ATI Medical-Surgical | Week 4 Study Guide (Neurological Conditions)
2026/2027 Questions |Answers |Rationales
1. A nurse is monitoring a client who has increased intracranial pressure (ICP).
Which of the following findings is a component of Cushing’s triad?
A. Tachycardia
B. Widened pulse pressure
C. Hypotension
D. Tachypnea
Answer: B
Rationale: Cushing’s triad is a late sign of increased ICP and consists of severe
hypertension with a widened pulse pressure, bradycardia, and irregular respirations.
2. A nurse is assessing a client for Brudzinski’s sign. Which of the following
actions should the nurse take?
A. Flex the client’s neck and observe for hip and knee flexion.
B. Flex the client’s hip and knee and then straighten the leg.
C. Stroke the lateral aspect of the foot and observe for toe fanning.
D. Apply pressure to the client’s fingernail bed and observe for withdrawal.
Answer: A
Rationale: Brudzinski’s sign is positive when neck flexion causes involuntary flexion of the
hips and knees, indicating meningeal irritation.
,3. A nurse is reviewing the cerebrospinal fluid (CSF) analysis of a client with
bacterial meningitis. Which of the following results should the nurse expect?
A. Decreased protein levels
B. Increased glucose levels
C. Increased protein levels
D. Clear and colorless appearance
Answer: C
Rationale: Bacterial meningitis typically shows CSF with increased protein, decreased
glucose, and a cloudy appearance due to the presence of WBCs and bacteria.
4. A nurse is caring for a client with a Glasgow Coma Scale (GCS) score of 7. How
should the nurse interpret this finding?
A. The client is fully awake and alert.
B. The client is in a deep coma.
C. The client is considered to have a severe head injury.
D. The client has a mild head injury.
Answer: C
Rationale: A GCS score of 8 or less is generally accepted as the definition of a coma and
indicates a severe head injury.
5. Which of the following interventions is the priority for a nurse caring for a
client immediately following a generalized tonic-clonic seizure?
A. Administering an antiepileptic medication
B. Assessing the client’s airway and breathing
C. Documenting the duration of the seizure
D. Reorienting the client to the environment
Answer: B
Rationale: Following a seizure, the post-ictal phase priority is airway, breathing, and
circulation (ABCs) to ensure the client is ventilating adequately.
, 6. A client is prescribed Phenytoin for seizure control. The nurse should instruct
the client to monitor for which of the following common side effects?
A. Gingival hyperplasia
B. Excessive salivation
C. Urinary retention
D. Hypertension
Answer: A
Rationale: Gingival hyperplasia (overgrowth of gum tissue) is a well-known side effect of
long-term phenytoin therapy; regular dental checkups are essential.
7. A nurse is caring for a client who has a spinal cord injury at the T4 level. The
client reports a sudden, severe headache and has a blood pressure of 190/100
mmHg. What is the nurse’s priority action?
A. Place the client in a high-Fowler’s position.
B. Administer an analgesic for the headache.
C. Check for a distended bladder or fecal impaction.
D. Notify the provider immediately.
Answer: A
Rationale: The client is showing signs of autonomic dysreflexia. The first priority is to sit
the client upright to help lower blood pressure via orthostatic effect, then identify/remove
the stimulus.
8. A nurse is teaching a client who has Multiple Sclerosis (MS) about managing
fatigue. Which of the following instructions should the nurse include?
A. Schedule rest periods throughout the day.
B. Take a hot bath daily to relax muscles.
C. Exercise vigorously in the afternoon.
D. Limit fluid intake to reduce bathroom trips.
Answer: A
2026/2027 Questions |Answers |Rationales
1. A nurse is monitoring a client who has increased intracranial pressure (ICP).
Which of the following findings is a component of Cushing’s triad?
A. Tachycardia
B. Widened pulse pressure
C. Hypotension
D. Tachypnea
Answer: B
Rationale: Cushing’s triad is a late sign of increased ICP and consists of severe
hypertension with a widened pulse pressure, bradycardia, and irregular respirations.
2. A nurse is assessing a client for Brudzinski’s sign. Which of the following
actions should the nurse take?
A. Flex the client’s neck and observe for hip and knee flexion.
B. Flex the client’s hip and knee and then straighten the leg.
C. Stroke the lateral aspect of the foot and observe for toe fanning.
D. Apply pressure to the client’s fingernail bed and observe for withdrawal.
Answer: A
Rationale: Brudzinski’s sign is positive when neck flexion causes involuntary flexion of the
hips and knees, indicating meningeal irritation.
,3. A nurse is reviewing the cerebrospinal fluid (CSF) analysis of a client with
bacterial meningitis. Which of the following results should the nurse expect?
A. Decreased protein levels
B. Increased glucose levels
C. Increased protein levels
D. Clear and colorless appearance
Answer: C
Rationale: Bacterial meningitis typically shows CSF with increased protein, decreased
glucose, and a cloudy appearance due to the presence of WBCs and bacteria.
4. A nurse is caring for a client with a Glasgow Coma Scale (GCS) score of 7. How
should the nurse interpret this finding?
A. The client is fully awake and alert.
B. The client is in a deep coma.
C. The client is considered to have a severe head injury.
D. The client has a mild head injury.
Answer: C
Rationale: A GCS score of 8 or less is generally accepted as the definition of a coma and
indicates a severe head injury.
5. Which of the following interventions is the priority for a nurse caring for a
client immediately following a generalized tonic-clonic seizure?
A. Administering an antiepileptic medication
B. Assessing the client’s airway and breathing
C. Documenting the duration of the seizure
D. Reorienting the client to the environment
Answer: B
Rationale: Following a seizure, the post-ictal phase priority is airway, breathing, and
circulation (ABCs) to ensure the client is ventilating adequately.
, 6. A client is prescribed Phenytoin for seizure control. The nurse should instruct
the client to monitor for which of the following common side effects?
A. Gingival hyperplasia
B. Excessive salivation
C. Urinary retention
D. Hypertension
Answer: A
Rationale: Gingival hyperplasia (overgrowth of gum tissue) is a well-known side effect of
long-term phenytoin therapy; regular dental checkups are essential.
7. A nurse is caring for a client who has a spinal cord injury at the T4 level. The
client reports a sudden, severe headache and has a blood pressure of 190/100
mmHg. What is the nurse’s priority action?
A. Place the client in a high-Fowler’s position.
B. Administer an analgesic for the headache.
C. Check for a distended bladder or fecal impaction.
D. Notify the provider immediately.
Answer: A
Rationale: The client is showing signs of autonomic dysreflexia. The first priority is to sit
the client upright to help lower blood pressure via orthostatic effect, then identify/remove
the stimulus.
8. A nurse is teaching a client who has Multiple Sclerosis (MS) about managing
fatigue. Which of the following instructions should the nurse include?
A. Schedule rest periods throughout the day.
B. Take a hot bath daily to relax muscles.
C. Exercise vigorously in the afternoon.
D. Limit fluid intake to reduce bathroom trips.
Answer: A
