the patient is pled system that can provide direct access
a. aseptic technique to prevent for microorganisms to enter the ventricles
infection of the brain, and aseptic technique is a very
b. constant monitoring of ICP high nursing priority to decrease the risk
waveforms for infection. Constant monitoring of ICP
c. removal of CSF to maintain waveforms is not usually necessary, and
normal ICP removal of CSF for sampling or to maintain
d. sampling CSF to determine normal ICP is done only when specifically
abnormalities ordered
6. A patient with ICP monitoring D. A normal balance between brain tissue,

has pressure of 12 mm Hg. blood, and CSF- normal is 10- 15 mm Hg
The nurse understand that this
pressure reflects
a. a severe decrease in cerebral
perfusion pressure
b. an alteration in the produc-
2/8
tion of CSF
c. the loss of autoregulatory
control of ICP
d. a normal balance between
brain tissue, blood, and CSF
7. During admission of a patient A. Patency of airway is the #1 priority with

with a severe head injury to the all head injuries
ED, the nurse places highest
priority on assessment for
a. patency of of airway
b. presence of a neck injury
c. neurologic status with Glas-
cow Coma Scale
d. CSF leakage from ears and
nose
8. When a patient is admitted A. In addition to monitoring for a patent air-

to the emergency department way during emergency care of the patient
following a head injury, the with a head injury, the nurse must always
nurse's first priority in man- assume that a patient with a head injury
agement of the patient once a may have a cervical spine injury. Maintain-
patent airway is confirmed is ing cervical spine precautions in all assess-
a. maintaining cervical spine ment and treatment activities with the pa-
precautions tient is essential to prevent additional neu-
b. determining the presence of rologic damage.
increased ICP
c. monitoring for changes in
neurologic status
d. establishing IV access with a
large-bore catheter
9. The nurse recognizes the pres- B. Cushing's triad consists of three vital
ence of Cushing's triad in the sign measures that reflect ICP and its ef-
patient with fect on the medulla, the hypothalamus, the
a. Increased pulse, irregular pons, and the thalamus. Because these
respiration, increased BP structures are very deep, Cushing's triad is
b. decreased pulse, irregu- usually a late sign of ICP. The signs include
lar respiration, increased pulse an increasing systolic BP with a widening
3/8
pressure pulse pressure, a bradycardia with a full
c. increased pulse, decreased and bounding pulse, and irregular respira-
respiration, increased pulse tions.
pressure
d. decreased pulse, increased
respiration, decreased systolic
BP
10. A nurse is positioning a client B. head turned to the side

with increased ICP. Which posi-
tion would the nurse avoid? The head of a client with increased ICP
A. head midline should be positioned so that the head is
B. head turned to the side in a neutral, midline position. The nurse
C. neck in neutral position should avoid flexing or extending the neck
D. head of bed elevated 30-45 or turning the head side to side . The head
degrees of the bed should be raised 30-45 degrees
. Use of proper position promotes venous
drainage from the cranium to keep ICP
down
11. A patient with a head injury B. Tests the fluid for a halo sing on a white
has bloody drainage from the dressing- Testing clear drainage for CSF in
ear. To determine whether CSF nasal or ear drainage may be done with a
is present in the drainage, the Dextrostik or Tes-Tape strip, but if blood is
nurse present, the glucose in the blood will pro-
a. examines the tympanic mem- duce and unreliable result. To test bloody
brane for a tear drainage, the nurse should test the fluid for
b. tests the fluid for a halo sign a halo or ring that occurs when a yellowish
on a white dressing ring encircles blood dripped onto a white
c. tests the fluid with a glucose pad or towel
identifying strip or stick
d. collects 5 mL of fluid in a test
tube and sends it to the labora-
tory for analysis
12. A client recovering from a head D. exhaling during repositioning

injury is arousable and partic- (activities that increase intra-throacic and
ipating in care. The nurse de- intra-abdominal pressures cause indirect
termines that the client under- elevation of the ICP. Exhaling during ac-
4/8
stands measures to prevent el- tivities such as repositioning or pulling up
evations in intracranial pres- in bed opens the glottis, which prevents
sure if the nurse observes the intra-thoracic pressure from rising).
client doing which of the fol-
lowing activities?
A. blowing the nose
B. isometric exercises
C. coughing vigorously
D. exhaling during reposition-
ing
13. The earliest signs of increased C. One of the most sensitive signs of in-
ICP the nurse should assess creased intracranial pressure (ICP) is a
for include decreasing LOC. A decrease in LOC will
a. Cushing's triad occur before changes in vital signs, ocular
b. unexpected vomiting signs, and projectile vomiting occur
c. decreasing level of con-
sciousness (LOC)
d. dilated pupil with sluggish
response to light
14. A patient has a nursing diagno- A. Avoiding positioning the patient with
sis of risk for ineffective cere- neck and hip flexion- Nursing care activi-
bral tissue perfusion related to ties that increase ICP include hip and neck
cerebral edema. An appropri- flexion, suctioning, clustering care activi-
ate nursing intervention for the ties, and noxious stimuli; they should be
patient is avoided or performed as little as possible
a. avoiding positioning the pain the patient with increased ICP. Lowering
tient with neck and hip flexion the PaCO2 below 20 mm Hg can cause
b. maintaining hyperventilation ischemia and worsening of ICP; the PaCO2
to a PaCO2 of 15 to 20 mm Hg should be maintained at 30 to 35 mm Hg.
c. clustering nursing activities
to provide periods of uninter-
rupted rest
d. routine suctioning to prevent
accumulation of respiratory se-
cretions
15.
5/8
A patient with increased ICP C
has mannitol (Osmitrol) pre- LOC is the most sensitive indicator of ICP.
scribed. Which option is the Mannitol is an osmotic diuretic that works
best indication that the drug to decrease the ICP by plasma expansion
is achieving the desired thera- and an osmotic effect. Although the other
peutic effects? options may indicate a therapeutic effect of
A. Urine output increases from a diuretic, they are not the main reason this
30 mL to 50 mL/hour. drug is given.
B. Blood pressure remains less
than 150/90 mm Hg.
C. The LOC improves.
D. No crackles are auscultated
in the lung fields.
16. You are providing care for a A,C,D

patient who has been admitted The three dimensions of the Glasgow
to the hospital with a head in- Coma Scale are eye opening, best verbal
jury who requires regular neu- response, and best motor response.
rologic vital signs. Which as-
sessments are components of
the patient's score on the Glas-
gow Coma Scale (select all that
apply)?
A. Eye opening
B. Abstract reasoning
C. Best verbal response
D. Best motor response
E. Cranial nerve function
17. Which option indicates a sign D. Heart rate decreases from 75 to 55

of Cushing's triad, an indica- beats/minute
tion of increased intracranial
pressure (ICP)? Cushing's triad is systolic hypertension
A. Heart rate increases from 90 with a widening pulse pressure, bradycar-
to 110 beats/minute dia with a full and bounding pulse, and
B. Kussmaul respirations slowed respirations. The rise in blood pres-
C. Temperature over 100.4° F sure is an attempt to maintain cerebral per-
(38° C) fusion, and it is a neurologic emergency
D. Heart rate decreases from 75
6/8
to 55 beats/minute because decompensation is imminent. The
. other options are not part of Cushing's triad
18. The patient has rhinorrhea af- B. A loose collection pad may be placed
ter a head injury. What action under the nose.
should you take? A loose collection pad may be placed under
A. Pack the nares with sterile the nose. Do not place a dressing in the
gauze. nasal cavity, and nothing should be placed
B. A loose collection pad may inside the nostril. There is no need to cul-
be placed under the nose. ture the drainage. The concern is whether
C. Suction the drainage with an it is spinal fluid, which is determined by a
inline suction catheter. test for glucose or the halo or ring sign.
D. Obtain a sample for culture.
19. You plan care for the patient B. elevate the head of the bed to 30 de-
with increased ICP with the grees.
knowledge that the best way to You should maintain the patient with in-
position the patient is to creased ICP in the head-up position. Ele-
A. keep the head of the bed flat. vation of the head of the bed to 30 degrees
B. elevate the head of the bed enhances respiratory exchange and aids
to 30 degrees. in decreasing cerebral edema. You should
C. maintain patient on the left position the patient to prevent extreme neck
side with the head supported flexion, which can cause venous obstruc-
on a pillow. tion and contribute to elevated ICP. Eleva-
D. use a continuous-rotation tion of the head of the bed reduces sagit-
bed to continuously change pa- tal sinus pressure, promotes drainage from
tient position. the head through the valveless venous sys-
tem in the jugular veins, and decreases
the vascular congestion that can produce
cerebral edema. However, raising the head
of the bed above 30 degrees may decrease
the cerebral perfusion pressure (CPP) by
lowering systemic blood pressure. Careful
evaluation of the effects of elevation of the
head of the bed on the ICP and the CPP is
required.
20. You are caring for a pa- B. Bradycardia

tient admitted with a subdural Changes in vital signs indicative of in-
7/8
hematoma after a motor vehi- creased ICP are known as Cushing's tri-
cle accident. Which change in ad, which consists of increasing systolic
vital signs would you interpret pressure with a widening pulse pressure,
as a manifestation of increased bradycardia with a full and bounding pulse,
intracranial pressure? and irregular respirations.
A. Tachypnea
B. Bradycardia
C. Hypotension
D. Narrowing pulse pressure
8/8
Increased Intracranial Pressure NCLEX Practice Questions
Study online at https://quizlet.com/_9no72j
1. The nurse is assessing a client with Hemiparesis

a traumatic head injury and suspects
increased intracranial pressure (IICP). Drowsiness
Which assessment finding supports
this suspicion? (Select all that apply.) Double vision
Hemiparesis Blurred vision
Increased heart rate Hemiparesis or hemiplegia of the

contralateral side may be an early
Drowsiness sign of IICP. Drowsiness can oc-
cur with IICP. Double vision and
Double vision blurred vision can occur with IICP.
Headache is common with IICP.
Blurred vision The client may also report other
generalized manifestations such as
dizziness. The heart rate generally
decreases with IICP.
2. Which client is most at risk for in- Older adult

creased intracranial pressure? (Select
all that apply.) Newborn infant
Older adult Pregnant obese woman
Newborn infant School-aged child
Pregnant obese woman Adolescent
School-aged child Falls continue to be the major

cause of traumatic brain injury
Adolescent leading to increased intracranial
pressure (IICP). Older adults are
more prone to falls due to senso-
ry and motor losses, as well as
medication use. Adolescents are
at risk for motor vehicle crash-
es and trauma resulting from vio-
lence. Premature newborn infants
1 / 11
are at an increased risk of IICP.
School-aged children are prone to
falling. School-aged children are at
risk for bicycle, swimming, or ac-
tivity-related accidents that cause
IICP. Obese women of childbearing
age often have idiopathic intracra-
nial hypertension. During pregnan-
cy, these women must be close-
ly monitored for increased intracra-
nial pressure.
3. The nurse caring for a client with in- Lactic acid

creased intracranial pressure should
recognize that which compensatory Carbonic acid
mechanism stimulates the cerebral
blood vessels to regulate cerebral Carbon dioxide
pressure? (Select all that apply.)
Lactic acid, carbonic acid, and car-
Lactic acid bon dioxide are chemicals that
stimulate the dilation or contrac-
Serum uric acid tion of blood vessels within the
brain, which aids in regulation of
Carbonic acid cerebral pressure. Cerebral hem-
orrhage also regulates dilation or
Potassium constriction of the cerebral blood
vessels in response to the amount
Carbon dioxide of blood flow within the brain.
Serum uric acid and potassium do
not affect cerebral pressure.
4. The nurse assessing a client who Traumatic brain injury

presents with an altered level of
consciousness (LOC) should suspect Hematoma
which condition? (Select all that ap-
ply.) Seizure activity
Traumatic brain injury Cerebral infarction
2 / 11
Hematoma Localized and systemic disorders
can alter LOC. Processes occur-
Sciatica ring in the brain that may di-
rectly destroy or compress the
Seizure activity neurologic structures are numer-
ous but include increased in-
Cerebral infarction tracranial pressure, cerebral infarc-
tion, hematoma, hydrocephalus,
intracranial hemorrhage, tumors,
infections, traumatic brain injury,
seizure activity, and recovery. Sci-
atica, although painful, does not
cause an alteration of LOC.
5. An alert client presents at the urgent Level of consciousness (LOC)

care center after a fall. Which assess-
ment should the nurse perform? (Se- Vital signs
lect all that apply.)
Pupillary size and reaction to light
Level of consciousness (LOC)
Assessment of the neurologic sta-
Vital signs tus establishes the client's clinical
condition and provides a baseline
Body mass index for measuring changes. Assess-
ment areas include LOC, behavior,
Anthropometric measurements motor/sensory functions, pupillary
size and reaction to light, and vital
Pupillary size and reaction to light signs. Body mass index (BMI) and
anthropometric measurements are
commonly used during nutritional
assessment.
6. A parent brings a 12-year-old to the "How do you feel about your child
clinic after a fall from a bicycle. Which wearing a helmet while riding their
statement by the nurse is a health bicycle?"
promotion intervention to minimize fu-
ture risk of increased intracranial pres- Health promotion related to in-
sure? tracranial regulation generally in-
volves anticipatory guidance relat-
3 / 11
"Thank goodness your child sustained ed to the client's age, develop-
only a few cuts and bruises." ment, and activities. It also includes
providing information about protec-
"Let's hope this doesn't happen tive equipment for outdoor activi-
again." ties and vehicle restraint systems.
While the other answer options
"What will you do in the future to pre- are valid statements, by asking an
vent this from happening?" open-ended question with the sug-
gestion of protective equipment, a
"How do you feel about your child conversation can begin.
wearing a helmet while riding their bi-
cycle?"
7. The nurse is preparing to discharge an Home assessment

older adult who was admitted to the
hospital after hitting their head during Health promotion education for old-
a fall. Which service is most important er adults includes fall prevention
for the client when at home? and adhering to cautions that ac-
company prescription medications.
Home pharmacy delivery Older adults who are at risk for falls
may benefit from a home safety as-
Home assessment sessment. Other in-home services
may be valuable but will not nec-
In-home blood draws essarily prevent a fall?which is why
the client was admitted to the hos-
Meals on Wheels pital.
8. A 35-year-old client has been in the Purchase a medical alert bracelet.

hospital for 2 weeks recovering from
increased intracranial pressure. Which Discuss the care plan at the work-
instruction should the nurse provide place.
to the client? (Select all that apply.)
Take all medications as prescribed.
Purchase a medical alert bracelet.
Nurses can teach clients who are at
Wear a helmet to prevent head injury. risk for impaired intracranial regula-
tion about the importance of wear-
Remain on bedrest at all times of the ing a medical alert bracelet, dis-
day. cussing care plans at the school
4 / 11
or workplace, and taking all med-
Discuss the care plan at the work- ications as prescribed. For young
place. children, health promotion may in-
clude wearing a helmet to prevent
Take all medications as prescribed. head injury during a seizure. There
is no indication that requires com-
plete bedrest.
9. The nurse is reviewing medications Narcotic analgesic

with a client. The nurse should teach
the client that which medication may Nurses should review prescription
cause drowsiness and increase the and over-the-counter medications
risk for a fall? with all clients, making sure to dis-
cuss side effects that may affect in-
Anticoagulant tracranial regulation. For instance,
blood thinners may increase the
Narcotic analgesic risk of hemorrhagic stroke, and
medications such as narcotic anal-
Antihypertensive gesics may cause dizziness and
put the client at risk for falls. Antihy-
Antipruritic pertensives may cause dizziness
that can put a client at risk for a
fall. An antipruritic is used to relieve
itching.
10. A client is ready for discharge from "My spouse should avoid alcohol
the hospital after being treated for in- as it can increase the risk of injury."
creased intracranial pressure. Which
statement confirms that the client's Nurses should instruct clients to
spouse understands the discharge in- avoid alcohol, which can increase
structions? the risk of injury, and products that
contain nicotine, which increase
"My spouse should avoid alcohol as it the heart rate and blood pres-
can increase the risk of injury." sure and cause vasoconstriction
that can increase the client's risk
"My spouse can take any of stroke. The healthcare provider
over-the-counter medication." must review all over-the-counter
medications for possible contraindi-
"My spouse can continue to use a cations.
5 / 11
nicotine patch."
"My spouse does not need to do any-

thing differently when we get home."
11. The nurse is caring for a client who has Arterial blood gas
increased intracranial pressure from a
traumatic brain injury. Which diagnos- Computerized tomography (CT)
tic test should the nurse anticipate be- scan of the head
ing ordered? (Select all that apply.)
Cardiac monitoring
Arterial blood gas
Intracranial pressure monitor
Computerized tomography (CT) scan
of the head
Electromyogram
Cardiac monitoring
Intracranial pressure monitor
12. A client with increased intracranial To draw fluid from the brain tissue
pressure is prescribed mannitol. The
family asks, "What is the purpose Mannitol is used in the treatment
of this medication?" The nurse's re- of increased intracranial pressure
sponse should be based on which ac- to draw fluid out of the brain,
tion of the drug? thereby reducing intracranial pres-
sure. Mannitol does not establish
To create a sodium and potassium bal- a sodium and potassium balance.
ance Mannitol does not enhance excre-
tion of serum protein, which is not
To enhance renal excretion of retained an intended outcome. The medica-
protein tion does not prevent hemorrhages
within the brain.
To prevent tiny stress hemorrhages in
the brain
To draw fluid from the brain tissue
6 / 11
13. The nurse is requesting collaborative To recommend interventions for re-
therapy from physical therapy for a sulting hemiparesis or hemiplegia
client with increased intracranial pres-
sure. Which reason supports this re- The purpose of a physical therapy
quest? consult for a client with an alter-
ation in intracranial pressure is to
To determine if transfer to a skilled address the client's motor skills and
nursing facility is required strength in performing daily activi-
ties requiring mobility. This is espe-
To assess the living accommodations cially necessary if any hemiparesis
before the client's discharge to home or hemiplegia has resulted. A nurse
or social worker involved in home
To work with the nutritionist to deter- care would most likely assess the
mine effective methods to meet nutri- client's home environment. The nu-
tional needs tritionist would address the client's
nutritional needs; the physical or
To recommend interventions for re- occupational therapist may be in-
sulting hemiparesis or hemiplegia cluded in the plan to recommend
effective accommodations for the
motor skills that are involved in the
eating process. Many factors and
individuals are involved in the deci-
sion to transfer a client to a skilled
nursing facility. This decision would
most likely be directed through a
social service consult.
14. The nurse is caring for a client who has Administering acetaminophen per
increased intracranial pressure and a order
fever of 102°F. Which nursing inter-
vention promotes normal intracranial Providing supplemental oxygen
pressure? (Select all that apply.)
Monitoring level of consciousness
Administering acetaminophen per or-
der Increased intracranial pressure can
cause irregular and ineffective
Flexing the neck to open the airway respirations. Supplemental oxygen
helps prevent hypoxia and excess
Providing supplemental oxygen carbon dioxide, which is a va-
7 / 11
sodilator. A decreased level of con-
Increasing environmental stimuli sciousness can be a manifesta-
tion of pressure on the cerebral
Monitoring level of consciousness cortex. It can also be a manifes-
tation of decreased oxygen lev-
els in the brain. Hyperthermia in-
creases intracranial pressure and
affects hypothalamic function in
clients with increased intracranial
pressure; therefore, administering
an antipyretic medication is appro-
priate. Excess environmental stim-
uli can increase intracranial pres-
sure. Flexing the neck increases
intracranial pressure by preventing
blood return from the brain. The
head and neck must be kept in neu-
tral position.
15. Which collaborative therapy should Speech therapy

the nurse request when a client needs
to learn to swallow following damage Speech therapy may be needed if
to the associated area of the brain? the client needs to learn to eat or
talk following damage to the as-
Physical therapy sociated areas of the brain. Physi-
cal therapy to prevent muscle atro-
Occupational therapy phy may be necessary for a client
who is unconscious or bedridden.
Recreational therapy Occupational therapy can help the
client regain any motor skills need-
Speech therapy ed to perform activities of daily liv-
ing. Recreational therapy works to
restore motor, social, and cognitive
functioning, build confidence, de-
velop coping skills, and integrate
skills learned in treatment settings
into community settings.
16.
8 / 11
Which assessment finding for a client Slowed pupillary responses to light
should the nurse attribute to increased
intracranial pressure? (Select all that Decreased heart rate
apply.)
Decreased motor status and
Fluid intake for the past 24 hours strength
Slowed pupillary responses to light Altered level of consciousness
Decreased heart rate Neurologic assessments of a client

with a head injury include assess-
Decreased motor status and strength ment of the level of consciousness.
Decreased level of consciousness
Altered level of consciousness will often be the first indication of
an increase in intracranial pres-
sure. Assessment of the vital signs
will reveal a slowed heart and res-
piratory rate and increased blood
pressure. The motor status and
strength will decrease. The pupil-
lary response to light will be slow.
Previous oral fluid intake is not as-
sociated with a head injury, but on-
going fluid monitoring and limitation
may be part of the treatment plan.
17. A client is demonstrating signs of in- Monitoring pupillary response

creasing intracranial pressure. Which
intervention should the nurse imple- Reducing environmental stimuli
ment? (Select all that apply.)
Assessing cranial nerve function
Monitoring pupillary response
Assessing vital signs
Providing hypotonic fluids
Nursing actions for the client
Reducing environmental stimuli demonstrating signs of increas-
ing intracranial pressure include
Assessing cranial nerve function assessing vital signs, monitoring
pupillary response, assessing cra-
9 / 11
nial nerve function, and reducing
Assessing vital signs environmental stimuli. Intravenous
fluids administered at this time
would be isotonic or hypertonic.
18. Which nursing goal is appropriate for a Protection from sudden increases
client with increased intracranial pres- in intracranial pressure
sure (IICP)?
The nursing care of clients with
Protection from increases in cerebral IICP involves identifying those at
blood flow risk and managing factors known
to increase ICP. A major focus is
Protection from sudden decreases in protecting the client from sudden
intracranial pressure increases in ICP or decreases in
cerebral blood flow.
Protection from risk factors
Protection from sudden increases in

intracranial pressure
19. The nurse is caring for a client with Maintaining partial pressure of ar-
increased intracranial pressure (IICP) terial carbon dioxide of 35 mmHg
who is supported with mechanical
ventilation. Which intervention should Maintaining partial pressure of ar-
the nurse implement to ensure ade- terial oxygen of 100 mmHg
quate oxygenation for this client? (Se-
lect all that apply.) Performing suctioning as needed
Maintaining partial pressure of arterial Implementing measures to prevent

carbon dioxide of 35 mmHg atelectasis and fluid accumulation
Maintaining partial pressure of arterial Maintaining an appropriate arterial

oxygen of 100 mmHg oxygen and carbon dioxide assists
in oxygenation and prevents res-
Performing suctioning as needed piratory distress. Performing suc-
tioning ensures a patent airway,
Implementing measures to prevent at- and preventing atelectasis and flu-
electasis and fluid accumulation id accumulation allows for gas ex-
change in the alveoli. Judicious hy-
10 / 11
perventilation is only used as an
Initiating hyperventilation emergency intervention for clients
with IICP and impending hernia-
tion.
20. The nurse is caring for a client with "I will ask another nurse to help me
increased intracranial pressure (IICP) lift the client toward the head of the
from a cervical injury. Which statement bed."
by the nurse indicates an understand-
ing of how to position the client? To prevent a further increase in in-
tracranial pressure (ICP), the nurse
"I will ask the client to assist by push- should ask for assistance from an-
ing on the bed with their feet and other staff member. This prevents
hands." the client from pushing with their
hands or feet against the bed, both
"I will ask another nurse to help me lift of which can increase ICP. The
the client toward the head of the bed." prone, or flat, position should be
avoided; the head of the bed should
"The head of the bed should be kept be kept at 30 degrees to assist with
flat to make it easier to move the venous drainage from the brain. It
client." is not necessary to sit the client up
at a 90-degree angle.
"The head of the bed should be kept
at 90 degrees to assist with venous
drainage from the brain."
11 / 11
ICP NCLEX style Questions
Study online at https://quizlet.com/_7lwdxz
1. Which components are able to a, c, e. Blood adapts with increased

change to adapt to small increases in venous outflow,
intracranial pressure (ICP) (select all decreased cerebral blood flow
that (CBF), and collapse of
apply)? veins and dural sinuses. Brain tissue
a. Blood d. Scalp tissue adapts with distention
b. Skull bone e. Cerebrospinal fluid of the dura, slight compression of tis-
(CSF) sue, or herniation.
c. Brain tissue Cerebrospinal fluid (CSF) adapts
with increased absorption,
decreased production, and displace-
ment into the spinal
canal. Skull bone and scalp tissue do
not adapt to changes
in intracranial pressure (ICP).
2. The cerebral perfusion pressure 56 mm Hg

(CPP) is the pressure needed to en- Mean arterial pressure (MAP) = di-
sure blood flow to the brain. Normal astolic blood pressure
CPP is 60 to (DBP) + 1
100 mm Hg. Calculate the CPP of a D3 (systolic blood pressure [SBP] -
patient whose blood pressure (BP) is DBP) =
106/52 mm Hg and ICP is 14 mm Hg. 52 + 18 = 70
mm Hg Cerebral per
3. Calculate the CPP for the patient with 45 mm Hg

an ICP of 34 mm Hg and a systemic MAP = DBP + 1
BP of 108/64 mm Hg. D3 (SBP DBP) = 64 + 15 = 79
mm Hg CPP = MAP ICP = 79 34 = 45
4. Which factors decrease cerebral c, e. Cerebral blood flow is de-

blood flow (select all that apply)? creased when the MAP
a. Increased ICP d. Arterial blood pH and the PaCO2
of 7.3 are decreased. The other options
b. PaO2 of 45 mm Hg e. Decreased increase
mean arterial pressure (MAP) cerebral blood flow.
c. PaCO2 of 30 mm Hg
5.
1 / 15
What are causes of vasogenic cere- b, e. Vasogenic cerebral edema, the
bral edema (select all that apply)? most common type
a. Hydrocephalus of edema, occurs mainly in the white
b. Ingested toxins matter and is
c. Destructive lesions or trauma characterized by leakage of macro-
d. Local disruption of cell mem- molecules from the
branes capillaries into the surrounding extra-
e. Fluid flowing from intravascular to cellular space. This
extravascular space results in an osmotic gradient that
favors the flow of
fluid from the intravascular to the ex-
travascular space. A
variety of insults, such as brain tu-
mors, abscesses, and
ingested toxins, may cause an in-
crease in the permeability
of the blood-brain barrier and pro-
duce an increase in the
extracellular fluid volume. Hydro-
cephalus causes interstitial
cerebral edema.
6. Which events cause increased ICP a, b, d. Increased ICP is caused by

(select all that apply)? vasodilation and edema
a. Vasodilation d. Edema from initial from the initial brain insult or necrotic
brain insult tissue. Blood vessel
b. Necrotic tissue edema e. Brain- compression and brainstem com-
stem compression and herniation pression and herniation
c. Blood vessel compression occur as a result of increased ICP.
7. An early sign of increased ICP that . c. One of the most sensitive signs of
the nurse should assess for is increased ICP is a
a. Cushing's triad. c. decreasing level decreasing level of consciousness
of consciousness (LOC). (LOC). A decrease in
b. unexpected vomiting. d. dilated LOC will occur before changes in vi-
pupil with sluggish response to light. tal signs, ocular signs,
or projectile vomiting occur.
8.
2 / 15
The nurse recognizes the presence c. Cushing's triad consists of three
of Cushing's triad in the patient with vital sign measures that
which vital sign changes? reflect ICP and its effect on the
a. Increased pulse, irregular respira- medulla, hypothalamus,
tion, increased BP pons, and thalamus. Because these
b. Decreased pulse, increased respi- structures are very deep,
ration, decreased systolic BP Cushing's triad is usually a late sign
c. Decreased pulse, irregular respira- of ICP. The signs
tion, widened pulse pressure include an increasing SBP with a
d. Increased pulse, decreased respi- widening pulse pressure,
ration, widened pulse pressure a bradycardia with a full and bound-
ing pulse, and irregular
respirations.
9. Increased ICP in the left cerebral cor- c. The dural structures that separate
tex caused by intracranial bleeding the two hemispheres
causes displacement of brain tissue and the cerebral hemispheres from
to the the cerebellum influence
right hemisphere beneath the falx the patterns of cerebral herniation. A
cerebri. The nurse knows that this is cingulate herniation
referred to as what? occurs where there is lateral dis-
a. Uncal herniation c. Cingulate her- placement of brain tissue
niation beneath the falx cerebri. Uncal herni-
b. Tentorial herniation d. Temporal ation occurs when there
lobe herniation is lateral and downward herniation.
Tentorial herniation
occurs when the brain herniates
down through the opening
created by the brainstem. The tem-
poral lobe can be involved
in central herniation
10. Priority Decision: A patient has ICP a. An intraventricular catheter is a

monitoring with an intraventricular fluid-coupled system that
catheter. What is a priority nursing can provide direct access for mi-
intervention for the patient? croorganisms to enter the
a. Aseptic technique to prevent infec- ventricles of the brain and aseptic
tion c. Removal of CSF to maintain technique is a very high
normal ICP nursing priority to decrease the risk
3 / 15
b. Constant monitoring of ICP wave- for infection. Constant
forms d. Sampling CSF to determine monitoring of ICP waveforms is not
abnormalities usually necessary and
removal of CSF for sampling or to
maintain normal ICP is
done only when specifically ordered.
11. When using intraventricular ICP b. An inaccurate ICP reading can be

monitoring, what should the nurse be caused by CSF
aware of to prevent inaccurate read- leaks around the monitor device, ob-
ings? struction of the
a. The P2 wave is higher than the P1 intraventricular catheter, kinks or
wave. bubbles in the tubing,
b. CSF is leaking around the monitor- and incorrect height of the transduc-
ing device. er or drainage system
c. The transducer of the ventricu- relative to the patient's reference
lostomy monitor is at the level of the point. The P2 wave
upper ear. being higher than the P1 wave indi-
d. The drain of the CSF drainage de- cates poor ventricular
vice was closed for 6 minutes before compliance. The transducer height
taking the reading. should be at the tragus
of the ear. The drain of the CSF
drainage device should be
closed for 6 minutes preceding the
reading.
12. The patient is being monitored b. The normal pressure of oxygen in

long-term with a brain tissue oxy- brain tissue (PbtO2
genation catheter. What range for the )
pressure of is 20 to 40 mm Hg. The normal jugu-
oxygen in brain tissue (PbtO2 lar venous oxygen
) will maintain cerebral oxygen sup- saturation (SjvO2
ply and demand? ) is 55% to 75% and indicates total
a. 55% to 75% c. 70 to 150 mm Hg venous
b. 20 to 40 mm Hg d. 80 to 100 mm Hg brain tissue extraction of oxygen; this
is used for short-term
monitoring. The MAP of 70 to 150
mm Hg is needed for
effective autoregulation of CBF. The
4 / 15
normal range for PaO2
is 80 to 100 mm Hg.
13. Which drug treatment helps to de- c. Mannitol (Osmitrol) (25%) is an

crease ICP by expanding plasma and osmotic diuretic that
the osmotic effect to move fluid? expands plasma and causes fluid to
a. Oxygen administration c. Mannitol move from tissues into
(Osmitrol) (25%) the blood vessels. Hypertonic saline
b. Pentobarbital (Nembutal) d. Dex- reduces brain swelling
amethasone (Decadron) by moving water out of brain tissue.
Oxygen administration
is done to maintain brain function.
Pentobarbital
(Nembutal) and other barbiturates
are used to reduce
cerebral metabolism. The corticos-
teroid dexamethasone
(Decadron) is used to treat vaso-
genic edema to stabilize cell
membranes and improve neuronal
function by improving
CBF and restoring autoregulation
14. How are the metabolic and nutritional d. A patient with increased ICP is in
needs of the patient with increased a hypermetabolic and
ICP best met? hypercatabolic state and needs ade-
a. Enteral feedings that are low in quate glucose to maintain
sodium fuel for the brain and other nutrients
b. Simple glucose available in D5 to meet metabolic needs.
W IV solutions Malnutrition promotes cerebral ede-
c. Fluid restriction that promotes a ma and if a patient cannot
moderate dehydration take oral nutrition, other means of
d. Balanced, essential nutrition in a providing nutrition should
form that the patient can tolerate be used, such as tube feedings or
parenteral nutrition. Glucose
alone is not adequate to meet nutri-
tional requirements and 5%
dextrose solutions may increase
cerebral edema by lowering
5 / 15
serum osmolarity. Patients should re-
main in a normovolemic fluid state
with close monitoring of clinical fac-
tors such as
urine output, fluid intake, serum and
urine osmolality, serum
electrolytes, and insensible losses.
15. Why is the Glasgow Coma Scale a. The Glasgow Coma Scale (GCS)
(GCS) used? is used to quickly assess
a. To quickly assess the LOC the LOC with a standardized system.
b. To assess the patient's ability to The three areas assessed
communicate are the patient's ability to speak,
c. To assess the patient's ability to obey commands, and open
respond to commands eyes to verbal or painful stimulus. Al-
d. To assess the patient's coordina- though best motor
tion with motor responses response is an indicator, it is not
used to assess coordination.
16. A patient with an intracranial prob- b. No opening of eyes = 1; incompre-

lem does not open his eyes to any hensible words = 2;
stimulus, has no verbal response ex- flexion withdrawal = 4. Total = 7
cept
moaning and muttering when stimu-
lated, and flexes his arm in response
to painful stimuli. What should the
nurse
record as the patient's GCS score?
a. 6 c. 9
b. 7 d. 11
17. Priority Decision: When assessing d. Of the body functions that should
the body functions of a patient with be assessed in an
increased ICP, what should the nurse unconscious patient, cardiopul-
assess monary status is the most
first? vital function and gives priorities to
a. Corneal reflex testing c. Extremity the ABCs (airway,
strength testing breathing, and circulation).
6 / 15
b. Pupillary reaction to light d. Circu-
latory and respiratory status
18. How is cranial nerve (CN) III, origi- . c. One of the functions of cranial
nating in the midbrain, assessed by nerve (CN) III, the
the nurse for an early indication of oculomotor nerve, is pupillary con-
pressure striction and testing for
on the brainstem? pupillary constriction is important to
a. Assess for nystagmus c. Test pupil- identify patients at
lary reaction to light risk for brainstem herniation caused
b. Test the corneal reflex d. Test for by increased ICP. The
oculocephalic (doll's eyes) reflex corneal reflex is used to assess the
functions of CN V and
VII and the oculocephalic reflex tests
all cranial nerves
involved with eye movement. Nystag-
mus is commonly
associated with specific lesions or
chemical toxicities and is
not a definitive sign of ICP
19. A patient has a nursing diagnosis a. Nursing care activities that in-
of risk for ineffective cerebral tissue crease ICP include hip and
perfusion related to cerebral edema. neck flexion, suctioning, clustering
What is care activities, and
an appropriate nursing intervention noxious stimuli. They should be
for the patient? avoided or performed as
a. Avoid positioning the patient with little as possible in the patient with
neck and hip flexion. increased ICP. Lowering
b. Maintain hyperventilation to a the PaCO2
PaCO2 below 20 mm Hg can cause is-
of 15 to 20 mm Hg. chemia and
c. Cluster nursing activities to pro- worsening of ICP
vide periods of uninterrupted rest.
d. Routinely suction to prevent accu-
mulation of respiratory secretions.
20. An unconscious patient with in- c. A PaO2

creased ICP is on ventilatory sup- of 70 mm Hg reflects hypoxemia that
7 / 15
port. The nurse notifies the health may lead
care provider to further decreased cerebral perfu-
when arterial blood gas (ABG) mea- sion. PaO2
surement results reveal what? should be
a. pH of 7.43 c. PaO2 maintained at greater than or equal
of 70 mm Hg to 100 mm Hg. The pH
b. SaO2 and SaO2
of 94% d. PaCO2 are within normal range and a
of 35 mm Hg PaCO2
of 35 mm
Hg reflects a normal value.
21. The nurse is monitoring a patient for a, b, d, e. The first sign of increased
increased ICP following a head in- ICP is a change in
jury. What are manifestations of in- LOC. Other manifestations are dilat-
creased ed ipsilateral pupil,
ICP (select all that apply)? changes in motor response such as
a. Fever d. Right pupil dilated greater posturing, and fever,
than left pupil which may indicate pressure on the
b. Oriented to name only e. Decorti- hypothalamus. Changes
cate posturing to painful stimulus in vital signs would be an increased
c. Narrowing pulse pressure SBP with widened
pulse pressure and bradycardia.
22. Priority Decision: While the nurse b. If reflex posturing occurs during
performs range of motion (ROM) range of motion (ROM)
on an unconscious patient with in- or positioning of the patient, these
creased ICP, activities should be
the patient experiences severe de- done less frequently until the pa-
cerebrate posturing reflexes. What tient's condition stabilizes
should the nurse do first? because posturing can cause in-
a. Use restraints to protect the pa- creases in ICP and may
tient from injury. indicate herniation. Neither restraints
b. Perform the exercises less fre- nor central nervous
quently because posturing can in- system (CNS) depressants would be
crease ICP. indicated
c. Administer central nervous system
(CNS) depressants to lightly sedate
the patient.
8 / 15
d. Continue the exercises because
they are necessary to maintain mus-
culoskeletal function
23. The patient has been diagnosed with d. A cerebral concussion may include
a cerebral concussion. What should a brief disruption
the nurse expect to see in this pain LOC, retrograde amnesia, and a
tient? headache, all of short
a. Deafness, loss of taste, and CSF duration. A basilar skull fracture may
otorrhea have a dural tear
b. CSF otorrhea, vertigo, and Battle's with CSF or brain otorrhea, rhinor-
sign with a dural tear rhea, hearing difficulty,
c. Boggy temporal muscle because vertigo, and Battle's sign. A temporal
of extravasation of blood fracture would have a
d. Headache, retrograde amnesia, boggy temporal muscle because of
and transient reduction in LOC extravasation of blood,
Battle's sign, or CSF otorrhea.
24. The patient comes to the emergency c. The posterior fossa fracture caus-
department (ED) with cortical blind- es occipital bruising
ness and visual field defects. Which resulting in cortical blindness or visu-
type of al field defects.
head injury does the nurse suspect? A cerebral contusion is bruising of
a. Cerebral contusion c. Posterior brain tissue within
fossa fracture a focal area. An orbital skull fracture
b. Orbital skull fracture d. Frontal would cause
lobe skull fracture periorbital ecchymosis (raccoon
eyes) and possible
optic nerve injury. A frontal lobe skull
fracture would
expose the brain to contaminants
through the frontal
air sinus and the patient would have
CSF rhinorrhea or
pneumocranium.
25. The patient has a depressed skull c. The compound skull fracture is a
fracture and scalp lacerations with depressed skull fracture
communication to the intracranial and scalp lacerations with communi-
9 / 15
cavity. Which cating pathway(s) to the
type of injury should the nurse intracranial cavity. A linear skull frac-
record? ture is a straight break
a. Linear skull fracture c. Compound in the bone without alteration in the
skull fracture fragments. A depressed
b. Depressed skull fracture d. Com- skull fracture is an inward indentation
minuted skull fracture of the skull that may
cause pressure on the brain. A com-
minuted skull fracture
has multiple linear fractures with
bone fragmented into
many pieces.
26. A patient with a head injury has b. Testing clear drainage for CSF in
bloody drainage from the ear. What nasal or ear drainage
should the nurse do to determine if may be done with a Dextrostik or
CSF is Tes-Tape strip but if
present in the drainage? blood is present, the glucose in the
a. Examine the tympanic membrane blood will produce an
for a tear. unreliable result. To test bloody
b. Test the fluid for a halo sign on a drainage, the nurse should
white dressing. test the fluid for a "halo" or "ring" that
c. Test the fluid with a glucose-identi- occurs when a
fying strip or stick. yellowish ring encircles blood
d. Collect 5 mL of fluid in a test dripped onto a white pad or
tube and send it to the laboratory for towel within a few minutes.
analysis.
27. The nurse suspects the presence of d. An arterial epidural hematoma is

an arterial epidural hematoma in the the most acute
patient who experiences neurologic emergency and typical
a. failure to regain consciousness symptoms include
following a head injury. unconsciousness at the scene with a
b. a rapid deterioration of neurologic brief lucid interval
function within 24 to 48 hours follow- followed by a decrease in LOC. An
ing a head injury. acute subdural
c. nonspecific, nonlocalizing pro- hematoma manifests signs within 48
gression of alteration in LOC occur- hours of an injury. A
ring over weeks or months.
10 / 15
d. unconsciousness at the time of a chronic subdural hematoma devel-
head injury with a brief period of con- ops over weeks or months.
sciousness followed by a decrease in
LOC.
28. Skull x-rays and a computed tomog- d. When there is a depressed frac-
raphy (CT) scan provide evidence of ture or a fracture with
a depressed parietal fracture with a loose fragments, a craniotomy is in-
subdural dicated to elevate the
hematoma in a patient admitted to depressed bone and remove free
the ED following an automobile acci- fragments. A craniotomy
dent. In planning care for the patient, is also indicated in cases of acute
what subdural and epidural
should the nurse anticipate? hematomas to remove the blood and
a. The patient will receive life support control the bleeding.
measures until the condition stabi- Burr holes may be used in an ex-
lizes. treme emergency for rapid
b. Immediate burr holes will be made decompression or to aid in removing
to rapidly decompress the intracra- a bone flap but with
nial cavity. a depressed fracture, surgery would
c. The patient will be treated con- be the treatment of
servatively with close monitoring for choice.
changes in neurologic status.
d. The patient will be taken to surgery
for a craniotomy for evacuation of
blood and decompression of the cra-
nium.
29. Priority Decision: When a patient is a. In addition to monitoring for a

admitted to the ED following a head patent airway during
injury, what should be the nurse's emergency care of the patient with a
first head injury, the nurse
priority in management of the patient must always assume that a patient
once a patent airway is confirmed? with a head injury may
a. Maintain cervical spine precau- have a cervical spine injury. Main-
tions. c. Determine the presence of taining cervical spine
increased ICP. precautions in all assessment and
b. Monitor for changes in neurologic treatment activities with
the patient is essential to prevent ad-
11 / 15
status. d. Establish IV access with a ditional neurologic
large-bore catheter damage.
30. A 54-year-old man is recovering from a. Residual mental and emotional

a skull fracture with a subacute sub- changes of brain trauma
dural hematoma that caused uncon- with personality changes are often
sciousness. the most incapacitating
He has return of motor control and problems following head injury and
orientation but appears apathetic are common in patients
and has reduced awareness of his who have been comatose for longer
environment. When than 6 hours. Families
planning discharge of the patient, must be prepared for changes in the
what should the nurse explain to the patient's behavior
patient and the family? to avoid family-patient friction and
a. The patient is likely to have maintain family
long-term emotional and mental functioning and professional assis-
changes that may require profes- tance may be required.
sional help. There is no indication the patient will
b. Continuous improvement in the be dependent on
patient's condition should occur un- others for care but he likely will not
til he has returned to pretrauma sta- return to pretrauma
tus. status.
c. The patient's complete recovery
may take years and the family should
plan for his long-term dependent
care.
d. Role changes in family members
will be necessary because the pa-
tient will be dependent on his family
for care
and support.
31. The patient is suspected of having a d. The positron emission tomography

new brain tumor. Which test will the (PET) scan or
nurse expect to be ordered to detect magnetic resonance imaging (MRI)
a small are used to reliably
tumor? detect very small tumors. The com-
a. CT scan c. Electroencephalogra- puted tomography (CT)
phy (EEG) and brain scans are used to identify
12 / 15
b. Angiography d. Positron emission the location of a lesion.
tomography (PET) scan Angiography could be used to deter-
mine blood flow to
the tumor and further localize it. Elec-
troencephalography
(EEG) would be used to rule out
seizures.
32. Assisting the family to understand . b. Frontal lobe tumors often lead to
what is happening to the patient is an loss of emotional
especially important role of the nurse control, confusion, memory loss, dis-
when orientation,
the patient has a tumor in which part seizures, and personality and judg-
of the brain? ment changes that are
a. Ventricles c. Parietal lobe very disturbing and frightening to the
b. Frontal lobe d. Occipital lobe family. Physical
symptoms, such as blindness,
speech disturbances, or
disturbances in sensation and per-
ception that occur
with other tumors, are more likely to
be understood and
accepted by the family
33. Which cranial surgery would require d. A craniectomy is excision of cranial

the patient to learn how to protect the bone without
surgical area from trauma? replacement, so the patient will need
a. Burr holes c. Cranioplasty to protect the brain
b. Craniotomy d. Craniectomy from trauma in this surgical area.
Burr holes are opened
into the cranium with a drill to remove
blood and fluid. A
craniotomy is opening the cranium
with removal of a bone
flap to open the dura. The replaced
bone flap is wired or
sutured after surgery. A cranioplasty
replaces part of the
cranium with an artificial plate.
13 / 15
34. What is the best explanation of b. A stereotactic radiosurgery tech-
stereotactic radiosurgery? nique uses precisely
a. Radioactive seeds are implanted in focused radiation to destroy tumor
the brain. cells. The radiation is
b. Very precisely focused radiation computer and imagery guided. Ra-
destroys tumor cells. dioactive seeds are used
c. Tubes are placed to redirect CSF to deliver radiation. Ventricular
from one area to another. shunts are used to redirect
d. The cranium is opened with re- CSF from one area to another. A
moval of a bone flap to open the dura. craniotomy is done by
first making burr holes and then
opening the cranium by
connecting the holes to remove a
flap of bone to expose the
dura mater
35. For the patient undergoing a cran- a. To prevent undue concern and
iotomy, when should the nurse pro- anxiety about hair loss and
vide information about the use of postoperative self-esteem distur-
wigs and bances, a patient undergoing
hairpieces or other methods to dis- cranial surgery should be informed
guise hair loss? preoperatively that
a. During preoperative teaching the head is usually shaved in surgery
b. If the patient asks about their use while the patient is
c. In the immediate postoperative pe- anesthetized and that a turban, scarf,
riod or cap may be used
d. When the patient expresses nega- after the dressings are removed
tive feelings about his or her appear- postoperatively and a wig
ance also may be used after the incision
has healed to disguise
the hair loss. In the immediate post-
operative period the
patient is very ill and the focus is on
maintaining neurologic
function but preoperatively the nurse
should anticipate
the patient's postoperative need for
self-esteem and
maintenance of appearance.
14 / 15
36. Successful achievement of patient d. The primary goal after cranial
outcomes for the patient with cranial surgery is prevention
surgery would best be indicated by of increased ICP and interventions to
what? prevent ICP and
a. Ability to return home in 6 days infection postoperatively are nursing
c. Acceptance of residual neurologic priorities. The residual
deficits deficits, rehabilitation potential, and
b. Ability to meet all self-care needs ultimate function of the
d. Absence of signs and symptoms patient depend on the reason for
of increased ICP surgery, the postoperative
course, and the patient's general
state of health.
15 / 15
ICP Nclex Questions, ICP NCLEX style Questions, ICP Nclex Questions
Study online at https://quizlet.com/_8w3kab
1. The nurse notes that a patient Correct Answer: C

with a head injury has a clear Rationale: If the drainage is cere-
nasal drainage. The most appropri- brospinal fluid (CSF) leakage from a
ate nursing action for this finding dural tear, glucose will be present. Fluid
is to leaking from the nose will have normal
a. obtain a specimen of the fluid nasal flora, so culture and sensitivity
and send for culture and sensitiv- will not be useful. A dural tear does
ity. increase the risk for infections such as
b. take the patient's temperature to meningitis, but the nurse should first
determine whether a fever is pre- determine whether the clear drainage
sent. is CSF. Blowing the nose is avoided to
c. check the nasal drainage for glu- prevent CSF leakage.
cose with a Dextrostik or Testape.
d. have the patient to blow the nose Cognitive Level: Application Text Refer-
and then check the nares for red- ence: p. 1481
ness. Nursing Process: Implementation
NCLEX: Physiological Integrity
2. A patient admitted with a head in- Correct Answer: C

jury has admission vital signs of Rationale: Systolic hypertension with
temperature 98.6° F (37° C), blood widening pulse pressure, bradycar-
pressure 128/68, pulse 110, and dia, and respiratory changes represent
respirations 26. Which of these vi- Cushing's triad and indicate that the
tal signs, if taken 1 hour after ad- ICP has increased and brain herniation
mission, will be of most concern to may be imminent unless immediate ac-
the nurse? tion is taken to reduce ICP. The other
a. Blood pressure 130/72, pulse 90, vital signs may indicate the need for
respirations 32 changes in treatment, but they are not
b. Blood pressure 148/78, pulse indicative of an immediately life-threat-
112, respirations 28 ening process.
c. Blood pressure 156/60, pulse 60,
respirations 14 Cognitive Level: Application Text Refer-
d. Blood pressure 110/70, pulse ence: p. 1469
120, respirations 30 Nursing Process: Assessment NCLEX:
Physiological Integrity
3. When assessing a patient with a Correct Answer: C

head injury, the nurse recognizes Rationale: LOC is the most sensitive
that the earliest indication of in- indicator of the patient's neurologic sta-
1 / 31
creased intracranial pressure (ICP) tus and possible changes in ICP. Vom-
is iting and sluggish pupil response to
a. vomiting. light are later signs of increased ICP.
b. headache. A headache can be caused by com-
c. change in level of conscious- pression of intracranial structures as
ness (LOC). the brain swells, but it is not unexpected
d. sluggish pupil response to light. after a head injury.
Cognitive Level: Comprehension Text

Reference: p. 1470
Nursing Process: Assessment NCLEX:
4. A patient with a head injury has Correct Answer: C

an arterial blood pressure is 92/50 Rationale: The patient's cerebral perfu-
mm Hg and an intracranial pression pressure is only 46 mm Hg, which
sure of 18 mm Hg. Which action by will rapidly lead to cerebral ischemia
the nurse is appropriate? and neuronal death unless rapid action
a. Document and continue to mon- is taken to reduce ICP and increase
itor the parameters. arterial BP. Documentation and moni-
b. Elevate the head of the patient's toring are inadequate responses to the
bed. patient's problem. Elevating the head
c. Notify the health care provider of the bed will lower the ICP but may
about the assessments. also lower cerebral blood flow and fur-
d. Check the patient's pupillary re- ther decrease CPP. Changes in pupil
sponse to light. response to light are signs of increased
ICP, so the nurse will only take more
time doing this without adding any use-
ful information.
Cognitive Level: Analysis Text Refer-

ence: pp. 1468-1469
Nursing Process: Implementation
5. A patient has a systemic blood Correct Answer: C

pressure (BP) of 120/60 mm Hg and Rationale: The patient's CPP is 56, be-
an intracranial pressure of 24 mm low the normal of 70 to 100 mm Hg and
Hg. The nurse determines that the approaching the level of ischemia and
2 / 31
cerebral perfusion pressure (CPP) neuronal death. The patient has low
of this patient indicates cerebral blood flow/perfusion. Normal
a. high blood flow to the brain. ICP is 0 to 15 mm Hg.
b. normal intracranial pressure
(ICP). Cognitive Level: Application Text Refer-
c. impaired brain blood flow. ence: p. 1468
d. adequate cerebral perfusion. Nursing Process: Assessment NCLEX:
6. When caring for a patient who has Correct Answer: B

had a head injury, which assess- Rationale: The change in level of con-
ment information is of most consciousness (LOC) is an indicator of in-
cern to the nurse? creased ICP and suggests that action
a. The blood pressure increases by the nurse is needed to prevent com-
from 120/54 to 136/62. plications. The change in BP should
b. The patient is more difficult to be monitored but is not an indicator of
arouse. a need for immediate nursing action.
c. The patient complains of a Headache is not unusual in a patient
headache at pain level 5 of a after a head injury. A slightly irregular
10-point scale. apical pulse is not unusual.
d. The patient's apical pulse is
slightly irregular. Cognitive Level: Application Text Refer-
ence: p. 1470
7. When the nurse applies a painful Correct Answer: A

stimulus to the nailbeds of an un- Rationale: Internal rotation, adduction,
conscious patient, the patient re- and flexion of the arms in an uncon-
sponds with internal rotation, ad- scious patient is documented as decor-
duction, and flexion of the arms. ticate posturing. Extension of the arms
The nurse documents this as and legs is decerebrate posturing. Be-
a. decorticate posturing. cause the flexion is general, it does not
b. decerebrate posturing. indicate localization of pain or flexion
c. localization of pain. withdrawal.
Reference: p. 1472
3 / 31
8. A patient with possible cerebral Correct Answer: B

edema has a serum sodium lev- Rationale: The patient's low sodium
el of 115 mEq/L (115 mmol/L), indicates that hyponatremia may be
a decreasing level of conscious- causing the cerebral edema, and the
ness (LOC) and complains of a nurse's first action should be to correct
headache. All of the following or- the low sodium level. Acetaminophen
ders have been received. Which (Tylenol) will have minimal effect on the
one should the nurse accomplish headache because it is caused by cere-
first? bral edema and increased ICP. Drawing
a. Administer acetaminophen ABGs and obtaining a CT scan may
(Tylenol) 650 mg orally. add some useful information, but the
b. Administer 5% hypertonic saline low sodium level may lead to seizures
intravenously. unless it is addressed quickly.
c. Draw blood for arterial blood
gases (ABGs). Cognitive Level: Application Text Refer-
d. Send patient to radiology for ence: p. 1470
computed tomography (CT) of the Nursing Process: Implementation
head. NCLEX: Physiological Integrity
9. Mechanical ventilation with a rate Correct Answer: C

and volume to maintain a mild hy- Rationale: The purpose of hyperventi-
perventilation is used for a patient lation for a patient with a head injury
with a head injury. To evaluate the is reduction of ICP, and ICP should be
effectiveness of the therapy, the monitored to evaluate whether the ther-
nurse should apy is effective. Although oxygen satu-
a. monitor oxygen saturation. ration and ABGs are monitored in pa-
b. check arterial blood gases tient's receiving hyperventilation, they
(ABGs). do not provide data about whether the
c. monitor intracranial pressure therapy is successful in reducing ICP.
(ICP). Breath sounds are assessed, but they
d. assess patient breath sounds. are not helpful in determining whether
the hyperventilation is effective.
Cognitive Level: Application Text Refer-

ence: p. 1475
4 / 31
Nursing Process: Evaluation NCLEX:
10. A patient has ICP monitoring with A. Aseptic technique to prevent infec-
an intraventricular catheter. A pri- tion- An intraventricular catheter is a
ority nursing intervention for the fluid coupled system that can provide
patient is direct access for microorganisms to en-
a. aseptic technique to prevent inter the ventricles of the brain, and asep-
fection tic technique is a very high nursing pri-
b. constant monitoring of ICP ority to decrease the risk for infection.
waveforms Constant monitoring of ICP waveforms
c. removal of CSF to maintain nor- is not usually necessary, and removal
mal ICP of CSF for sampling or to maintain nor-
d. sampling CSF to determine ab- mal ICP is done only when specifically
normalities ordered
11. Skull radiographs and a computed D. When there is a depressed fracture

tomography (CT) scan provide evi- and fractures with loose fragments, a
dence of a depressed parietal frac- craniotomy is indicated to elevate the
ture with a subdural hematoma in a depressed bone and remove free frag-
patient admitted to the emergency ments. A craniotomy is also indicated
department following an automo- in cases of acute subdural and epidural
bile accident. In planning care for hematomas to remove the blood and
the patient, the nurse anticipates control the bleeding. Burr holes may
that be used in an extreme emergency for
a. the patient will receive life-sup- rapid decompression, but with a de-
port measures until the condition pressed fracture, surgery would be the
stabilizes treatment of choice
b. immediate burr holes will be
made to rapidly decompress the in-
tracranial activity
c. the patient will be treated con-
servatively with close monitoring
for changes in neurologic condi-
tion
d. the patient will be taken to
surgery for a craniotomy for evacu-
ation of blood and decompression
of the cranium
5 / 31
12. Metabolic and nutritional needs of D. Balanced, essential nutrition in a
the patient with increased ICP are form that the patient can tolerate= A
best met with patient with increased ICP is in a hyper-
a. enteral feedings that are low in metabolic and hypercatabolic state and
sodium needs adequate glucose to maintain
b. the simple glucose available in fuel for the brain and other nutrients
D5W IV solutions to meet metabolic needs. Malnutrition
c. a fluid restriction that promotes promotes cerebral edema, and if a pa-
a moderate dehydration tient cannot take oral nutrition, other
d. balanced, essential nutrition in a means of providing nutrition should be
form that the patient can tolerate used, such as tube feedings or par-
enteral nutrition. Glucose alone is not
adequate to meet nutritional require-
ments, and 5% dextrose solutions may
increase cerebral edema by lowering
main in a normovolemic fluid state with
close monitoring of clinical factors such
as urine output, fluid intake, serum and
urine osmolality, serum electrolytes,
and insensible losses.
13. The nurse suspects the presence D. An arterial epidural hematoma is the
of an arterial epidural hematoma in most acute neurologic emergency, and
the patient who experiences the typical symptoms include uncon-
a. failure to regain consciousness sciousness at the scene, with a brief
following a head injury lucid interval followed by a decrease
b. a rapid deterioration of neuro- in LOC. An acute subdural hematoma
logic function within 24 to 48 hours manifests signs within 48 hours of an
following a head injury injury; a chronic subdural hematoma
c. nonspecific, nonlocalizing pro- develops over weeks or months
gression of alteration in LOC oc-
curring over weeks or months
d. unconsciousness at the time of
a head injury with a brief period of
consciousness followed by a de-
crease in LOC
14.
6 / 31
The nurse on the clinical unit is as- C. patient with meningitis who is sud-
signed to four patients. Which pa- denly agitated and reporting a HA of 10
tient should she assess first? on a 0 to 10 scale
a. patient with a skull fracture
whose nose is bleeding
b. elderly patient with a stroke who
is confused and whose daughter is
present
c. patient with meningitis who is
suddenly agitated and reporting a
HA of 10 on a 0 to 10 scale
d. patient who had a craniotomy for
a brain tumor who is now 3 days
postoperative and has had contin-
ued emesis
15. The nurse is monitoring a patient A, B, D, E- The first sign of increased

for increased ICP following a head ICP is a change in LOC. Other man-
injury. Which of the following manifestations are dilated ipsilateral pupil,
ifestations indicate an increased changes in motor response such as
ICP (select all that apply) posturing, and fever, which may indi-
a. fever cate pressure on the hypothalamus.
b. oriented to name only Changes in vital signs would be an in-
c. narrowing pulse pressure creased systolic BP with widened pulse
d. dilated right pupil > left pupil pressure and bradycardia
e. decorticate posturing to painful
stimulus
16. When assessing the body function D. Circulatory and respiratory status-
of a patient with increased ICP, the Of the body functions that should be
nurse should initially assess assessed in an unconscious patient,
a. corneal reflex testing cardiopulmonary status is the most vi-
b. extremity strength testing tal function and gives priorities to the
c. pupillary reaction to light ABCs (airway, breathing, and circula-
d. circulatory and respiratory sta- tion)
tus
17. A patient with ICP monitoring has

pressure of 12 mm Hg. The nurse
7 / 31
understand that this pressure re- D. A normal balance between brain tis-
flects sue, blood, and CSF- normal is 10- 15
a. a severe decrease in cerebral mm Hg
perfusion pressure
b. an alteration in the production of
CSF
c. the loss of autoregulatory con-
trol of ICP
d. a normal balance between brain
tissue, blood, and CSF
18. During admission of a patient with A. Patency of airway is the #1 priority

a severe head injury to the ED, the with all head injuries
nurse places highest priority on
assessment for
c. neurologic status with Glascow
Coma Scale
d. CSF leakage from ears and nose
19. When a patient is admitted to the A. In addition to monitoring for a patent

emergency department following a airway during emergency care of the
head injury, the nurse's first prior- patient with a head injury, the nurse
ity in management of the patient must always assume that a patient with
once a patent airway is confirmed a head injury may have a cervical spine
is injury. Maintaining cervical spine pre-
a. maintaining cervical spine precautions in all assessment and treat-
cautions ment activities with the patient is es-
b. determining the presence of in- sential to prevent additional neurologic
creased ICP damage.
c. monitoring for changes in neuro-
logic status
large-bore catheter
20. The nurse recognizes the presence B. Cushing's triad consists of three vital
of Cushing's triad in the patient sign measures that reflect ICP and its
with effect on the medulla, the hypothala-
8 / 31
a. Increased pulse, irregular respi- mus, the pons, and the thalamus. Be-
ration, increased BP cause these structures are very deep,
b. decreased pulse, irregular respi- Cushing's triad is usually a late sign
ration, increased pulse pressure of ICP. The signs include an increas-
c. increased pulse, decreased res- ing systolic BP with a widening pulse
piration, increased pulse pressure pressure, a bradycardia with a full and
d. decreased pulse, increased res- bounding pulse, and irregular respira-
piration, decreased systolic BP tions.
21. A patient with a head injury has B. Tests the fluid for a halo sing on a
bloody drainage from the ear. To white dressing- Testing clear drainage
determine whether CSF is present for CSF in nasal or ear drainage may
in the drainage, the nurse be done with a Dextrostik or Tes-Tape
a. examines the tympanic mem- strip, but if blood is present, the glucose
brane for a tear in the blood will produce and unreli-
b. tests the fluid for a halo sign on able result. To test bloody drainage, the
a white dressing nurse should test the fluid for a halo or
c. tests the fluid with a glucose ring that occurs when a yellowish ring
identifying strip or stick encircles blood dripped onto a white
d. collects 5 mL of fluid in a test pad or towel
tube and sends it to the laboratory
for analysis
22. Normal ICP ranges from: 5 to 15 mm Hg
23. Successful achievement of patient D. Absence of signs and symptoms of

outcomes for the patient with cra- increased ICP- The primary goal af-
nial surgery would be best indicat- ter cranial surgery is prevention of in-
ed by the creased ICP, and interventions to pre-
a. ability to return home in 6 days vent ICP and infection postoperative-
b. ability to meet all self-care needs ly are nursing priorities. The residual
c. acceptance of residual neurolog- deficits, rehabilitation potential, and ul-
ic deficits timate function of the patient depend on
d. absence of signs and symptoms the reason for surgery, the postopera-
of increased ICP tive course, and the patient's general
state of health
24. While the nurse performs ROM on C. Perform the exercises less frequent-
an unconscious patient with in- ly because posturing can increase ICP-
creased ICP, the patient experi- If reflex posturing occurs during ROM
9 / 31
ences severe decerebrate postur- or positioning of the patient, these ac-
ing reflexes. The nurse should tivities should be done less frequently
a. use restraints to protect the pa- until the patient's condition stabilizes,
tient from injury because posturing can case increases
b. administer CNS depressants to in ICP. Neither restraints nor CNS de-
lightly sedate the patient pressants would be indicated.
c. perform the exercises less fre-
quently because posturing can in-
crease ICP
d. continue the exercises because
they are necessary to maintain
musculoskeletal function
25. A patient with an intracranial prob- B. 7- no opening of eyes = 1; incompre-

lem does not open his eyes to hensible words= 2, flexion withdrawal =
any stimulus, has no verbal re- 4
sponse except moaning and mut- Total = 7
tering when stimulated, and flexes
his arm in response to painful stim-
uli. The nurse records the patients
GCS score as
a. 6
b. 7
c. 9
d. 11
26. The nurse plans care for a patient B. elevate the head of the bed to 30
with increased ICP with the knowl- degrees
edge that the best way to position
the patient is to
a. keep the head of the bed flat
b. elevate the head of the bed to 30
degrees
c. maintain patient on the left side
with the head supported on a pil-
low
d. use a continuous rotation bed to
continuously change patient posi-
tion
10 / 31
27. The earliest signs of increased ICP C. One of the most sensitive signs of
the nurse should assess for in- increased intracranial pressure (ICP) is
clude a decreasing LOC. A decrease in LOC
a. Cushing's triad will occur before changes in vital signs,
b. unexpected vomiting ocular signs, and projectile vomiting oc-
c. decreasing level of conscious- cur
ness (LOC)
d. dilated pupil with sluggish re-
sponse to light
28. A 54-year old man is recovering C. Residual mental and emotional

from a skull fracture with a suba- changes of brain trauma with personal-
cute subdural hematoma. He has ity changes are often the most incapac-
return of motor control and orien- itating problems following head injury
tation but appears apathetic and and are common in patients who have
has reduced awareness of his envi- been comatose longer than 6 hours.
ronment. When planning discharge Families must be prepared for changes
or the patient, the nurse explains to in the patient's behavior to avoid fam-
the patient and the family that ily-patient friction and maintain fami-
a. continuous improvement in the ly functioning, and professional assis-
patient's condition should occur tance may be required. There is no in-
until he has returned to pre trauma dication he will be dependent on others
status for care, but he likely will not return to
b. the patient's complete recov- pre trauma status
ery may take years, and the family
should plan for his long term de-
pendent care
c. the patient is likely to have
long term emotional and mental
changes that may require contin-
ued professional help
d. role changes in family members
tient will be dependent on his fam-
ily for care and support
29. A patient has a nursing diagnosis A. Avoiding positioning the patient with
of risk for ineffective cerebral tis- neck and hip flexion- Nursing care ac-
sue perfusion related to cerebral tivities that increase ICP include hip
11 / 31
edema. An appropriate nursing in- and neck flexion, suctioning, clustering
tervention for the patient is care activities, and noxious stimuli; they
a. avoiding positioning the patient should be avoided or performed as lit-
with neck and hip flexion tle as possible in the patient with in-
b. maintaining hyperventilation to creased ICP. Lowering the PaCO2 be-
a PaCO2 of 15 to 20 mm Hg low 20 mm Hg can cause ischemia and
c. clustering nursing activities to worsening of ICP; the PaCO2 should
provide periods of uninterrupted be maintained at 30 to 35 mm Hg.
rest
accumulation of respiratory secre-
tions
30. The patient reports falling when A

he his foot got "stuck" on a crack Epidural hematoma often results from
in the sidewalk, hitting his head a linear fracture crossing a major artery
when he fell, and "passing out". in the dura. The classic sign is an ini-
The paramedics found the patient tial period of unconsciousness at the
walking at the scene and talking scene and a brief lucid interval fol-
before transporting the patient to lowed by a decrease in LOC. A subdur-
the hospital. In the emergency deal hematoma often results from injury
partment, the patient starts to lose to the brain and veins and develops
consciousness. This is a classic more slowly. The classic sign or symp-
scenario for which complication? tom of subarachnoid hemorrhage is a
A. Epidural hematoma patient describing "the worst headache
B. Subdural hematoma of my life." Diffuse axonal injury is wide-
C. Subarachnoid bleed spread axonal damage occurring after
D. Diffuse axial inju a traumatic brain injury.
31. A patient with a suspected closed A

head injury has bloody nasal When drainage containing CSF and
drainage. You suspect that this blood is allowed to drip onto a white
patient has a cerebrospinal fluid pad, the blood coalesces into the cen-
(CSF) leak when observing which ter within a few minutes, and a yellow-
of the following? ish ring of CSF encircles the blood, giv-
A. A halo sign on the nasal drip pad ing a halo effect. The presence of glu-
B. Decreased blood pressure and cose is unreliable for determining the
urinary output presence of CSF because blood also
C. A positive reading for glucose contains glucose.
12 / 31
on a Test-tape strip
D. Clear nasal drainage along with
the bloody discharge
32. A patient with increased ICP is be- c

ing monitored in the intensive care he priority is to treat the known existing
unit (ICU) with a fiberoptic catheter. problem, and mannitol is the only thing
Which order is a priority for you? that can do that. Because the patient
A. Perform hourly neurologic is having the current pressure mea-
checks. sured with objective numbers, treating
B. Take a complete set of vital the known problem is a priority over ad-
signs. ditional assessments. H2-blockers are
C. Administer the prescribed man- given when corticosteroids are admin-
nitol (Osmitrol). istered to help prevent gastrointestinal
D. Give an H2-receptor blocker. bleeding, but they are not a priority
compared with the treatment of ICP.
33. Which nursing action should be A

implemented in the care of a Fluid and electrolyte disturbances can
patient who is experiencing in- have an adverse effect on ICP and
creased ICP? must be vigilantly monitored. The head
A. Monitor fluid and electrolyte sta- of the patient's bed should be kept
tus astutely. at 30 degrees in most circumstances,
B. Position the patient in a and physical restraints are not applied
high-Fowler's position. unless absolutely necessary. Vasocon-
C. Administer vasoconstrictors to strictors are not typically administered
maintain cerebral perfusion. in the treatment of ICP.
D. Maintain physical restraints to
prevent episodes of agitation.
34. A patient with increased ICP has C

mannitol (Osmitrol) prescribed. LOC is the most sensitive indicator of
Which option is the best indication ICP. Mannitol is an osmotic diuretic that
that the drug is achieving the de- works to decrease the ICP by plasma
sired therapeutic effects? expansion and an osmotic effect. Al-
A. Urine output increases from 30 though the other options may indicate a
mL to 50 mL/hour. therapeutic effect of a diuretic, they are
B. Blood pressure remains less not the main reason this drug is given.
than 150/90 mm Hg.
13 / 31
D. No crackles are auscultated in
the lung fields.
35. Which option is the most sensitive D

indication of increased ICP? The LOC is the most sensitive and re-
A. Papilledema liable indicator of the patient's neuro-
B. Cushing's triad logic status. Changes in LOC are a
C. Projectile vomiting result of impaired cerebral brain flow.
D. Change in the level of con- Papilledema and Cushing's triad are
sciousness (LOC) late signs. Projectile vomiting is not a
sensitive indicator.
36. You are providing care for a pa- A,C,D

tient who has been admitted to The three dimensions of the Glasgow
the hospital with a head injury Coma Scale are eye opening, best
who requires regular neurologic vi- verbal response, and best motor re-
tal signs. Which assessments are sponse.
components of the patient's score
on the Glasgow Coma Scale (se-
lect all that apply)?
A. Eye opening
37. You are alerted to a possible acute An acute subdural hematoma mani-
subdural hematoma in the patient fests within 24 to 48 hours of the injury.
who The signs and symptoms are similar
A. has a linear skull fracture cross- to those associated with brain tissue
ing a major artery. compression by increased intracranial
B. has focal symptoms of brain pressure (ICP) and include decreasing
damage with no recollection of a LOC and headache.
head injury.
C. develops decreasing LOC and a
headache within 48 hours of a head
injury.
D. has an immediate loss of con-
14 / 31
sciousness with a brief lucid inter-
val followed by decreasing LOC.
38. Which option indicates a sign D

of Cushing's triad, an indication Cushing's triad is systolic hyperten-
of increased intracranial pressure sion with a widening pulse pressure,
(ICP)? bradycardia with a full and bounding
A. Heart rate increases from 90 to pulse, and slowed respirations. The rise
110 beats/minute in blood pressure is an attempt to
B. Kussmaul respirations maintain cerebral perfusion, and it is
C. Temperature over 100.4° F (38° a neurologic emergency because de-
C) compensation is imminent. The other
D. Heart rate decreases from 75 to options are not part of Cushing's triad.
55 beats/minute
39. A patient being monitored has an D

ICP pressure of 12 mm Hg. You un- Normal ICP ranges from 5 to 15 mm
derstand that this pressure reflects Hg. A sustained pressure above the
A. a severe decrease in cerebral upper limit is considered abnormal.
perfusion pressure.
B. an alteration in the production of
cerebrospinal fluid.
C. the loss of autoregulatory con-
trol of intracranial pressure.
D. a normal balance between brain
tissue, blood, and cerebrospinal
fluid.
40. The patient has rhinorrhea after B

a head injury. What action should A loose collection pad may be placed
you take? under the nose. Do not place a dressing
A. Pack the nares with sterile in the nasal cavity, and nothing should
gauze. be placed inside the nostril. There is no
B. A loose collection pad may be need to culture the drainage. The con-
placed under the nose. cern is whether it is spinal fluid, which
C. Suction the drainage with an in- is determined by a test for glucose or
line suction catheter. the halo or ring sign.
D. Obtain a sample for culture.
41.
15 / 31
You plan care for the patient with B
increased ICP with the knowledge You should maintain the patient with
that the best way to position the increased ICP in the head-up position.
patient is to Elevation of the head of the bed to
A. keep the head of the bed flat. 30 degrees enhances respiratory ex-
B. elevate the head of the bed to 30 change and aids in decreasing cerebral
degrees. edema. You should position the patient
C. maintain patient on the left side to prevent extreme neck flexion, which
with the head supported on a pil- can cause venous obstruction and con-
low. tribute to elevated ICP. Elevation of the
D. use a continuous-rotation bed to head of the bed reduces sagittal sinus
continuously change patient posi- pressure, promotes drainage from the
tion. head through the valveless venous sys-
the vascular congestion that can pro-
duce cerebral edema. However, raising
the head of the bed above 30 degrees
may decrease the cerebral perfusion
pressure (CPP) by lowering systemic
blood pressure. Careful evaluation of
the effects of elevation of the head of
the bed on the ICP and the CPP is
required.
42. You are caring for a patient admit- B

ted with a subdural hematoma af- Changes in vital signs indicative of in-
ter a motor vehicle accident. Which creased ICP are known as Cushing's
change in vital signs would you triad, which consists of increasing sys-
interpret as a manifestation of in- tolic pressure with a widening pulse
creased intracranial pressure? pressure, bradycardia with a full and
A. Tachypnea bounding pulse, and irregular respira-
B. Bradycardia tions.
C. Hypotension
43. Which components are able to a, c, e. Blood adapts with increased

change to adapt to small increases venous outflow,
in intracranial pressure (ICP) (se- decreased cerebral blood flow (CBF),
lect all that and collapse of
16 / 31
apply)? veins and dural sinuses. Brain tissue
a. Blood d. Scalp tissue adapts with distention
b. Skull bone e. Cerebrospinal fluid of the dura, slight compression of tis-
(CSF) sue, or herniation.
c. Brain tissue Cerebrospinal fluid (CSF) adapts with
increased absorption,
decreased production, and displace-
ment into the spinal
canal. Skull bone and scalp tissue do
not adapt to changes
in intracranial pressure (ICP).
44. The cerebral perfusion pressure 56 mm Hg

(CPP) is the pressure needed to Mean arterial pressure (MAP) = dias-
ensure blood flow to the brain. Nor- tolic blood pressure
mal CPP is 60 to (DBP) + 1
100 mm Hg. Calculate the CPP of a D3 (systolic blood pressure [SBP] - DBP)
patient whose blood pressure (BP) =
is 106/52 mm Hg and ICP is 14 mm 52 + 18 = 70
Hg. Cerebral per
mm Hg
45. Calculate the CPP for the patient 45 mm Hg

with an ICP of 34 mm Hg and a MAP = DBP + 1
systemic BP of 108/64 mm Hg. D3 (SBP DBP) = 64 + 15 = 79
mm Hg CPP = MAP ICP = 79 34 = 45
46. Which factors decrease cerebral c, e. Cerebral blood flow is decreased

blood flow (select all that apply)? when the MAP
a. Increased ICP d. Arterial blood and the PaCO2
pH of 7.3 are decreased. The other options in-
b. PaO2 of 45 mm Hg e. Decreased crease
mean arterial pressure (MAP) cerebral blood flow.
c. PaCO2 of 30 mm Hg
47. What are causes of vasogenic b, e. Vasogenic cerebral edema, the

cerebral edema (select all that ap- most common type
ply)? of edema, occurs mainly in the white
a. Hydrocephalus matter and is
b. Ingested toxins characterized by leakage of macromol-
17 / 31
c. Destructive lesions or trauma ecules from the
d. Local disruption of cell mem- capillaries into the surrounding extra-
branes cellular space. This
e. Fluid flowing from intravascular results in an osmotic gradient that fa-
to extravascular space vors the flow of
fluid from the intravascular to the ex-
travascular space. A
variety of insults, such as brain tumors,
abscesses, and
ingested toxins, may cause an increase
in the permeability
of the blood-brain barrier and produce
an increase in the
extracellular fluid volume. Hydro-
cephalus causes interstitial
cerebral edema.
48. Which events cause increased ICP a, b, d. Increased ICP is caused by

(select all that apply)? vasodilation and edema
a. Vasodilation d. Edema from ini- from the initial brain insult or necrotic
tial brain insult tissue. Blood vessel
b. Necrotic tissue edema e. Brain- compression and brainstem compres-
stem compression and herniation sion and herniation
c. Blood vessel compression occur as a result of increased ICP.
49. An early sign of increased ICP that . c. One of the most sensitive signs of
the nurse should assess for is increased ICP is a
a. Cushing's triad. c. decreasing decreasing level of consciousness
level of consciousness (LOC). (LOC). A decrease in
b. unexpected vomiting. d. dilat- LOC will occur before changes in vital
ed pupil with sluggish response to signs, ocular signs,
light. or projectile vomiting occur.
50. The nurse recognizes the presence c. Cushing's triad consists of three vital
of Cushing's triad in the patient sign measures that
with which vital sign changes? reflect ICP and its effect on the medul-
a. Increased pulse, irregular respi- la, hypothalamus,
ration, increased BP pons, and thalamus. Because these
b. Decreased pulse, increased res- structures are very deep,
18 / 31
piration, decreased systolic BP Cushing's triad is usually a late sign of
c. Decreased pulse, irregular respi- ICP. The signs
ration, widened pulse pressure include an increasing SBP with a
d. Increased pulse, decreased res- widening pulse pressure,
piration, widened pulse pressure a bradycardia with a full and bounding
pulse, and irregular
respirations.
51. Increased ICP in the left cere- c. The dural structures that separate
bral cortex caused by intracranial the two hemispheres
bleeding causes displacement of and the cerebral hemispheres from the
brain tissue to the cerebellum influence
right hemisphere beneath the falx the patterns of cerebral herniation. A
cerebri. The nurse knows that this cingulate herniation
is referred to as what? occurs where there is lateral displace-
a. Uncal herniation c. Cingulate ment of brain tissue
herniation beneath the falx cerebri. Uncal hernia-
b. Tentorial herniation d. Temporal tion occurs when there
lobe herniation is lateral and downward herniation.
Tentorial herniation
occurs when the brain herniates down
through the opening
created by the brainstem. The temporal
lobe can be involved
in central herniation
52. Priority Decision: A patient has ICP a. An intraventricular catheter is a flu-

monitoring with an intraventricular id-coupled system that
catheter. What is a priority nursing can provide direct access for microor-
intervention for the patient? ganisms to enter the
a. Aseptic technique to prevent in- ventricles of the brain and aseptic tech-
fection c. Removal of CSF to main- nique is a very high
tain normal ICP nursing priority to decrease the risk for
b. Constant monitoring of ICP infection. Constant
waveforms d. Sampling CSF to de- monitoring of ICP waveforms is not
termine abnormalities usually necessary and
removal of CSF for sampling or to main-
tain normal ICP is
done only when specifically ordered.
19 / 31
53. When using intraventricular ICP b. An inaccurate ICP reading can be
monitoring, what should the nurse caused by CSF
be aware of to prevent inaccurate leaks around the monitor device, ob-
readings? struction of the
a. The P2 wave is higher than the intraventricular catheter, kinks or bub-
P1 wave. bles in the tubing,
b. CSF is leaking around the moni- and incorrect height of the transducer
toring device. or drainage system
c. The transducer of the ventricu- relative to the patient's reference point.
lostomy monitor is at the level of The P2 wave
the upper ear. being higher than the P1 wave indi-
d. The drain of the CSF drainage cates poor ventricular
device was closed for 6 minutes compliance. The transducer height
before taking the reading. should be at the tragus
of the ear. The drain of the CSF
drainage device should be
closed for 6 minutes preceding the
reading.
54. The patient is being monitored b. The normal pressure of oxygen in

long-term with a brain tissue oxy- brain tissue (PbtO2
genation catheter. What range for )
the pressure of is 20 to 40 mm Hg. The normal jugular
oxygen in brain tissue (PbtO2 venous oxygen
) will maintain cerebral oxygen saturation (SjvO2
supply and demand? ) is 55% to 75% and indicates total
a. 55% to 75% c. 70 to 150 mm Hg venous
b. 20 to 40 mm Hg d. 80 to 100 mm brain tissue extraction of oxygen; this is
Hg used for short-term
monitoring. The MAP of 70 to 150 mm
Hg is needed for
effective autoregulation of CBF. The
normal range for PaO2
is 80 to 100 mm Hg.
55. Which drug treatment helps to de- c. Mannitol (Osmitrol) (25%) is an os-
crease ICP by expanding plasma motic diuretic that
and the osmotic effect to move flu- expands plasma and causes fluid to
id? move from tissues into
20 / 31
a. Oxygen administration c. Manni- the blood vessels. Hypertonic saline re-
tol (Osmitrol) (25%) duces brain swelling
b. Pentobarbital (Nembutal) d. Dex- by moving water out of brain tissue.
amethasone (Decadron) Oxygen administration
is done to maintain brain function. Pen-
tobarbital
(Nembutal) and other barbiturates are
used to reduce
cerebral metabolism. The corticos-
teroid dexamethasone
(Decadron) is used to treat vasogenic
edema to stabilize cell
membranes and improve neuronal
function by improving
CBF and restoring autoregulation
56. How are the metabolic and nutri- d. A patient with increased ICP is in a
tional needs of the patient with in- hypermetabolic and
creased ICP best met? hypercatabolic state and needs ade-
a. Enteral feedings that are low in quate glucose to maintain
sodium fuel for the brain and other nutrients to
b. Simple glucose available in D5 meet metabolic needs.
W IV solutions Malnutrition promotes cerebral edema
c. Fluid restriction that promotes a and if a patient cannot
moderate dehydration take oral nutrition, other means of pro-
d. Balanced, essential nutrition in a viding nutrition should
form that the patient can tolerate be used, such as tube feedings or par-
enteral nutrition. Glucose
alone is not adequate to meet nutrition-
al requirements and 5%
dextrose solutions may increase cere-
bral edema by lowering
main in a normovolemic fluid state with
close monitoring of clinical factors such
as
urine output, fluid intake, serum and
urine osmolality, serum
electrolytes, and insensible losses.
21 / 31
57. Why is the Glasgow Coma Scale a. The Glasgow Coma Scale (GCS) is
(GCS) used? used to quickly assess
a. To quickly assess the LOC the LOC with a standardized system.
b. To assess the patient's ability to The three areas assessed
communicate are the patient's ability to speak, obey
c. To assess the patient's ability to commands, and open
respond to commands eyes to verbal or painful stimulus. Al-
d. To assess the patient's coordina- though best motor
tion with motor responses response is an indicator, it is not used
to assess coordination.
58. A patient with an intracranial prob- b. No opening of eyes = 1; incompre-

lem does not open his eyes to any hensible words = 2;
stimulus, has no verbal response flexion withdrawal = 4. Total = 7
except
moaning and muttering when stim-
ulated, and flexes his arm in re-
sponse to painful stimuli. What
should the nurse
record as the patient's GCS score?
a. 6 c. 9
b. 7 d. 11
59. Priority Decision: When assessing d. Of the body functions that should be
the body functions of a patient assessed in an
with increased ICP, what should unconscious patient, cardiopulmonary
the nurse assess status is the most
first? vital function and gives priorities to the
a. Corneal reflex testing c. Extrem- ABCs (airway,
ity strength testing breathing, and circulation).
b. Pupillary reaction to light d. Cir-
culatory and respiratory status
60. How is cranial nerve (CN) III, orig- . c. One of the functions of cranial nerve
inating in the midbrain, assessed (CN) III, the
by the nurse for an early indication oculomotor nerve, is pupillary constric-
of pressure tion and testing for
on the brainstem? pupillary constriction is important to
a. Assess for nystagmus c. Test identify patients at
22 / 31
pupillary reaction to light risk for brainstem herniation caused by
b. Test the corneal reflex d. Test for increased ICP. The
oculocephalic (doll's eyes) reflex corneal reflex is used to assess the
functions of CN V and
VII and the oculocephalic reflex tests all
cranial nerves
involved with eye movement. Nystag-
mus is commonly
associated with specific lesions or
chemical toxicities and is
not a definitive sign of ICP
61. A patient has a nursing diagnosis a. Nursing care activities that increase
of risk for ineffective cerebral tis- ICP include hip and
sue perfusion related to cerebral neck flexion, suctioning, clustering care
edema. What is activities, and
an appropriate nursing interven- noxious stimuli. They should be avoid-
tion for the patient? ed or performed as
a. Avoid positioning the patient little as possible in the patient with in-
with neck and hip flexion. creased ICP. Lowering
b. Maintain hyperventilation to a the PaCO2
PaCO2 below 20 mm Hg can cause ischemia
of 15 to 20 mm Hg. and
c. Cluster nursing activities to pro- worsening of ICP
vide periods of uninterrupted rest.
d. Routinely suction to prevent ac-
cumulation of respiratory secre-
tions.
62. An unconscious patient with in- c. A PaO2

creased ICP is on ventilatory sup- of 70 mm Hg reflects hypoxemia that
port. The nurse notifies the health may lead
care provider to further decreased cerebral perfu-
when arterial blood gas (ABG) sion. PaO2
measurement results reveal what? should be
a. pH of 7.43 c. PaO2 maintained at greater than or equal to
of 70 mm Hg 100 mm Hg. The pH
b. SaO2 and SaO2
are within normal range and a PaCO2
23 / 31
of 94% d. PaCO2 of 35 mm
of 35 mm Hg Hg reflects a normal value.
63. The nurse is monitoring a patient a, b, d, e. The first sign of increased ICP
for increased ICP following a head is a change in
injury. What are manifestations of LOC. Other manifestations are dilated
increased ipsilateral pupil,
ICP (select all that apply)? changes in motor response such as
a. Fever d. Right pupil dilated posturing, and fever,
greater than left pupil which may indicate pressure on the hy-
b. Oriented to name only e. Decor- pothalamus. Changes
ticate posturing to painful stimulus in vital signs would be an increased
c. Narrowing pulse pressure SBP with widened
pulse pressure and bradycardia.
64. Priority Decision: While the nurse b. If reflex posturing occurs during
performs range of motion (ROM) range of motion (ROM)
on an unconscious patient with in- or positioning of the patient, these ac-
creased ICP, tivities should be
the patient experiences severe de- done less frequently until the patient's
cerebrate posturing reflexes. What condition stabilizes
should the nurse do first? because posturing can cause increas-
a. Use restraints to protect the pa- es in ICP and may
tient from injury. indicate herniation. Neither restraints
b. Perform the exercises less fre- nor central nervous
quently because posturing can in- system (CNS) depressants would be
crease ICP. indicated
c. Administer central nervous sys-
tem (CNS) depressants to lightly
sedate the patient.
d. Continue the exercises because
65. The patient has been diagnosed d. A cerebral concussion may include a
with a cerebral concussion. What brief disruption
should the nurse expect to see in in LOC, retrograde amnesia, and a
this patient? headache, all of short
a. Deafness, loss of taste, and CSF duration. A basilar skull fracture may
24 / 31
otorrhea have a dural tear
b. CSF otorrhea, vertigo, and Bat- with CSF or brain otorrhea, rhinorrhea,
tle's sign with a dural tear hearing difficulty,
c. Boggy temporal muscle because vertigo, and Battle's sign. A temporal
of extravasation of blood fracture would have a
d. Headache, retrograde amnesia, boggy temporal muscle because of ex-
and transient reduction in LOC travasation of blood,
Battle's sign, or CSF otorrhea.
66. The patient comes to the emer- c. The posterior fossa fracture causes
gency department (ED) with corti- occipital bruising
cal blindness and visual field de- resulting in cortical blindness or visual
fects. Which type of field defects.
head injury does the nurse sus- A cerebral contusion is bruising of brain
pect? tissue within
a. Cerebral contusion c. Posterior a focal area. An orbital skull fracture
fossa fracture would cause
b. Orbital skull fracture d. Frontal periorbital ecchymosis (raccoon eyes)
lobe skull fracture and possible
optic nerve injury. A frontal lobe skull
fracture would
expose the brain to contaminants
through the frontal
air sinus and the patient would have
CSF rhinorrhea or
pneumocranium.
67. The patient has a depressed skull c. The compound skull fracture is a de-
fracture and scalp lacerations with pressed skull fracture
communication to the intracranial and scalp lacerations with communi-
cavity. Which cating pathway(s) to the
type of injury should the nurse intracranial cavity. A linear skull fracture
record? is a straight break
a. Linear skull fracture c. Com- in the bone without alteration in the
pound skull fracture fragments. A depressed
b. Depressed skull fracture d. Com- skull fracture is an inward indentation of
minuted skull fracture the skull that may
cause pressure on the brain. A com-
minuted skull fracture
25 / 31
has multiple linear fractures with bone
fragmented into
many pieces.
68. A patient with a head injury has b. Testing clear drainage for CSF in
bloody drainage from the ear. What nasal or ear drainage
should the nurse do to determine if may be done with a Dextrostik or
CSF is Tes-Tape strip but if
present in the drainage? blood is present, the glucose in the
a. Examine the tympanic mem- blood will produce an
brane for a tear. unreliable result. To test bloody
b. Test the fluid for a halo sign on a drainage, the nurse should
white dressing. test the fluid for a "halo" or "ring" that
c. Test the fluid with a glu- occurs when a
cose-identifying strip or stick. yellowish ring encircles blood dripped
d. Collect 5 mL of fluid in a test onto a white pad or
tube and send it to the laboratory towel within a few minutes.
for analysis.
69. The nurse suspects the presence d. An arterial epidural hematoma is the
of an arterial epidural hematoma in most acute
the patient who experiences neurologic emergency and typical
a. failure to regain consciousness symptoms include
following a head injury. unconsciousness at the scene with a
b. a rapid deterioration of neuro- brief lucid interval
logic function within 24 to 48 hours followed by a decrease in LOC. An
following a head injury. acute subdural
c. nonspecific, nonlocalizing pro- hematoma manifests signs within 48
gression of alteration in LOC oc- hours of an injury. A
curring over weeks or months. chronic subdural hematoma develops
d. unconsciousness at the time of over weeks or months.
crease in LOC.
70. Skull x-rays and a computed to- d. When there is a depressed fracture
mography (CT) scan provide evi- or a fracture with
dence of a depressed parietal frac- loose fragments, a craniotomy is indi-
ture with a subdural cated to elevate the
26 / 31
hematoma in a patient admitted to depressed bone and remove free frag-
the ED following an automobile ac- ments. A craniotomy
cident. In planning care for the pa- is also indicated in cases of acute sub-
tient, what dural and epidural
should the nurse anticipate? hematomas to remove the blood and
a. The patient will receive life sup- control the bleeding.
port measures until the condition Burr holes may be used in an extreme
stabilizes. emergency for rapid
b. Immediate burr holes will be decompression or to aid in removing a
made to rapidly decompress the in- bone flap but with
tracranial cavity. a depressed fracture, surgery would be
c. The patient will be treated con- the treatment of
servatively with close monitoring choice.
for changes in neurologic status.
d. The patient will be taken to
surgery for a craniotomy for evacu-
ation of blood and decompression
of the cranium.
71. Priority Decision: When a patient is a. In addition to monitoring for a patent

admitted to the ED following a head airway during
injury, what should be the nurse's emergency care of the patient with a
first head injury, the nurse
priority in management of the pa- must always assume that a patient with
tient once a patent airway is con- a head injury may
firmed? have a cervical spine injury. Maintain-
a. Maintain cervical spine precau- ing cervical spine
tions. c. Determine the presence of precautions in all assessment and
increased ICP. treatment activities with
b. Monitor for changes in neuro- the patient is essential to prevent addi-
logic status. d. Establish IV access tional neurologic
with a large-bore catheter damage.
72. A 54-year-old man is recover- a. Residual mental and emotional

ing from a skull fracture with a changes of brain trauma
subacute subdural hematoma that with personality changes are often the
caused unconsciousness. most incapacitating
He has return of motor control and problems following head injury and are
orientation but appears apathetic common in patients
27 / 31
and has reduced awareness of his who have been comatose for longer
environment. When than 6 hours. Families
planning discharge of the patient, must be prepared for changes in the
what should the nurse explain to patient's behavior
the patient and the family? to avoid family-patient friction and
a. The patient is likely to have maintain family
long-term emotional and mental functioning and professional assis-
changes that may require profes- tance may be required.
sional help. There is no indication the patient will be
b. Continuous improvement in the dependent on
patient's condition should occur others for care but he likely will not re-
until he has returned to pretrauma turn to pretrauma
status. status.
c. The patient's complete recov-
ery may take years and the family
should plan for his long-term de-
pendent care.
d. Role changes in family members
ily for care
and support.
73. The patient is suspected of having d. The positron emission tomography

a new brain tumor. Which test will (PET) scan or
the nurse expect to be ordered to magnetic resonance imaging (MRI) are
detect a small used to reliably
tumor? detect very small tumors. The comput-
a. CT scan c. Electroencephalogra- ed tomography (CT)
phy (EEG) and brain scans are used to identify the
b. Angiography d. Positron emis- location of a lesion.
sion tomography (PET) scan Angiography could be used to deter-
mine blood flow to
the tumor and further localize it. Elec-
troencephalography
(EEG) would be used to rule out
seizures.
74.
28 / 31
Assisting the family to understand . b. Frontal lobe tumors often lead to
what is happening to the patient is loss of emotional
an especially important role of the control, confusion, memory loss, disori-
nurse when entation,
the patient has a tumor in which seizures, and personality and judgment
part of the brain? changes that are
a. Ventricles c. Parietal lobe very disturbing and frightening to the
b. Frontal lobe d. Occipital lobe family. Physical
symptoms, such as blindness, speech
disturbances, or
disturbances in sensation and percep-
tion that occur
with other tumors, are more likely to be
understood and
accepted by the family
75. Which cranial surgery would re- d. A craniectomy is excision of cranial

quire the patient to learn how to bone without
protect the surgical area from trau- replacement, so the patient will need to
ma? protect the brain
a. Burr holes c. Cranioplasty from trauma in this surgical area. Burr
b. Craniotomy d. Craniectomy holes are opened
into the cranium with a drill to remove
blood and fluid. A
craniotomy is opening the cranium with
removal of a bone
flap to open the dura. The replaced
bone flap is wired or
sutured after surgery. A cranioplasty re-
places part of the
cranium with an artificial plate.
76. What is the best explanation of b. A stereotactic radiosurgery tech-

stereotactic radiosurgery? nique uses precisely
a. Radioactive seeds are implanted focused radiation to destroy tumor
in the brain. cells. The radiation is
b. Very precisely focused radiation computer and imagery guided. Ra-
destroys tumor cells. dioactive seeds are used
c. Tubes are placed to redirect CSF to deliver radiation. Ventricular shunts
29 / 31
from one area to another. are used to redirect
d. The cranium is opened with re- CSF from one area to another. A cran-
moval of a bone flap to open the iotomy is done by
dura. first making burr holes and then open-
ing the cranium by
connecting the holes to remove a flap
of bone to expose the
dura mater
77. For the patient undergoing a cran- a. To prevent undue concern and anxi-
iotomy, when should the nurse pro- ety about hair loss and
vide information about the use of postoperative self-esteem distur-
wigs and bances, a patient undergoing
hairpieces or other methods to dis- cranial surgery should be informed pre-
guise hair loss? operatively that
a. During preoperative teaching the head is usually shaved in surgery
b. If the patient asks about their while the patient is
use anesthetized and that a turban, scarf,
c. In the immediate postoperative or cap may be used
period after the dressings are removed post-
d. When the patient expresses neg- operatively and a wig
ative feelings about his or her ap- also may be used after the incision has
pearance healed to disguise
the hair loss. In the immediate postop-
erative period the
patient is very ill and the focus is on
maintaining neurologic
function but preoperatively the nurse
should anticipate
the patient's postoperative need for
self-esteem and
maintenance of appearance.
78. Successful achievement of patient d. The primary goal after cranial

outcomes for the patient with cra- surgery is prevention
nial surgery would best be indicat- of increased ICP and interventions to
ed by what? prevent ICP and
a. Ability to return home in 6 days c. infection postoperatively are nursing
Acceptance of residual neurologic priorities. The residual
30 / 31
deficits deficits, rehabilitation potential, and ul-
b. Ability to meet all self-care timate function of the
needs d. Absence of signs and patient depend on the reason for
symptoms of increased ICP surgery, the postoperative
course, and the patient's general state
of health.
31 / 31
Increased Intracranial Pressure (ICP) NCLEX Questions
Study online at https://quizlet.com/_654rum
1. 1. Select the main structures below that The answers are A, C, and D. In-
play a role with altering intracranial side the skull are three structures
pressure: that can alter intracranial pres-
sure. They are the brain, cere-
A. Brain brospinal fluid (CSF), and blood.
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater
2. 2. The Monro-Kellie hypothesis explains The answers are B and D. These

the compensatory relationship among are NOT compensatory mecha-
the structures in the skull that play a role nisms, but actions that will actual-
with intracranial pressure. Which of the ly increase intracranial pressure.
following are NOT compensatory mech- Vasoconstriction (not dilation) de-
anisms performed by the body to decreases blood flow and helps low-
crease intracranial pressure naturally? er ICP. Leaking of protein actual-
Select all that apply: ly leads to more swelling of the
brain tissue. Remember water is
A. Shifting cerebrospinal fluid to other attracted to protein (oncotic pres-
areas of the brain and spinal cord sure).
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid pro-

duction
D. Leaking proteins into the brain barrier
3. 3. A patient is being treated for in- The answers are A, B, D, and E.

creased intracranial pressure. Which These activities can increase ICP.
activities below should the patient avoid
performing?
1/9
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between

30- 35 degrees
4. 4. A patient is experiencing hyperventi-

The answer is C. An elevated car-
lation and has a PaCO2 level of 52. Thebon dioxide level (52 is high...nor-
patient has an ICP of 20 mmHg. As the mal 35-45) in the blood will cause
nurse you know that the PaCO2 level vasodilation (NOT constriction),
will? which will increase ICP (normal
ICP 5 to 15 mmHg). Therefore,
A. cause vasoconstriction and decrease many patients with severe ICP
the ICP may need to be mechanical ven-
tilated so PaCO2 levels can be
B. promote diuresis and decrease the lowered (30-35), which will lead
ICP to vasoconstriction and decrease
ICP (with constriction there is
C. cause vasodilation and increase the less blood volume and flow go-
ICP ing to the brain and this helps
decrease pressure)....remember
D. cause vasodilation and decrease the Monro-Kellie hypothesis.
ICP
5. 5. You're providing education to a group The answer is B. This is a normal

of nursing students about ICP. You ex- CPP. Option A represents a nor-
plain that when cerebral perfusion pres- mal intracranial pressure.
sure falls too low the brain is not prop-
erly perfused and brain tissue dies. A
student asks, "What is a normal cere-
bral perfusion pressure level?" Your re-
2/9
sponse is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg
6. 6. Which patient below is at MOST risk The answer is B. Remember head

for increased intracranial pressure? trauma, cerebral hemorrhage,
hematoma, hydrocephalus, tu-
A. A patient who is experiencing severe mor, encephalitis etc. can all in-
hypotension. crease ICP.
B. A patient who is admitted with a trau-

matic brain injury.
C. A patient who recently experienced a

myocardial infarction.
D. A patient post-op from eye surgery.
7. 7. A patient with increased ICP has the The answer is C. It is impor-

following vital signs: blood pressure tant to monitor the patient for hy-
99/60, HR 65, Temperature 101.6 'F, res- perthermia (a fever). A fever in-
pirations 14, oxygen saturation of 95%. creases ICP and cerebral blood
ICP reading is 21 mmHg. Based on these volume, and metabolic needs of
findings you would? the patient. The nurse can ad-
minister antipyretics per MD or-
A. Administered PRN dose of a vaso- der, remove extra blankets, de-
pressor crease room temperature, give a
cool bath or use a cooling system.
B. Administer 2 L of oxygen Remember it is important to pre-
vent shivering (this also increases
C. Remove extra blankets and give the metabolic needs and ICP).
patient a cool bath
3/9
D. Perform suctioning
8. 8. A patient has a ventriculostomy. The answer is C. A ventricu-

Which finding would you immediately lostomy is a catheter inserted
report to the doctor? in the area of the lateral ven-
tricle to assess ICP. It will help
A. Temperature 98.4 'F drain CSF during increase pres-
sure readings and measure ICP.
B. CPP 70 mmHg The nurse must monitor for ICP
levels greater than 20 mmHg and
C. ICP 24 mmHg report it to the doctor.
D. PaCO2 35
9. 9. External ventricular drains monitor The answer is B. External ventric-

ICP and are inserted where? ular drains (also called ventricu-
lostomy) are inserted in the lateral
A. Subarachnoid space ventricle.
B. Lateral Ventricle
C. Epidural space
D. Right Ventricle
10. 10. Which of the following is contraindi- The answer is A. LPs are avoided
cated in a patient with increased ICP? in patients with ICP because they
can lead to possible brain hernia-
A. Lumbar puncture tion.
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications
11. 11. You're collecting vital signs on a pa- The answer is A. This GCS rating
tient with ICP. The patient has a Glas- demonstrates the patient is un-
coma Scale rating of 4. How will you conscious. If a patient is uncon-
4/9
assess the patient's temperature? scious the nurse should take the
patient's temperature either via
A. Rectal the rectal, tympanic, or temporal
method. Oral and axillary are not
B. Oral reliable.
C. Axillary
12. 12. A patient who experienced a cerebral The answer is C. Mental status
hemorrhage is at risk for developing in- changes are the earliest indica-
creased ICP. Which sign and symptom tor a patient is experiencing in-
below is the EARLIEST indicator the pa- creased ICP. All the other signs
tient is having this complication? and symptoms listed happen lat-
er.
A. Bradycardia
C. Restlessness
D. Unequal pupil size
13. 13. Select all the signs and symptoms The answers are A, D, E, and F.
that occur with increased ICP: Option B is wrong because brady-
cardia (not tachycardia) happens
A. Decorticate posturing in the late stage along with an IN-
CREASE (not decrease) in pulse
B. Tachycardia pressure
C. Decrease in pulse pressure
D. Cheyne-stokes
E. Hemiplegia
F. Decerebrate posturing
14. 14. You're maintaining an external ven- The answer is A. Normal ICP
tricular drain. The ICP readings should should be 5 to 15 mmHg.
5/9
be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg
15. 15. Which patient below with ICP is ex- The answer is C. These vital signs
periencing Cushing's Triad? A patient represent Cushing's triad. There
with the following: is an increase in the systolic pres-
sure, widening pulse pressure of
A. BP 150/112, HR 110, RR 8 140 (200-60=140), bradycardia,
and bradypnea.
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12
16. 16. The patient has a blood pressure The answer is A. CPP is cal-
of 130/88 and ICP reading of 12. What culated by the following formu-
is the patient's cerebral perfusion pres- la: CPP=MAP-ICP. The patient's
sure, and how do you interpret this as CPP is 90 and this is normal. A
the nurse? normal CPP is 60-100 mmHg.
A. 90 mmHg, normal
B. 62 mmHg, abnormal
C. 36 mmHg, abnormal
D. 56 mmHg, normal
17. 17. According to question 16, the pa- The answer is C. MAP is calcu-
tient's blood pressure is 130/88. What lated by taking the DBP (88) and
is the patient's mean arterial pressure multiplying it by 2. This equals
6/9
(MAP)? 176. Then take this number and
add the SBP (130). This equals
A. 42 306. Then take this number and
divide by 3, which equal 102.
B. 74
C. 102
D. 88
18. 18. During the assessment of a patient The answer is B.

with increased ICP, you note that the
patient's arms are extended straight out
and toes pointed downward. You will
document this as:
A. Decorticate posturing
C. Flaccid posturing
19. 19. While positioning a patient in bed The answer is D. Avoid flexing the
with increased ICP, it important to hips because this can increase in-
avoid? tra-abdominal/thoracic pressure,
which will increase ICP.
A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
20. 20. During the eye assessment of a pa- The answer is D. This is known as
tient with increased ICP, you need to a negative doll's eye and repre-
assess the oculocephalic reflex. If the sents brain stem damage. It is a
patient has brain stem damage what re- very bad sign.
sponse will you find?
7/9
A. The eyes will move in the same direc-

tion as the head is moved side to side.
B. The eyes will move in the opposite

direction as the head is moved side to
side.
C. The eyes will roll back as the head is

moved side to side.
D. The eyes will be in a fixed position as

the head is moved side to side.
21. 21. A patient is receiving Mannitol for

The answer is B. All the other
increased ICP. Which statement is IN- options are correct. Mannitol will
CORRECT about this medication? PREVENT (not cause) water and
electrolytes (specifically sodium
A. Mannitol will remove water from the and chloride) from being reab-
brain and place it in the blood to be sorbed....hence it will leave the
removed from the body. body as urine.
B. Mannitol will cause water and elec-

trolyte reabsorption in the renal tubules.
C. When a patient receives Mannitol the

nurse must monitor the patient for both
fluid volume overload and depletion.
D. Mannitol is not for patients who are

experiencing anuria.
22. 22. What assessment finding requires he answer is B. Mannitol can

immediate intervention if found while a cause fluid volume overload that
patient is receiving Mannitol? leads to heart failure and pul-
monary edema. Crackles in the
A. An ICP of 10 mmHg lung fields represent pulmonary
edema and requires immediate
B. Crackles throughout lung fields intervention. Option A is a nor-
8/9
mal ICP reading and shows the
C. BP 110/72 mannitol is being effective. BP
is within normal limits, and dry
D. Patient complains of dry mouth and mouth/thirst will occur with this
thirst medication because remember
we are trying to dehydrate the
brain to keep edema and intracra-
nial pressure decreased.
9/9
ICP Nclex Questions
Study online at https://quizlet.com/_765aup
1. The nurse notes that a patient Correct Answer: C

with a head injury has a clear Rationale: If the drainage is cere-
nasal drainage. The most appro- brospinal fluid (CSF) leakage from a
priate nursing action for this find- dural tear, glucose will be present. Fluid
ing is to leaking from the nose will have normal
a. obtain a specimen of the fluid nasal flora, so culture and sensitivity will
and send for culture and sensitiv- not be useful. A dural tear does increase
ity. the risk for infections such as meningi-
b. take the patient's temperature tis, but the nurse should first determine
to determine whether a fever is whether the clear drainage is CSF. Blow-
present. ing the nose is avoided to prevent CSF
c. check the nasal drainage for leakage.
glucose with a Dextrostik or
Testape. Cognitive Level: Application Text Refer-
d. have the patient to blow the ence: p. 1481
nose and then check the nares for Nursing Process: Implementation
redness. NCLEX: Physiological Integrity
2. A patient admitted with a head in- Correct Answer: C

jury has admission vital signs of Rationale: Systolic hypertension with
temperature 98.6° F (37° C), blood widening pulse pressure, bradycar-
pressure 128/68, pulse 110, and dia, and respiratory changes represent
respirations 26. Which of these vi- Cushing's triad and indicate that the ICP
tal signs, if taken 1 hour after ad- has increased and brain herniation may
mission, will be of most concern be imminent unless immediate action
to the nurse? is taken to reduce ICP. The other vital
a. Blood pressure 130/72, pulse signs may indicate the need for changes
90, respirations 32 in treatment, but they are not indica-
b. Blood pressure 148/78, pulse tive of an immediately life-threatening
112, respirations 28 process.
c. Blood pressure 156/60, pulse
60, respirations 14 Cognitive Level: Application Text Refer-
d. Blood pressure 110/70, pulse ence: p. 1469
120, respirations 30 Nursing Process: Assessment NCLEX:
3. When assessing a patient with Correct Answer: C

a head injury, the nurse recog- Rationale: LOC is the most sensitive in-
nizes that the earliest indication dicator of the patient's neurologic status
1 / 16
ICP Nclex Questions
of increased intracranial pressure and possible changes in ICP. Vomiting
(ICP) is and sluggish pupil response to light are
a. vomiting. later signs of increased ICP. A headache
b. headache. can be caused by compression of in-
c. change in level of conscious- tracranial structures as the brain swells,
ness (LOC). but it is not unexpected after a head
d. sluggish pupil response to injury.
light.
Reference: p. 1470
4. A patient with a head injury has Correct Answer: C

an arterial blood pressure is 92/50 Rationale: The patient's cerebral perfu-
mm Hg and an intracranial pression pressure is only 46 mm Hg, which
sure of 18 mm Hg. Which action by will rapidly lead to cerebral ischemia and
the nurse is appropriate? neuronal death unless rapid action is
a. Document and continue to mon- taken to reduce ICP and increase ar-
itor the parameters. terial BP. Documentation and monitor-
b. Elevate the head of the patient's ing are inadequate responses to the pa-
bed. tient's problem. Elevating the head of
c. Notify the health care provider the bed will lower the ICP but may also
about the assessments. lower cerebral blood flow and further de-
d. Check the patient's pupillary re- crease CPP. Changes in pupil response
sponse to light. to light are signs of increased ICP, so the
nurse will only take more time doing this
without adding any useful information.
Cognitive Level: Analysis Text Refer-

ence: pp. 1468-1469
Nursing Process: Implementation
5. A patient has a systemic blood Correct Answer: C

pressure (BP) of 120/60 mm Hg Rationale: The patient's CPP is 56, be-
and an intracranial pressure of 24 low the normal of 70 to 100 mm Hg
mm Hg. The nurse determines that and approaching the level of ischemia
the cerebral perfusion pressure and neuronal death. The patient has low
2 / 16
ICP Nclex Questions
(CPP) of this patient indicates cerebral blood flow/perfusion. Normal
a. high blood flow to the brain. ICP is 0 to 15 mm Hg.
b. normal intracranial pressure
(ICP). Cognitive Level: Application Text Refer-
c. impaired brain blood flow. ence: p. 1468
d. adequate cerebral perfusion. Nursing Process: Assessment NCLEX:
6. When caring for a patient who has Correct Answer: B

had a head injury, which assess- Rationale: The change in level of con-
ment information is of most consciousness (LOC) is an indicator of in-
cern to the nurse? creased ICP and suggests that action
a. The blood pressure increases by the nurse is needed to prevent com-
from 120/54 to 136/62. plications. The change in BP should
b. The patient is more difficult to be monitored but is not an indicator of
arouse. a need for immediate nursing action.
c. The patient complains of a Headache is not unusual in a patient
headache at pain level 5 of a after a head injury. A slightly irregular
10-point scale. apical pulse is not unusual.
d. The patient's apical pulse is
slightly irregular. Cognitive Level: Application Text Refer-
ence: p. 1470
7. When the nurse applies a painful Correct Answer: A

stimulus to the nailbeds of an un- Rationale: Internal rotation, adduction,
conscious patient, the patient re- and flexion of the arms in an uncon-
sponds with internal rotation, ad- scious patient is documented as decor-
duction, and flexion of the arms. ticate posturing. Extension of the arms
The nurse documents this as and legs is decerebrate posturing. Be-
a. decorticate posturing. cause the flexion is general, it does not
b. decerebrate posturing. indicate localization of pain or flexion
c. localization of pain. withdrawal.
Reference: p. 1472
3 / 16
ICP Nclex Questions
8. A patient with possible cerebral Correct Answer: B
edema has a serum sodium lev- Rationale: The patient's low sodium in-
el of 115 mEq/L (115 mmol/L), dicates that hyponatremia may be caus-
a decreasing level of conscious- ing the cerebral edema, and the nurse's
ness (LOC) and complains of a first action should be to correct the low
headache. All of the following or- sodium level. Acetaminophen (Tylenol)
ders have been received. Which will have minimal effect on the headache
one should the nurse accomplish because it is caused by cerebral ede-
first? ma and increased ICP. Drawing ABGs
a. Administer acetaminophen and obtaining a CT scan may add some
(Tylenol) 650 mg orally. useful information, but the low sodium
b. Administer 5% hypertonic level may lead to seizures unless it is
saline intravenously. addressed quickly.
c. Draw blood for arterial blood
gases (ABGs). Cognitive Level: Application Text Refer-
d. Send patient to radiology for ence: p. 1470
computed tomography (CT) of the Nursing Process: Implementation
head. NCLEX: Physiological Integrity
9. Mechanical ventilation with a rate Correct Answer: C

and volume to maintain a mild hy- Rationale: The purpose of hyperventi-
perventilation is used for a patient lation for a patient with a head injury
with a head injury. To evaluate the is reduction of ICP, and ICP should be
effectiveness of the therapy, the monitored to evaluate whether the ther-
nurse should apy is effective. Although oxygen satura-
a. monitor oxygen saturation. tion and ABGs are monitored in patient's
b. check arterial blood gases receiving hyperventilation, they do not
(ABGs). provide data about whether the thera-
c. monitor intracranial pressure py is successful in reducing ICP. Breath
(ICP). sounds are assessed, but they are not
d. assess patient breath sounds. helpful in determining whether the hy-
perventilation is effective.
Cognitive Level: Application Text Refer-

ence: p. 1475
Nursing Process: Evaluation NCLEX:
10.
4 / 16
ICP Nclex Questions
A patient has ICP monitoring with A. Aseptic technique to prevent infec-
an intraventricular catheter. A pri- tion- An intraventricular catheter is a flu-
ority nursing intervention for the id coupled system that can provide di-
patient is rect access for microorganisms to enter
a. aseptic technique to prevent in- the ventricles of the brain, and aseptic
fection technique is a very high nursing priority
b. constant monitoring of ICP to decrease the risk for infection. Con-
waveforms stant monitoring of ICP waveforms is not
c. removal of CSF to maintain nor- usually necessary, and removal of CSF
mal ICP for sampling or to maintain normal ICP
d. sampling CSF to determine ab- is done only when specifically ordered
normalities
11. Skull radiographs and a comput- D. When there is a depressed fracture

ed tomography (CT) scan pro- and fractures with loose fragments, a
vide evidence of a depressed craniotomy is indicated to elevate the
parietal fracture with a subdural depressed bone and remove free frag-
hematoma in a patient admitted ments. A craniotomy is also indicated
to the emergency department fol- in cases of acute subdural and epidural
lowing an automobile accident. In hematomas to remove the blood and
planning care for the patient, the control the bleeding. Burr holes may be
nurse anticipates that used in an extreme emergency for rapid
a. the patient will receive life-sup- decompression, but with a depressed
port measures until the condition fracture, surgery would be the treatment
stabilizes of choice
b. immediate burr holes will be
made to rapidly decompress the
intracranial activity
c. the patient will be treated con-
servatively with close monitoring
for changes in neurologic condi-
tion
d. the patient will be taken to
surgery for a craniotomy for evac-
uation of blood and decompres-
sion of the cranium
12. Metabolic and nutritional needs of D. Balanced, essential nutrition in a form

the patient with increased ICP are that the patient can tolerate= A patient
5 / 16
ICP Nclex Questions
best met with with increased ICP is in a hypermetabol-
a. enteral feedings that are low in ic and hypercatabolic state and needs
sodium adequate glucose to maintain fuel for
b. the simple glucose available in the brain and other nutrients to meet
D5W IV solutions metabolic needs. Malnutrition promotes
c. a fluid restriction that promotes cerebral edema, and if a patient can-
a moderate dehydration not take oral nutrition, other means of
d. balanced, essential nutrition in providing nutrition should be used, such
a form that the patient can tolerate as tube feedings or parenteral nutrition.
Glucose alone is not adequate to meet
nutritional requirements, and 5% dex-
trose solutions may increase cerebral
edema by lowering serum osmolarity.
Patients should remain in a normov-
olemic fluid state with close monitoring
of clinical factors such as urine output,
fluid intake, serum and urine osmolality,
serum electrolytes, and insensible loss-
es.
13. The nurse suspects the presence D. An arterial epidural hematoma is the
of an arterial epidural hematoma most acute neurologic emergency, and
in the patient who experiences the typical symptoms include uncon-
a. failure to regain consciousness sciousness at the scene, with a brief
following a head injury lucid interval followed by a decrease
b. a rapid deterioration of neu- in LOC. An acute subdural hematoma
rologic function within 24 to 48 manifests signs within 48 hours of an
hours following a head injury injury; a chronic subdural hematoma de-
c. nonspecific, nonlocalizing pro- velops over weeks or months
gression of alteration in LOC oc-
curring over weeks or months
d. unconsciousness at the time of
crease in LOC
14. The nurse on the clinical unit is C. patient with meningitis who is sud-
assigned to four patients. Which denly agitated and reporting a HA of 10
patient should she assess first? on a 0 to 10 scale
6 / 16
ICP Nclex Questions
a. patient with a skull fracture
whose nose is bleeding
b. elderly patient with a stroke who
is confused and whose daughter
is present
c. patient with meningitis who is
suddenly agitated and reporting a
HA of 10 on a 0 to 10 scale
d. patient who had a craniotomy
for a brain tumor who is now 3
days postoperative and has had
continued emesis
15. The nurse is monitoring a patient A, B, D, E- The first sign of increased

for increased ICP following a head ICP is a change in LOC. Other man-
injury. Which of the following manifestations are dilated ipsilateral pupil,
ifestations indicate an increased changes in motor response such as
ICP (select all that apply) posturing, and fever, which may indi-
a. fever cate pressure on the hypothalamus.
b. oriented to name only Changes in vital signs would be an in-
c. narrowing pulse pressure creased systolic BP with widened pulse
d. dilated right pupil > left pupil pressure and bradycardia
e. decorticate posturing to painful
stimulus
16. When assessing the body func- D. Circulatory and respiratory status- Of
tion of a patient with increased the body functions that should be as-
ICP, the nurse should initially assessed in an unconscious patient, car-
sess diopulmonary status is the most vital
a. corneal reflex testing function and gives priorities to the ABCs
b. extremity strength testing (airway, breathing, and circulation)
c. pupillary reaction to light
d. circulatory and respiratory sta-
tus
17. A patient with ICP monitoring has D. A normal balance between brain tis-
pressure of 12 mm Hg. The nurse sue, blood, and CSF- normal is 10- 15
understand that this pressure re- mm Hg
flects
7 / 16
ICP Nclex Questions
a. a severe decrease in cerebral
perfusion pressure
b. an alteration in the production
of CSF
c. the loss of autoregulatory con-
trol of ICP
d. a normal balance between brain
tissue, blood, and CSF
18. During admission of a patient with A. Patency of airway is the #1 priority

a severe head injury to the ED, the with all head injuries
nurse places highest priority on
assessment for
c. neurologic status with Glascow
Coma Scale
d. CSF leakage from ears and nose
19. When a patient is admitted to the A. In addition to monitoring for a patent

emergency department following airway during emergency care of the pa-
a head injury, the nurse's first pri- tient with a head injury, the nurse must
ority in management of the patient always assume that a patient with a
once a patent airway is confirmed head injury may have a cervical spine in-
is jury. Maintaining cervical spine precau-
a. maintaining cervical spine pre- tions in all assessment and treatment
cautions activities with the patient is essential to
b. determining the presence of in- prevent additional neurologic damage.
creased ICP
c. monitoring for changes in neu-
rologic status
large-bore catheter
20. The nurse recognizes the pres- B. Cushing's triad consists of three vi-
ence of Cushing's triad in the pa- tal sign measures that reflect ICP and
tient with its effect on the medulla, the hypothal-
a. Increased pulse, irregular respi- amus, the pons, and the thalamus. Be-
ration, increased BP cause these structures are very deep,
8 / 16
ICP Nclex Questions
b. decreased pulse, irregular res- Cushing's triad is usually a late sign
piration, increased pulse pressure of ICP. The signs include an increas-
c. increased pulse, decreased res- ing systolic BP with a widening pulse
piration, increased pulse pressure pressure, a bradycardia with a full and
d. decreased pulse, increased res- bounding pulse, and irregular respira-
piration, decreased systolic BP tions.
21. A patient with a head injury has B. Tests the fluid for a halo sing on a
bloody drainage from the ear. To white dressing- Testing clear drainage
determine whether CSF is present for CSF in nasal or ear drainage may
in the drainage, the nurse be done with a Dextrostik or Tes-Tape
a. examines the tympanic mem- strip, but if blood is present, the glucose
brane for a tear in the blood will produce and unreliable
b. tests the fluid for a halo sign on result. To test bloody drainage, the nurse
a white dressing should test the fluid for a halo or ring that
c. tests the fluid with a glucose occurs when a yellowish ring encircles
identifying strip or stick blood dripped onto a white pad or towel
d. collects 5 mL of fluid in a test
tube and sends it to the laboratory
for analysis
22. Normal ICP ranges from: 5 to 15 mm Hg
23. Successful achievement of pa- D. Absence of signs and symptoms of in-

tient outcomes for the patient with creased ICP- The primary goal after cra-
cranial surgery would be best in- nial surgery is prevention of increased
dicated by the ICP, and interventions to prevent ICP
a. ability to return home in 6 days and infection postoperatively are nurs-
b. ability to meet all self-care ing priorities. The residual deficits, reha-
needs bilitation potential, and ultimate function
c. acceptance of residual neuro- of the patient depend on the reason for
logic deficits surgery, the postoperative course, and
d. absence of signs and symp- the patient's general state of health
toms of increased ICP
24. While the nurse performs ROM on C. Perform the exercises less frequently
an unconscious patient with in- because posturing can increase ICP-
creased ICP, the patient experi- If reflex posturing occurs during ROM
ences severe decerebrate postur- or positioning of the patient, these ac-
ing reflexes. The nurse should tivities should be done less frequently
9 / 16
ICP Nclex Questions
a. use restraints to protect the pa- until the patient's condition stabilizes,
tient from injury because posturing can case increases
b. administer CNS depressants to in ICP. Neither restraints nor CNS de-
lightly sedate the patient pressants would be indicated.
c. perform the exercises less fre-
quently because posturing can in-
crease ICP
d. continue the exercises because
25. A patient with an intracranial prob- B. 7- no opening of eyes = 1; incompre-

lem does not open his eyes to hensible words= 2, flexion withdrawal =
any stimulus, has no verbal re- 4
sponse except moaning and mut- Total = 7
tering when stimulated, and flex-
es his arm in response to painful
stimuli. The nurse records the pa-
tients GCS score as
a. 6
b. 7
c. 9
d. 11
26. The nurse plans care for a patient B. elevate the head of the bed to 30
with increased ICP with the knowl- degrees
edge that the best way to position
the patient is to
a. keep the head of the bed flat
b. elevate the head of the bed to 30
degrees
c. maintain patient on the left side
with the head supported on a pil-
low
d. use a continuous rotation bed
to continuously change patient
position
27.
10 / 16
ICP Nclex Questions
The earliest signs of increased C. One of the most sensitive signs of
ICP the nurse should assess for increased intracranial pressure (ICP) is
include a decreasing LOC. A decrease in LOC
a. Cushing's triad will occur before changes in vital signs,
b. unexpected vomiting ocular signs, and projectile vomiting oc-
c. decreasing level of conscious- cur
ness (LOC)
d. dilated pupil with sluggish re-
sponse to light
28. A 54-year old man is recover- C. Residual mental and emotional

ing from a skull fracture with a changes of brain trauma with personal-
subacute subdural hematoma. He ity changes are often the most incapac-
has return of motor control and itating problems following head injury
orientation but appears apathetic and are common in patients who have
and has reduced awareness of his been comatose longer than 6 hours.
environment. When planning dis- Families must be prepared for changes
charge or the patient, the nurse ex- in the patient's behavior to avoid fam-
plains to the patient and the family ily-patient friction and maintain fami-
that ly functioning, and professional assis-
a. continuous improvement in the tance may be required. There is no in-
patient's condition should occur dication he will be dependent on others
until he has returned to pre trauma for care, but he likely will not return to
status pre trauma status
b. the patient's complete recov-
ery may take years, and the family
should plan for his long term de-
pendent care
c. the patient is likely to have
long term emotional and mental
changes that may require contin-
ued professional help
d. role changes in family members
ily for care and support
29. A patient has a nursing diagnosis A. Avoiding positioning the patient with
of risk for ineffective cerebral tis- neck and hip flexion- Nursing care ac-
11 / 16
ICP Nclex Questions
sue perfusion related to cerebral tivities that increase ICP include hip
edema. An appropriate nursing in- and neck flexion, suctioning, clustering
tervention for the patient is care activities, and noxious stimuli; they
a. avoiding positioning the patient should be avoided or performed as little
with neck and hip flexion as possible in the patient with increased
b. maintaining hyperventilation to ICP. Lowering the PaCO2 below 20 mm
a PaCO2 of 15 to 20 mm Hg Hg can cause ischemia and worsen-
c. clustering nursing activities to ing of ICP; the PaCO2 should be main-
provide periods of uninterrupted tained at 30 to 35 mm Hg.
rest
accumulation of respiratory se-
cretions
30. The patient reports falling when A

he his foot got "stuck" on a crack Epidural hematoma often results from a
in the sidewalk, hitting his head linear fracture crossing a major artery
when he fell, and "passing out". in the dura. The classic sign is an initial
The paramedics found the patient period of unconsciousness at the scene
walking at the scene and talking and a brief lucid interval followed by a
before transporting the patient to decrease in LOC. A subdural hematoma
the hospital. In the emergency de- often results from injury to the brain and
partment, the patient starts to lose veins and develops more slowly. The
consciousness. This is a classic classic sign or symptom of subarach-
scenario for which complication? noid hemorrhage is a patient describing
A. Epidural hematoma "the worst headache of my life." Diffuse
B. Subdural hematoma axonal injury is widespread axonal dam-
C. Subarachnoid bleed age occurring after a traumatic brain in-
D. Diffuse axial inju jury.
31. A patient with a suspected closed A

head injury has bloody nasal When drainage containing CSF and
drainage. You suspect that this blood is allowed to drip onto a white
patient has a cerebrospinal fluid pad, the blood coalesces into the center
(CSF) leak when observing which within a few minutes, and a yellowish
of the following? ring of CSF encircles the blood, giving a
A. A halo sign on the nasal drip halo effect. The presence of glucose is
pad unreliable for determining the presence
B. Decreased blood pressure and
12 / 16
ICP Nclex Questions
urinary output of CSF because blood also contains glu-
C. A positive reading for glucose cose.
on a Test-tape strip
D. Clear nasal drainage along with
the bloody discharge
32. A patient with increased ICP is c

being monitored in the intensive he priority is to treat the known exist-
care unit (ICU) with a fiberoptic ing problem, and mannitol is the only
catheter. Which order is a priority thing that can do that. Because the pa-
for you? tient is having the current pressure mea-
A. Perform hourly neurologic sured with objective numbers, treating
checks. the known problem is a priority over ad-
B. Take a complete set of vital ditional assessments. H2-blockers are
signs. given when corticosteroids are admin-
C. Administer the prescribed man- istered to help prevent gastrointestinal
nitol (Osmitrol). bleeding, but they are not a priority com-
D. Give an H2-receptor blocker. pared with the treatment of ICP.
33. Which nursing action should be A

implemented in the care of a Fluid and electrolyte disturbances can
patient who is experiencing in- have an adverse effect on ICP and must
creased ICP? be vigilantly monitored. The head of the
A. Monitor fluid and electrolyte patient's bed should be kept at 30 de-
status astutely. grees in most circumstances, and phys-
B. Position the patient in a ical restraints are not applied unless
high-Fowler's position. absolutely necessary. Vasoconstrictors
C. Administer vasoconstrictors to are not typically administered in the
maintain cerebral perfusion. treatment of ICP.
D. Maintain physical restraints to
prevent episodes of agitation.
34. A patient with increased ICP has C

mannitol (Osmitrol) prescribed. LOC is the most sensitive indicator of
Which option is the best indica- ICP. Mannitol is an osmotic diuretic that
tion that the drug is achieving the works to decrease the ICP by plasma
desired therapeutic effects? expansion and an osmotic effect. Al-
A. Urine output increases from 30 though the other options may indicate a
mL to 50 mL/hour.
13 / 16
ICP Nclex Questions
B. Blood pressure remains less therapeutic effect of a diuretic, they are
than 150/90 mm Hg. not the main reason this drug is given.
D. No crackles are auscultated in
the lung fields.
35. Which option is the most sensitive D

indication of increased ICP? The LOC is the most sensitive and reli-
A. Papilledema able indicator of the patient's neurologic
B. Cushing's triad status. Changes in LOC are a result of
C. Projectile vomiting impaired cerebral brain flow. Papillede-
D. Change in the level of con- ma and Cushing's triad are late signs.
sciousness (LOC) Projectile vomiting is not a sensitive in-
dicator.
36. You are providing care for a pa- A,C,D

tient who has been admitted to The three dimensions of the Glasgow
the hospital with a head injury Coma Scale are eye opening, best ver-
who requires regular neurologic bal response, and best motor response.
vital signs. Which assessments
are components of the patient's
score on the Glasgow Coma Scale
(select all that apply)?
A. Eye opening
37. You are alerted to a possible acute An acute subdural hematoma manifests
subdural hematoma in the patient within 24 to 48 hours of the injury. The
who signs and symptoms are similar to those
A. has a linear skull fracture cross- associated with brain tissue compres-
ing a major artery. sion by increased intracranial pressure
B. has focal symptoms of brain (ICP) and include decreasing LOC and
damage with no recollection of a headache.
head injury.
C. develops decreasing LOC and
a headache within 48 hours of a
14 / 16
ICP Nclex Questions
head injury.
D. has an immediate loss of con-
sciousness with a brief lucid inter-
val followed by decreasing LOC.
38. Which option indicates a sign D

of Cushing's triad, an indication Cushing's triad is systolic hypertension
of increased intracranial pressure with a widening pulse pressure, brady-
(ICP)? cardia with a full and bounding pulse,
A. Heart rate increases from 90 to and slowed respirations. The rise in
110 beats/minute blood pressure is an attempt to maintain
B. Kussmaul respirations cerebral perfusion, and it is a neurologic
C. Temperature over 100.4° F (38° emergency because decompensation is
C) imminent. The other options are not part
D. Heart rate decreases from 75 to of Cushing's triad.
55 beats/minute
39. A patient being monitored has an D

ICP pressure of 12 mm Hg. You Normal ICP ranges from 5 to 15 mm Hg.
understand that this pressure re- A sustained pressure above the upper
flects limit is considered abnormal.
A. a severe decrease in cerebral
perfusion pressure.
B. an alteration in the production
of cerebrospinal fluid.
C. the loss of autoregulatory con-
trol of intracranial pressure.
D. a normal balance between brain
tissue, blood, and cerebrospinal
fluid.
40. The patient has rhinorrhea after B

a head injury. What action should A loose collection pad may be placed
you take? under the nose. Do not place a dressing
A. Pack the nares with sterile in the nasal cavity, and nothing should
gauze. be placed inside the nostril. There is no
B. A loose collection pad may be need to culture the drainage. The con-
placed under the nose. cern is whether it is spinal fluid, which is
C. Suction the drainage with an
15 / 16
ICP Nclex Questions
inline suction catheter. determined by a test for glucose or the
D. Obtain a sample for culture. halo or ring sign.
41. You plan care for the patient with B

increased ICP with the knowledge You should maintain the patient with in-
that the best way to position the creased ICP in the head-up position.
patient is to Elevation of the head of the bed to
A. keep the head of the bed flat. 30 degrees enhances respiratory ex-
B. elevate the head of the bed to 30 change and aids in decreasing cerebral
degrees. edema. You should position the patient
C. maintain patient on the left side to prevent extreme neck flexion, which
with the head supported on a pil- can cause venous obstruction and con-
low. tribute to elevated ICP. Elevation of the
D. use a continuous-rotation bed head of the bed reduces sagittal sinus
to continuously change patient pressure, promotes drainage from the
position. head through the valveless venous sys-
the vascular congestion that can pro-
duce cerebral edema. However, raising
the head of the bed above 30 degrees
may decrease the cerebral perfusion
pressure (CPP) by lowering systemic
blood pressure. Careful evaluation of
the effects of elevation of the head of the
bed on the ICP and the CPP is required.
42. You are caring for a patient ad- B

mitted with a subdural hematoma Changes in vital signs indicative of in-
after a motor vehicle accident. creased ICP are known as Cushing's tri-
Which change in vital signs would ad, which consists of increasing systolic
you interpret as a manifestation of pressure with a widening pulse pres-
increased intracranial pressure? sure, bradycardia with a full and bound-
A. Tachypnea ing pulse, and irregular respirations.
B. Bradycardia
C. Hypotension
16 / 16

Icp, Sci, Cva Q&a

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Icp, Sci, Cva Q&a

Uploaded by

Copyright:

Available Formats

Stroke NCLEX All

Study online at https://quizlet.com/_5lvk8u

1. In promoting health maintenance for prevention of C: Individuals

2. A thrombus that develops in a cerebral artery does not C: Circulation

3. A patient comes to the emergency department im- D: The patient

5. A patient is admitted to the hospital with a left hemi- A: CT scan- A CT

6. A carotid endarterectomy is being considered as a C: Involves re-

8. The priority intervention in the emergency department D: Maintenance of

9. A diagnosis of a ruptured cerebral aneurysm has been B: Surgical clip-

14. An appropriate food for a patient with a stroke who C: scrambled

16. To promote communication during rehabilitation of B: Talk about ADLs

20. Which intervention should the nurse delegate to the C: Administer

21. Characteristics of a thrombotic stroke Type most often

22. Characteristics of embolic stroke Onset unrelated

23. Characteristics of intracerebral hemorrhage Rupture of ather-

24. Characteristics of subarachnoid hemorrhage High initial mortal-

25. Manifestations of left brain damage Aphasia, inabili-

26. Manifestations of right brain damage Left homonymous

28. 1st thing you do when you suspect a stroke Non-contrast CT

29. Most common artery involved Internal Carotid

30. Permissive hypertension If you drop

31. Treat for hemorrhagic stroke Lower BP

32. Problem with IV-TPA only 1-3% of pa-

33. Arterial sources of stroke (3)

34. Secondary prevention of stroke (3) 1. Anticoagulants

35. Secondary prevention: Risk factor modification (4) 1. smoking cessa-

36. 4 major causes of hemorrhagic stroke 1)deep

38. After a patient experienced a brief episode of tinnitus, C. The patient's

39. A 68-year-old patient is being admitted with a possible C. A sudden onset

40. A 73-year-old patient with a stroke experiences facial D. Right-sided

42. When teaching about clopidogrel (Plavix), the nurse D. Clopidogrel

45. A 56-year-old patient arrives in the emergency depart- D. The patient's

51. A 58-year-old patient with a left-brain stroke sudden- D. Patients who

54. A 40-year-old patient has a ruptured cerebral A. The patient

59. Nurses in change-of-shift report are discussing the D. Protection of the

60. Several weeks after a stroke, a 50-year-old male pa- B. Developing a

63. After receiving change-of-shift report on the follow- A. tPA needs to be

67. A 63-year-old patient who began experiencing right C, D, A, B

1. c The nurse expects that management of the patient who

a. prophylactic clipping of cerebral aneurysms.

2. c Aspirin is ordered for a patient who is admitted with a

a. The patient has dysphasia.

3. d A patient with a stroke experiences right-sided arm and

4. c The nurse receives a verbal report that a patient has an

5. b The health care provider prescribes clopidogrel (Plavix)

a. to monitor and record the blood pressure daily.

6. a The health care provider recommends a carotid en-

a. The carotid endarterectomy involves surgical removal of

7. d When assessing a patient with a possible stroke, the nurse

a. Infuse normal saline at 75 mL/hr.

8. d A patient with a history of several transient ischemic at-

9. b The nurse identifies the nursing diagnosis of impaired ver-

a. have the patient practice facial and tongue exercises.

10. b A patient has a stroke affecting the right hemisphere of

a. impaired physical mobility related to right hemiplegia.

a. Apply an eye patch to the left eye.

12. c The nurse identifies the nursing diagnosis of imbalanced

a. Provide a wide variety of food choices.

13. a A 32-year-old patient has a stroke resulting from a rup-

a. Applying intermittent pneumatic compression stockings

a. order a varied pureed diet.

15. c A patient who has right-sided weakness after a stroke is

a. Situational low self-esteem related to increasing depen-