4. Myasthenic crisis and cholinergic crisis are the major complications of myasthenia gravis. Which of the following is essential nursing knowledge when caring for a client in crisis?

a. Weakness and paralysis of the muscles for swallowing and breathing occur in either crisisb. Cholinergic drugs should be administered to prevent further complications associated with the crisisc. The clinical condition of the client usually improves after several days of treatmentd. Loss of body function creates high levels of anxiety and fear

Answer: a

Rationale: The client cannot handle his own secretions, and respiratory arrest may beimminent. Atropine may be administered to prevent crisis. Anticholinergic drugs are administered to increase the levels of acetylcholine at the myoneural junction. Cholinergic drugs mimic the actions of the parasympathetic nervous system and would not be used.

13. A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid?

a. Obtain a culture of the specimen using sterile swabs and send to the laboratoryb. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the bloodc. Suction the nose gently with a bulb syringe and send specimen to the laboratoryd. Insert sterile packing into the nares and remove in 24 hours

Answer: b

Rationale: The halo or "bull's eye" sign seen when drainage from the nose or ear of ahead-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result.

16. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is 

a. That it is reversibleb. Amnesia will occurc. Loss of consciousness may be transientd. Laceration of the brain may occur

Answer: d

Rationale: Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness, retrograde amnesia, and is generally reversible.

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

measures is inappropriate when providing oral hygiene?

1. Placing the client on the back with a small pillow under the head.

2. Keeping portable suctioning equipment at the bedside.

3. Opening the client’s mouth with a padded tongue blade.

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

2. A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred

speech. Which nursing intervention is priority?

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

2. Discuss the precipitating factors that caused the symptoms.

3. Schedule for A STAT computer tomography (CT) scan of the head.

4. Notify the speech pathologist for an emergency consult.

3. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA)

administration. Which is the priority nursing assessment?

1. Current medications.

2. Complete physical and history.

3. Time of onset of current stroke.

4. Upcoming surgical procedures.

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

1. Pulse

2. Respirations

3. Blood pressure

4. Temperature

5. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

1. Cholesterol level

2. Pupil size and pupillary response

3. Bowel sounds

4. Echocardiogram

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

1. Increased vascular permeability.

2. Vasoconstriction.

3. Dissolved emboli.

4. Prevention of hemorrhage

7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would

the nurse anticipate being ordered for the client on discharge?

1. An oral anticoagulant medication.

2. A beta-blocker medication.

3. An anti-hyperuricemic medication.

4. A thrombolytic medication.

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

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

2. An 84-year-old Japanese female.

3. A 67-year-old Caucasian male.

4. A 39-year-old pregnant female.

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

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

2. A right-sided carotid bruit.

3. A blood pressure of 220/120 mmHg.

4. The presence of bronchogenic carcinoma.

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

the UAP requires the nurse to intervene?

1. The assistant places a gait belt around the client’s waist prior to ambulating.

2. The assistant places the client on the back with the client’s head to the side.

3. The assistant places her hand under the client’s right axilla to help him/her move up in bed.

4. The assistant praises the client for attempting to perform ADL’s independently.

Answers and Rationale

1. Answer: 1. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape

from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction, so having suction equipment at the

bedside is necessary. Padded tongue blades are safe to use. A toothbrush is appropriate to use.

2. Answer: 3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This

would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use

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

the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching.

Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to

protocol.

3. Answer: 3. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes.

A complete history is not possible in emergency care. Upcoming surgical procedures will need to be delay if t-PA is

administered. Current medications are relevant, but onset of current stroke takes priority.

4. Answer: 3. Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of

thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client’s ischemic tissue

needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.

5. Answer: 2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.

Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be

assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. An echocardiogram is not needed

for the client with a thrombotic stroke.

6. Answer: 3. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.

7. Answer: 1. Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to prevent thrombi

formation; and oral (warfarin [Coumadin]) at discharge verses intravenous.  Beta blockers slow the heart rate and lower the blood

pressure. Anti-hyperuricemic medication is given to clients with gout. Thrombolytic medication might have been given at initial

presentation but would not be a drug prescribed at discharge.

8. Answer: 1. Africana Americans have twice the rate of CVA’s as Caucasians; males are more likely to have strokes than

females except in advanced years. Oriental’s have a lower risk, possibly due to their high omega-3 fatty acids. Pregnancy is a

minimal risk factor for CVA.

9. Answer: 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium.

A bruit in the carotid artery would predispose a client to an embolic or ischemic stroke. High blood glucose levels could

predispose a patient to ischemic stroke, but not hemorrhagic. Cancer is not a precursor to stroke.

10. Answer: 3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder

joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. All the other actions are

appropriate.

1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows

an upward trend. Which intervention should the nurse perform first?

1. Reposition the client to avoid neck flexion

2. Administer 1 g Mannitol IV as ordered

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

4. Administer 100 mg of pentobarbital IV as ordered.

2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is

most important when administering this dose?

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

2. Rapid dilantin administration can cause cardiac arrhythmias.

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

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

3. A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the

following nursing interventions is the most appropriate to perform initially?

1. Evaluate urine specific gravity

2. Anticipate treatment for renal failure

3. Provide emollients to the skin to prevent breakdown

4. Slow down the IV fluids and notify the physician

4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of

the following responses best describes this result?

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

2. Emergent; the client is poorly oxygenated.

3. Normal

4. Significant; the client has alveolar hypoventilation.

5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown

by which of the following signs?

1. Bloody drainage from the ears

2. Frequent swallowing

3. Guaiac-positive stools

4. Hematuria

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

1. To treat growth failure

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

3. To reduce cerebral edema and lower intracranial pressure

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

7. A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing

interventions should be done first?

1. Assess full ROM to determine extent of injuries

2. Call for an immediate chest x-ray

3. Immobilize the client’s head and neck

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

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

1. Aphasia

2. Hemiparesis

3. Paraplegia

4. Tetraplegia

9. A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the

following assessments would take priority?

1. Bladder distension

2. Neurological deficit

3. Pulse ox readings

4. The client’s feelings about the injury

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

suspects which of the following conditions?

1. Autonomic dysreflexia

2. Hemorrhagic shock

3. Neurogenic shock

4. Pulmonary embolism

11. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities.

Which of the following medications would be used to control edema of the spinal cord?

1. Acetazolamide (Diamox)

2. Furosemide (Lasix)

3. Methylprednisolone (Solu-Medrol)

4. Sodium bicarbonate

12. A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate

of 50 bpm. Which of the following nursing interventions should be done first?

1. Place the client flat in bed

2. Assess patency of the indwelling urinary catheter

3. Give one SL nitroglycerin tablet

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

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

1. To hasten wound healing

2. To immobilize the cervical spine

3. To prevent autonomic dysreflexia

4. To hold bony fragments of the skull together

14. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal

cord injury?

1. Insert an indwelling urinary catheter to straight drainage

2. Schedule intermittent catheterization every 2 to 4 hours

3. Perform a straight catheterization every 8 hours while awake

4. Perform Crede’s maneuver to the lower abdomen before the client voids.

15. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of

epidural hematoma is usually related to which of the following conditions?

1. Laceration of the middle meningeal artery

2. Rupture of the carotid artery

3. Thromboembolism from a carotid artery

4. Venous bleeding from the arachnoid space

16. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears

and nose. Which of the following nursing interventions should be done first?

1. Position the client flat in bed

2. Check the fluid for dextrose with a dipstick

3. Suction the nose to maintain airway patency

4. Insert nasal and ear packing with sterile gauze

17. When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid

interval. Which of the following statements best described a lucid interval?

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

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

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

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

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

1. A client with a brain injury

2. A client with a herniated nucleus pulposus

3. A client with a high cervical spine injury

4. A client with a stroke

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

1. Absence of pain sensation in chest

2. Spasticity

3. Spontaneous respirations

4. Urinary continence

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

autonomic dysreflexia?

1. Headache

2. Lumbar spinal cord injury

3. Neurogenic shock

4. Noxious stimuli

21. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which

of the following interventions?

1. Elevate the client’s legs

2. Put the client flat in bed

3. Put the client in the Trendelenburg’s position

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

22. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and

flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?

1. Autonomic dysreflexia

2. Hypervolemia

3. Neurogenic shock

4. Sepsis

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

during the acute phase?

1. Absent corneal reflex

2. Decerebrate posturing

3. Movement of only the right or left half of the body

4. The need for mechanical ventilation

24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following

symptoms would also be anticipated?

1. Decreased urine output or oliguria

2. Hypertension and bradycardia

3. Respiratory depression

4. Symptoms of shock

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

instructions should be given?

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

2. “Measure the quantity of urine.”

3. “Gently rotate the catheter during removal.”

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

26. An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his

mother, the nurse gives which of the following instructions?

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

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

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

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

27. Which neurotransmitter is responsible for may of the functions of the frontal lobe?

1. Dopamine

2. GABA

3. Histamine

4. Norepinephrine

28. The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive

cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the

test measures which of the following conditions?

1. Extent of intracranial bleeding

2. Sites of brain injury

3. Activity of the brain

4. Percent of functional brain tissue

29. A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a

collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

1. Subdural hematoma

2. Subarachnoid hemorrhage

3. Epidural hematoma

4. Contusion

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

the nurse expect?

1. Quadriplegia with gross arm movement and diaphragmatic breathing

2. Quadriplegia and loss of respiratory function

3. Paraplegia with intercostal muscle loss

4. Loss of bowel and bladder control

31. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected.

How should the first-responder open the client’s airway for rescue breathing?

1. By inserting a nasopharyngeal airway

2. By inserting a oropharyngeal airway

3. By performing a jaw-thrust maneuver

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

32. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin,

diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the

following nursing interventions would be appropriate for this client? Select all that apply.

1. Elevate the HOB to 90 degrees

2. Loosen constrictive clothing

3. Use a fan to reduce diaphoresis

4. Assess for bladder distention and bowel impaction

5. Administer antihypertensive medication

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

33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The

client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:

1. Desmopressin (DDAVP, stimate)

2. Dexamethasone (Decadron)

3. Ethacrynic acid (Edecrin)

4. Mannitol (Osmitrol)

34. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the

time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action,

knowing this is compatible with:

1. Skull fracture

2. Concussion

3. Subdural hematoma

4. Epidural hematoma

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

complications by assessing for:

1. A flattened abdomen

2. Hematest positive nasogastric tube drainage

3. Hyperactive bowel sounds

4. A history of diarrhea

36. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the

following measures to minimize the risk of recurrence?

1. Strict adherence to a bowel retraining program

2. Limiting bladder catheterization to once every 12 hours

3. Keeping the linen wrinkle-free under the client

4. Preventing unnecessary pressure on the lower limbs

37. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in

minimizing the effects of vasodilation below the level of the injury?

1. Monitoring vital signs before and during position changes

2. Using vasopressor medications as prescribed

3. Moving the client quickly as one unit

4. Applying Teds or compression stockings.

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

injury most effectively by:

1. Keeping the client on a stretcher

2. Logrolling the client on a firm mattress

3. Logrolling the client on a soft mattress

4. Placing the client on a Stryker frame

39. The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the

following observations by the nurse indicates that spinal shock persists?

1. Positive reflexes

2. Hyperreflexia

3. Inability to elicit a Babinski’s reflex

4. Reflex emptying of the bladder

40. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the

client’s vital signs, list in order of priority, the nurse’s actions (Number 1 being the first priority and number 5 being the

last priority).

1. Check for bladder distention

2. Raise the head of the bed

3. Contact the physician

4. Loosen tight clothing on the client

5. Administer an antihypertensive medication

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

1. Unequal pupil size

2. Decreasing systolic blood pressure

3. Tachycardia

4. Decreasing body temperature

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

1. Slow, irregular respirations

2. Rapid, shallow respirations

3. Asymmetric chest expansion

4. Nasal flaring

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

1. Give the client a warming blanket

2. Administer low-dose barbiturate

3. Encourage the client to hyperventilate

4. Restrict fluids

44. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s

condition?

1. Widening pulse pressure

2. Decrease in the pulse rate

3. Dilated, fixed pupil

4. Decrease in LOC

45. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line.

Which nursing intervention protects the client without increasing her ICP?

1. Place her in a jacket restraint

2. Wrap her hands in soft “mitten” restraints

3. Tuck her arms and hands under the draw sheet

4. Apply a wrist restraint to each arm

46. Which of the following describes decerebrate posturing?

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

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

3. Supination of arms, dorsiflexion of feet

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

47. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial

occipital bleeding. Which action would be most appropriate?

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

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

3. Call the physician to adjust the ventilator settings.

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

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

is contraindicated when positioning the client?

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

2. Elevating the head of the bed to 30 degrees

3. Log rolling or turning as a unit when turning

4. Keeping the head in neutral position

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

1. Decerebrate posturing

2. Dilated nonreactive pupils

3. Deep tendon reflexes

4. Absent corneal reflex

50. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized

tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom

you are supervising? (Choose all that apply).

1. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.

2. Administer phenytoin (Dilantin) 200 mg PO daily.

3. Teach patient about the need for good oral hygiene.

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

 Answers and Rationale

1. Answer: 1. The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which

increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol,

pentobarbital, or hyperventilation therapy.

2. Answer: 2. Dilantin IV shouldn’t be given at a rate exceeding 50 mg/minute. Rapid administration can depress the

myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldn’t be mixed in solution

for administration. However, because it’s compatible with normal saline solution, it can be injected through an IV line containing

normal saline. When given through an IV catheter hand, dilantin may cause purple glove syndrome.

3. Answer: 1. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic

hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity,

increased serum osmolarity, and dehydration. There’s no evidence that the client is experiencing renal failure. Providing

emollients to prevent skin breakdown is important, but doesn’t need to be performed immediately. Slowing the rate of IV fluid

would contribute to dehydration when polyuria is present.

4. Answer: 1. A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through

hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen

saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

5. Answer: 2. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx.

Blood or fluid draining from the ear may indicate a basilar skull fracture.

6. Answer: 4. After hypophysectomy, or removal of the pituitary gland, the body can’t synthesize ADH. Somatropin or growth

hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or

corticosteroids are used to decrease cerebral edema.

7. Answer: 3. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence.

ROM would be contraindicated at this time. There is no indication that the client needs a chest x-ray. The airway doesn’t need to

be opened since the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldn’t be

used until the cervical spine injury is ruled out.

8. Answer: 4. Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord

and below.

9. Answer: 3. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at

the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be

necessary at a later time, observation for respiratory failure is the priority.

10. Answer: 3. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of

adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with

autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn’t be suspected

without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may

be a later complication of spinal cord injury due to immobility.

11. Answer: 3. High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit

neurological deficit. The other drugs aren’t indicated in this circumstance.

12. Answer: 4. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of

autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer.

Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed

immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn’t used for hypertension

or dysreflexia.

13. Answer: 2. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.

14. Answer: 2. Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less

than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are

removed as soon as possible. Crede’s maneuver is not used on people with spinal cord injury.

15. Answer: 1. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An

embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually

observed with subdural hematoma.

16. Answer: 2. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of

dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn’t be suctioned

because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull

fracture because of the risk of infection.

17. Answer: 3. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the

client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can’t recall

recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.

18. Answer: 3. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the

level of T10. The other clients aren’t prone to dysreflexia.

19. Answer: 2. Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by

hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain

sensation in the chest doesn’t apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at

C4 and above.

20. Answer: 4. Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A

headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10

or above. Neurogenic shock isn’t a cause of dysreflexia.

21. Answer: 4. Putting the client in the high-Fowler’s position will decrease cerebral blood flow, decreasing hypertension.

Elevating the client’s legs, putting the client flat in bed, or putting the bed in the Trendelenburg’s position places the client in

positions that improve cerebral blood flow, worsening hypertension.

22. Answer: 3. Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause

hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is

indicated by rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis

would include elevated temperature, increased heart rate, and increased respiratory rate.

23. Answer: 4. The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation

due to cord edema. This may resolve in time. Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain

injuries, not spinal cord injuries.

24. Answer: 2. Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic

dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.

25. Answer: 4. Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the

urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the

meatus in a man. It isn’t necessary to measure the urine. The catheter doesn’t need to be rotated during removal.

26. Answer: 3. Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed

frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased ICP

and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches

should be reported.

27. Answer: 1. The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate

widely throughout this lobe, which is why it’s such an important neurotransmitter in schizophrenia.

28. Answer: 3. An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site

would be determined by CT or MRI. Percent of functional brain tissue would be determined by a series of tests.

29. Answer: 3. An epidural hematoma occurs when blood collects between the skull and the dura mater. In a subdural hematoma,

venous blood collects between the dura mater and the arachnoid mater. In a subarachnoid hemorrhage, blood collects between the

pia mater and arachnoid membrane. A contusion is a bruise on the brain’s surface.

30. Answer: 1. A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic

breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle

loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.

31. Answer: 3. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the

tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however,

the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck

hyperextension, which can worsen the cervical spine injury.

32. Answer: 1, 2, 4, 5. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is

caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic

nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease

venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia,

any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which

may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication

of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s

blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic

dysreflexia.

33. Answer: 1. A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the

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

with desmopressin. Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may be ordered

for the head injured patient. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.

34. Answer: 4. The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood

collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed

rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of

additional blood can cause the intracranial pressure to rise rapidly, and the client’s neurological status deteriorates quickly.

35. Answer: 2. After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel

sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. A

history of diarrhea is irrelevant.

36. Answer: 2. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catherization should be done

every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal

impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from

tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

37. Answer: 3. Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension,

which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a

tilt-table with early mobilization, and changing the client’s position slowly. Venous pooling can be reduced by using Teds

(compression stockings) or pneumatic boots. Vasopressor medications are administered per protocol.

38. Answer: 4. Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord.

Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of

immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should

be used.

39. Answer: 3. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous

stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski’s reflex.

40. Answer: 2, 4, 1, 3, 5.  Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal

stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia

is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit

the client up in bed in a high-Fowler’s position and remove the noxious stimulus. The nurse should loosen any tight clothing and

then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also

would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve

the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.

41. Answer: 1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an

increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the

vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

42. Answer: 1. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular

respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of

respiratory distress or hypoxia.

43. Answer: 3. Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood

volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of

temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to

reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by

supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

44. Answer: 4. A decrease in the client’s LOC is an early indicator of deterioration of the client’s neurological status. Changes in

LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated,

fixed pupils occur later if the increased ICP is not treated.

45. Answer: 2. It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing

additional agitation. Using a jacket or wrist restraint or tucking the client’s arms and hands under the draw sheet restrict

movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

46. Answer: 4. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is

demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the

feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which

indicates damage to corticospinal tracts and cerebral hemispheres.

47. Answer: 2. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A

lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital

lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored

very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations

cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence.

Checking deep tendon reflexes is one part of the GCS analysis.

48. Answer: 2. Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause

herniation of the brain down onto the brainstem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30

degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for

supratentorial craniotomies.

49. Answer: 2, 3, 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent

corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death.

Decerebrate or decorticate posturing would not be seen.

50. Answer: 2 – Administration of medications is included in LPN education and scope of practice. Collection of data about the

seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call

the supervising RN immediately if a patient started to seize. Documentation of the seizure, patient teaching, and planning of care

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

1. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity,

and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the

following circumstances?

1. Vomiting continues

2. Intracranial pressure (ICP) is increased

3. The client needs mechanical ventilation

4. Blood is anticipated in the cerebrospinal fluid (CSF)

2. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician

orders mannitol for which of the following reasons?

1. To reduce intraocular pressure

2. To prevent acute tubular necrosis

3. To promote osmotic diuresis to decrease ICP

4. To draw water into the vascular system to increase blood pressure

3. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following

results would best show the mannitol was effective?

1. Urine output increases

2. Pupils are 8 mm and nonreactive

3. Systolic blood pressure remains at 150 mm Hg

4. BUN and creatinine levels return to normal

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

1. 0 to 15 mm Hg

2. 25 mm Hg

3. 35 to 45 mm Hg

4. 120/80 mm Hg

5. Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?

1. Ataxia and confusion

2. Sodium depletion

3. Tonic-clonic seizure

4. Urinary incontinence

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

1. Bradycardia

2. Large amounts of very dilute urine

3. Restlessness and confusion

4. Widened pulse pressure

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

1. Frontal

2. Occipital

3. Parietal

4. Temporal

8. While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?

1. Frontal

2. Occipital

3. Parietal

4. Temporal

9. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following

to test the client’s peripheral response to pain?

1. Sternal rub

2. Pressure on the orbital rim

3. Squeezing the sternocleidomastoid muscle

4. Nail bed pressure

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

procedure?

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

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

3. Prone, in a slight Trendelenburg’s position

4. Prone, with a pillow under the abdomen.

11. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected

into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus

toward the right. The nurse understands that this indicates the client has:

1. A cerebral lesion

2. A temporal lesion

3. An intact brainstem

4. Brain death

12. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following

trends in vital signs if the ICP is rising?

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

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

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

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

13. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is

developing meningitis as a complication of surgery if the client exhibits:

1. A positive Brudzinski’s sign

2. A negative Kernig’s sign

3. Absence of nuchal rigidity

4. A Glascow Coma Scale score of 15

14. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge

that the human body typically and automatically responds to pain first with attempts to:

1. Tolerate the pain

2. Decrease the perception of pain

3. Escape the source of pain

4. Divert attention from the source of pain.

15. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most

appropriate to institute?

1. Limiting conversation with the child

2. Keeping extraneous noise to a minimum

3. Allowing the child to play in the bathtub

4. Performing treatments quickly

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

intravascular coagulation?

1. Hemorrhagic skin rash

2. Edema

3. Cyanosis

4. Dyspnea on exertion

17. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse

to suspect pneumococcal meningitis?

1. Bladder infection

2. Middle ear infection

3. Fractured clavicle

4. Septic arthritis

18. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the

nurse expect the child to demonstrate? Select all that apply.

1. Head tilt

2. Vomiting

3. Polydipsia

4. Lethargy

5. Increased appetite

6. Increased pulse

19. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A

nurse reviews the results of the CSF analysis and determines that which of the following results would verify the

diagnosis?

1. Cloudy CSF, decreased protein, and decreased glucose

2. Cloudy CSF, elevated protein, and decreased glucose

3. Clear CSF, elevated protein, and decreased glucose

4. Clear CSF, decreased pressure, and elevated protein

20. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this

infection, which of the following would be included in the plan of care?

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

2. Maintain enteric precautions

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

4. Maintain neutropenic precautions

21. A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of

decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of

posturing was present?

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

2. Rigid extension and pronation of the arms and legs

3. Rigid pronation of all extremities

4. Flaccid paralysis of all extremities

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

1. Positive Kernig’s sign

2. Negative Brudzinski’s sign

3. Positive homan’s sign

4. Negative Kernig’s sign

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

1. Congenital anatomic abnormality of the meninges

2. Lack of acquired resistance to the various etiologic organisms

3. Occlusion or narrowing of the CSF pathway

4. Natural affinity of the CNS to certain pathogens

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

1. Ischemic infarction of cerebral tissue

2. Childhood diseases of viral causation such as mumps

3. Brain abscesses caused by a variety of pyogenic organisms

4. Cerebral ventricular irritation from a traumatic brain injury

25. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to

LPN/LVN?

1. Complete admission assessment.

2. Set up oxygen and suction equipment.

3. Place a padded tongue blade at bedside.

4. Pad the side rails before patient arrives.

Answers and Rationale

1. Answer: 2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the

brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP;

therefore, LP isn’t strictly contraindicated. An LP may be performed on clients needing mechanical ventilation. Blood in the CSF

is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

2. Answer: 3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to

intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

3. Answer: 1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils

are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or

that mannitol is being given for renal dysfunction or blood pressure maintenance.

4. Answer: 1. Normal ICP is 0-15 mm Hg.

5. Answer: 1. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity

include confusion and ataxia. Phenytoin doesn’t cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur

during or after a seizure.

6. Answer: 3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and

bradypnea occur later. The client may void large amounts of very dilute urine if there’s damage to the posterior pituitary.

7. Answer: 4. The temporal lobe functions to regulate memory and learning problems because of the integration of the

hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions

regulate vision. The parietal lobe primarily functions with sensory function.

8. Answer: 3. The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The

frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The

temporal lobe regulates memory.

9. Answer: 4. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nail Bed pressure

tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital

rim, or squeezing the clavicle or sternocleidomastoid muscle.

10. Answer: 1. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and

with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.

11. Answer: 3. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After

determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact

function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid

nystagmus to the opposite side. Absent or disconjugate eye movements indicate brainstem damage.

12. Answer: 2. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing

temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

13. Answer: 1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski’s sign, and

positive Kernig’s sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck

is fixed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are

extended from a flexed-right angle position. 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. Answer: 3. The client’s innate responses to pain are directed initially toward escaping from the source of pain. Variations in

individuals’ tolerance and perception of pain are apparent only in conscious clients, and only conscious clients are able to employ

distraction to help relieve pain.

15. Answer: 2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore,

extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with

the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because

of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be

completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace

that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

16. Answer: 1. DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues.

An abnormal coagulation phenomenon causes the condition.

17. Answer: 2. Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the

body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal

and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is frequently also found.

18. Answer: 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical

manifestations are the result of location and size of the tumor.

19. Answer: 2. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial

meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and

decreased glucose levels.

20. Answer: 3. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed

antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are

obtained and the antibiotic is having an effect.

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

22. Answer: 1. A positive Kernig’s sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space.

Brudzinski’s sign is also indicative of the condition.

23. Answer: 2. Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a

lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility.

24. Answer: 2. Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles,

mumps, herpes, and leukemia. Incidences of brain abscess are high in bacterial meningitis, and ischemic infarction of cerebral

tissue can occur with tubercular meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.

25. Answer: 2 – The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial

assessment. Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and

family. Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins.

Focus: Delegation/supervision.

1. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her

history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for

CVA?

A. Caucasian race

B. Female sex

C. Obesity

D. Bronchial asthma

2. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse

should tell the client to:

A. take a hot bath.

B. rest in an air-conditioned room.

C. increase the dose of muscle relaxants.

D. avoid naps during the day.

3. A male client is having a tonic-clonic seizures. What should the nurse do first?

A. Elevate the head of the bed.

B. Restrain the client’s arms and legs.

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

D. Take measures to prevent injury.

4. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical

ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

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

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

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

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

5. The nurse is working on a surgical floor. The nurse must logroll a male client following a:

A. laminectomy.

B. thoracotomy.

C. hemorrhoidectomy.

D. cystectomy.

6. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do

when preparing the client for this test?

A. Immobilize the neck before the client is moved onto a stretcher.

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

C. Place a cap over the client’s head.

D. Administer a sedative as ordered.

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

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

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

C. tap the tendon slowly and softly

D. hold the reflex hammer tightly.

8. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which

nursing diagnosis takes highest priority in this client’s plan of care?

A. Disturbed sensory perception (visual)

B. Self-care deficient: Dressing/grooming

C. Impaired verbal communication

D. Risk for injury

9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrateD. I can’t do

anything without help!” This comment best supports which nursing diagnosis?

A. Anxiety

B. Powerlessness

C. Ineffective denial

D. Risk for disuse syndrome

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

A. prevent respiratory alkalosis.

B. lower arterial pH.

C. promote carbon dioxide elimination.

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

11. Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes to the victim

and determines the need to opens the airway in this victim by using which method?

A. Flexed position

B. Head tilt-chin lift

C. Jaw thrust maneuver

D. Modified head tilt-chin lift

12. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use

which of the following to test the client’s peripheral response to pain?

A. Sternal rub

B. Nail bed pressure

C. Pressure on the orbital rim

D. Squeezing of the sternocleidomastoid muscle

13. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance

imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the

client’s history of:

A. Hypertension

B. Heart failure

C. Prosthetic valve replacement

D. Chronic obstructive pulmonary disorder

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

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

B. Prone, with a pillow under the abdomen

C. Prone, in slight-Trendelenburg’s position

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

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

the nurse avoid?

A. Head mildline

B. Head turned to the side

C. Neck in neutral position

D. Head of bed elevated 30 to 45 degrees

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

cerebrospinal fluid if the fluid:

A. Is clear and tests negative for glucose

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

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

D. Separates into concentric rings and test positive of glucose

17. A male client with a spinal cord injury is prone to experiencing automatic dysreflexiA. The nurse would avoid which

of the following measures to minimize the risk of recurrence?

A. Strict adherence to a bowel retraining program

B. Keeping the linen wrinkle-free under the client

C. Preventing unnecessary pressure on the lower limbs

D. Limiting bladder catheterization to once every 12 hours

18. The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following

actions by the nurse would be contraindicated?

A. Loosening restrictive clothing

B. Restraining the client’s limbs

C. Removing the pillow and raising padded side rails

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

19. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing

that this condition:

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

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

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

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

20. The client with a brain attack (stroke) has residual dysphagiA. When a diet order is initiated, the nurse avoids doing

which of the following?

A. Giving the client thin liquids

B. Thickening liquids to the consistency of oatmeal

C. Placing food on the unaffected side of the mouth

D. Allowing plenty of time for chewing and swallowing

21. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke).

The nurse assesses that the client is adapting most successfully if the client:

A. Gets angry with family if they interrupt a task

B. Experiences bouts of depression and irritability

C. Has difficulty with using modified feeding utensils

D. Consistently uses adaptive equipment in dressing self

22. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasiA. Which of the following

actions by the nurse would be least helpful to the client?

A. Speaking to the client at a slower rate

B. Allowing plenty of time for the client to respond

C. Completing the sentences that the client cannot finish

D. Looking directly at the client during attempts at speech

23. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has

precipitating factors such as:

A. Getting too little exercise

B. Taking excess medication

C. Omitting doses of medication

D. Increasing intake of fatty foods

24. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic

crises. The nurse tells the client that this is most effectively done by:

A. Eating large, well-balanced meals

B. Doing muscle-strengthening exercises

C. Doing all chores early in the day while less fatigued

D. Taking medications on time to maintain therapeutic blood levels

25. A male client with Bell’s palsy asks the nurse what has caused this problem. The nurse’s response is based on an

understanding that the cause is:

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

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

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

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

26. The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing

denervation. The nurse determines that the client needs additional information if the client states that he or she will:

A. Exposure to cold and drafts

B. Massage the face with a gentle upward motion

C. Perform facial exercises

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

27. Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the

nursing admission interview if the client has history of:

A. Seizures or trauma to the brain

B. Meningitis during the last 5 years

C. Back injury or trauma to the spinal cord

D. Respiratory or gastrointestinal infection during the previous month.

28. A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving

mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client

cope with this illness?

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

B. Providing positive feedback and encouraging active range of motion

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

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

29. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which

of the following to ensure client to ensure client safety?

A. Speak loudly to the client

B. Test the temperature of the shower water

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

D. Provide a clear path for ambulation without obstacles

30. A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would

document which of the following information related to the client’s behavior.

A. Is disoriented to person, place, and time

B. Affect is flat, with periods of emotional lability

C. Cannot recall what was eaten for breakfast today

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

Answers and Rationale

1. Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease,

diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral

contraceptive use, emotional stress, family history of CVA, and advancing age. The client’s race, sex, and bronchial asthma

aren’t risk factors for CVA.

2. Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an

air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body

temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for

frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include

treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

3. Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would

have no effect on the client’s condition or safety. Restraining the client’s arms and legs could cause injury. Placing a tongue

blade or other object in the client’s mouth could damage the teeth.

4. Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary.

Return of motor function begins proximally and extends distally in the legs.

5. Answer A. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight

when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable

position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities

immediately after surgery.

6. Answer B. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to

iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a

cap over the client’s head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The

physician orders a sedative only if the client can’t be expected to remain still during the CT scan.

7. Answer B. To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being

tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is

used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn’t

provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and

fingers so it can swing in an arc.

8. Answer D. Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the

other options may be appropriate, they’re secondary because they don’t immediately affect the client’s health or safety.

9. Answer B. This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome,

characterized by an active and functioning mind locked in a body that can’t perform even simple daily tasks. Although Anxiety

and Risk for disuse syndrome may be diagnoses associated with ALS, the client’s comment specifically refers to an inability to

act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn’t seem to perceive the personal

relevance of symptoms or danger.

10. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment

in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH

may bring about acidosis, an undesirable condition in this case. It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60

mm Hg will adequately oxygenate most clients.

11. Answer C. If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt–chin lift maneuver

produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an

inappropriate position for opening the airway.

12. Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure

tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital

rim, or squeezing the clavicle or sternocleidomastoid muscle.

13. Answer C. The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic

field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as

orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become

dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists.

14. Answer D. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and

the head bent down onto the chest. This position helps open the spaces between the vertebrae.

15. Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline

position. The nurse should avoid flexing or extending the client’s neck or turning the head side to side. The head of the bed

should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial

pressure down.

16. Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be

distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing

material, called a halo sign. The fluid also tests positive for glucose.

17. Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done

every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal

impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from

tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

18. Answer B. Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow

and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to

fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client

harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head

from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.

19. Answer B. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is

weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition. The

client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and

ambulating.

20. Answer A. Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client

is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the

mouth. Liquids are thickened to avoid aspiration.

21. Answer D. Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make

appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options A, B, and C are not

adaptive behaviors.

22. Answer C. Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. General

guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response

time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding

manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family

members provide all the responses for the client.

23. Answer C. Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic

medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is

caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect.

Overexertion and overeating possibly could trigger myasthenic crisis.

24. Answer D. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore

muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-

strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is

exposure to heat, crowds, erratic sleep habits, and emotional stress.

25. Answer A. Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but

may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a

combination of these factors.

26. Answer A. Prevention of muscle atrophy with Bell’s palsy is accomplished with facial massage, facial exercises, and

electrical stimulation of the nerves. Exposure to cold or drafts is avoided. Local application of heat to the face may improve

blood flow and provide comfort.

27. Answer D. Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves.

Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological

deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.

28. Answer C. The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden

onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client’s condition, giving

expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with

selected care activities and provide diversion for the client as well.

29. Answer D. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired

client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were an

impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial

nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue,

respectively.

30. Answer B. The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current

events relates to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation.

Recall of recent events is controlled by the hippocampus.