NSG 4100 Exam 4 Final: Complete
Neurological & Critical Care Nursing
Review –Practice Questions with
Rationales
A patient with a traumatic brain injury has a Glasgow Coma Scale
(GCS) score of 12 (Eye opening to pain, Incomprehensible sounds,
Abnormal flexion). How should the nurse interpret this score?
Correct Answer: Moderate head injury.
Rationale: A GCS score of 9–12 indicates a moderate head
injury. Scores of 13–15 indicate mild injury, and scores of 8 or
less indicate severe injury (coma).
Which finding should the nurse recognize as the earliest sign of
neurologic deterioration in a patient with a traumatic brain injury?
Correct Answer: Change in level of consciousness (LOC).
Rationale: Change in LOC is the earliest and most sensitive
indicator of neurologic deterioration. Pupillary changes and
vital sign changes are later signs of increased ICP.
A patient has a GCS score of 6. How should the nurse interpret
this finding?
Correct Answer: The patient is in a comatose state.
Rationale: A GCS score of 8 or less indicates a severe head
injury and a comatose state.
,A client with a closed head injury is on mechanical ventilation.
Which intervention reduces the risk of increased ICP?
Correct Answer: Elevate HOB 30–45 degrees.
Rationale: Elevating the head of bed promotes venous
drainage from the brain, reducing ICP. Flat positioning
increases cerebral venous pressure and raises ICP.
A nurse is caring for a client with head trauma. The client's urinary
output is 300 mL over 2 hours. Which action should the nurse take
first?
Correct Answer: Check specific gravity.
Rationale: 300 mL over 2 hours is 150 mL/hr, which is above
normal (30–80 mL/hr). This may indicate diabetes insipidus
due to posterior pituitary injury. A low specific gravity
(<1.005) would confirm this. The nurse must assess before
notifying the provider.
A client with traumatic brain injury (TBI) had a peak ICP reading 12
hours ago. Now at 36 hours post-injury, the client becomes
unconscious for 1 minute. What should the nurse do first?
Correct Answer: Notify provider of increased pupil size from
7 to 10 mm.
Rationale: Pupil dilation from 7 mm to 10 mm indicates
worsening brainstem compression and imminent herniation,
which requires immediate notification.
A client admitted to the neurological ICU following an acute head
injury resulting in cerebral edema. What priority medication does
the nurse expect to administer?
, Correct Answer: Mannitol (Osmitrol).
Rationale: Mannitol is an osmotic diuretic that draws fluid
from brain tissue into the vascular space, reducing cerebral
edema and lowering ICP.
A client with a head injury has been increasingly agitated. What is
the nurse's best intervention for preventing injury?
Correct Answer: Pad the side rails of the client's bed.
Rationale: Padding side rails prevents injury from agitation
without the use of restraints, which can increase ICP.
What is the normal range for intracranial pressure (ICP) in adults?
Correct Answer: 5–15 mmHg.
Rationale: Normal ICP is 5–15 mmHg. Pressures above 20
mmHg require intervention.
Which component of the Glasgow Coma Scale assesses brainstem
function?
Correct Answer: Eye opening.
Rationale: The GCS assesses eye opening (brainstem), verbal
response (cerebral cortex), and motor response (brainstem
and cerebral cortex).
A patient with a head injury has a blood pressure of 190/100
mmHg and a heart rate of 50 bpm. What does this indicate?
Correct Answer: Cushing's triad (late sign of increased ICP).
Rationale: Cushing's triad—hypertension, bradycardia, and
irregular respirations—is a late sign of increased ICP and
indicates brainstem compression.
, The nurse is caring for a patient with an ICP monitor. Which ICP
reading requires immediate intervention?
Correct Answer: 22 mmHg.
Rationale: Normal ICP is 5–15 mmHg. Readings above 20
mmHg are considered elevated and require intervention to
prevent brain damage.
A patient with increased ICP is prescribed hyperventilation. What
is the goal of this therapy?
Correct Answer: Decrease PaCO2 to 30-35 mmHg to cause
cerebral vasoconstriction.
Rationale: Hyperventilation lowers PaCO2, which causes
cerebral vasoconstriction, reducing cerebral blood volume
and ICP. However, it should be used cautiously to avoid
cerebral ischemia.
Which position is most appropriate for a patient with increased
ICP?
Correct Answer: Head of bed elevated 30–45 degrees with
head in midline.
Rationale: Elevating the HOB promotes venous drainage.
Keeping the head in midline prevents jugular vein
compression, which can increase ICP.
A patient with a brain injury has a cerebral perfusion pressure
(CPP) of 50 mmHg. What is the nurse's priority action?
Correct Answer: Notify the provider immediately.
Neurological & Critical Care Nursing
Review –Practice Questions with
Rationales
A patient with a traumatic brain injury has a Glasgow Coma Scale
(GCS) score of 12 (Eye opening to pain, Incomprehensible sounds,
Abnormal flexion). How should the nurse interpret this score?
Correct Answer: Moderate head injury.
Rationale: A GCS score of 9–12 indicates a moderate head
injury. Scores of 13–15 indicate mild injury, and scores of 8 or
less indicate severe injury (coma).
Which finding should the nurse recognize as the earliest sign of
neurologic deterioration in a patient with a traumatic brain injury?
Correct Answer: Change in level of consciousness (LOC).
Rationale: Change in LOC is the earliest and most sensitive
indicator of neurologic deterioration. Pupillary changes and
vital sign changes are later signs of increased ICP.
A patient has a GCS score of 6. How should the nurse interpret
this finding?
Correct Answer: The patient is in a comatose state.
Rationale: A GCS score of 8 or less indicates a severe head
injury and a comatose state.
,A client with a closed head injury is on mechanical ventilation.
Which intervention reduces the risk of increased ICP?
Correct Answer: Elevate HOB 30–45 degrees.
Rationale: Elevating the head of bed promotes venous
drainage from the brain, reducing ICP. Flat positioning
increases cerebral venous pressure and raises ICP.
A nurse is caring for a client with head trauma. The client's urinary
output is 300 mL over 2 hours. Which action should the nurse take
first?
Correct Answer: Check specific gravity.
Rationale: 300 mL over 2 hours is 150 mL/hr, which is above
normal (30–80 mL/hr). This may indicate diabetes insipidus
due to posterior pituitary injury. A low specific gravity
(<1.005) would confirm this. The nurse must assess before
notifying the provider.
A client with traumatic brain injury (TBI) had a peak ICP reading 12
hours ago. Now at 36 hours post-injury, the client becomes
unconscious for 1 minute. What should the nurse do first?
Correct Answer: Notify provider of increased pupil size from
7 to 10 mm.
Rationale: Pupil dilation from 7 mm to 10 mm indicates
worsening brainstem compression and imminent herniation,
which requires immediate notification.
A client admitted to the neurological ICU following an acute head
injury resulting in cerebral edema. What priority medication does
the nurse expect to administer?
, Correct Answer: Mannitol (Osmitrol).
Rationale: Mannitol is an osmotic diuretic that draws fluid
from brain tissue into the vascular space, reducing cerebral
edema and lowering ICP.
A client with a head injury has been increasingly agitated. What is
the nurse's best intervention for preventing injury?
Correct Answer: Pad the side rails of the client's bed.
Rationale: Padding side rails prevents injury from agitation
without the use of restraints, which can increase ICP.
What is the normal range for intracranial pressure (ICP) in adults?
Correct Answer: 5–15 mmHg.
Rationale: Normal ICP is 5–15 mmHg. Pressures above 20
mmHg require intervention.
Which component of the Glasgow Coma Scale assesses brainstem
function?
Correct Answer: Eye opening.
Rationale: The GCS assesses eye opening (brainstem), verbal
response (cerebral cortex), and motor response (brainstem
and cerebral cortex).
A patient with a head injury has a blood pressure of 190/100
mmHg and a heart rate of 50 bpm. What does this indicate?
Correct Answer: Cushing's triad (late sign of increased ICP).
Rationale: Cushing's triad—hypertension, bradycardia, and
irregular respirations—is a late sign of increased ICP and
indicates brainstem compression.
, The nurse is caring for a patient with an ICP monitor. Which ICP
reading requires immediate intervention?
Correct Answer: 22 mmHg.
Rationale: Normal ICP is 5–15 mmHg. Readings above 20
mmHg are considered elevated and require intervention to
prevent brain damage.
A patient with increased ICP is prescribed hyperventilation. What
is the goal of this therapy?
Correct Answer: Decrease PaCO2 to 30-35 mmHg to cause
cerebral vasoconstriction.
Rationale: Hyperventilation lowers PaCO2, which causes
cerebral vasoconstriction, reducing cerebral blood volume
and ICP. However, it should be used cautiously to avoid
cerebral ischemia.
Which position is most appropriate for a patient with increased
ICP?
Correct Answer: Head of bed elevated 30–45 degrees with
head in midline.
Rationale: Elevating the HOB promotes venous drainage.
Keeping the head in midline prevents jugular vein
compression, which can increase ICP.
A patient with a brain injury has a cerebral perfusion pressure
(CPP) of 50 mmHg. What is the nurse's priority action?
Correct Answer: Notify the provider immediately.
