Nursing 401 Critical Care
2026 | Study Guide,
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Answers, Rationales &
Exam Review
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Updated 2026 Questions and Answers
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,After a 4-year-old child undergoes craniotomy the nurse Motor function is part of a neurologic assessment and provides information about
performs a neurologic assessment that includes level of cerebral function. Blood pressure and temperature are not direct measures of
consciousness, pupillary activity, and reflex activity. What neurologic status. Head circumference provides information as to skeletal
else should the nurse include in this assessment development and brain growth, not neurologic data. A change in head
circumference as a result of increased intracranial pressure is not expected in a 4-
year-old whose cranial bones are fused.
A 12-year-old child is admitted to the hospital for Assessing the level of consciousness every hour. Evidence of a subdural
observation after sustaining a head injury. Twelve hours hemorrhage may take hours or days to develop; a diminishing level of
after the injury the child has none of the signs or symptoms consciousness is an early indication of neurological damage.
of a head injury. What is the nurse's priority intervention at
this time
What interventions should the nurse implement when Providing frequent oral care
caring for a client with syndrome of inappropriate Instituting fall risk precautions
antidiuretic hormone Monitoring for and reporting neurologic changes
The excess production of antidiuretic hormone associated with SIADH leads to
increased water reabsorption by the kidneys. Increased water reabsorption results
in decreased urinary output, increased intravascular fluid volume, serum
hypoosmolality, and dilutional hyponatremia. Because treatment includes restricting
fluids, frequent oral care is provided to increase client comfort. Fall risk precautions
are instituted to protect the client from injury that might occur as a result of
neurologic changes associated with declining serum sodium. The nurse monitors for
and reports changes in neurologic status resulting from cerebral edema and
hyponatremia. Immediate treatment goals are to restore normal fluid balance and
normal serum osmolality. Fluids are restricted to no more than 1000 mL and to no
more than 500 mL for the client with severe hyponatremia. Treatment of SIADH
includes placing the bed flat or elevating the head of the bed no more than 10
degrees. This position promotes venous return to the heart, which increases left
ventricular filling pressure. Increasing left ventricular filling pressure stimulates
osmoreceptors to send a message to the pituitary (via the hypothalamus) that
antidiuretic hormone release should be decreased.
A nurse is assessing sudden changes in the neurologic The Glasgow Coma Scale (GCS) assigns a numeric score for each of the areas of
status of different clients after an earthquake. Which client the client's neurologic status. The lower the score of the GCS, the lower the client's
should require endotracheal intubation and mechanical neurologic function. Client 3 is opening the eyes on pain, so the score is 2. The
ventilation? client shows abnormal flexion motor response, which has a score of 3, and the
verbal response is incomprehensible, scoring 2. Therefore, the total score is
2+3+2=7. A score equal to or below 8 indicates a need for endotracheal intubation
and mechanical ventilation. Client 1 will have a GCS score of 12. Client 2 will have
a GCS score of 13. Client 4 will have a GCS score of 9.
A nurse is assessing the level of consciousness of four GCS again
different clients. Which client would have the lowest
neurologic function?
The registered nurse is teaching a coworker about the care "Clients with decreased sensory perception of touch should be carefully monitored
to be taken in clients with neurologic changes associated for infection."
with aging. Which statement made by the coworker
indicates the nurse needs to intervene? Decreased sensory perception is a neurological change associated with aging.
Clients with this change should be instructed to reduce the risks associated with
falling. Therefore, the nurse should intervene to correct this misconception. All the
other statements are correct and require no follow up. Clients with an increased risk
for infections due to structural deterioration of microglia should be monitored for
infections. Clients with recent memory loss should be taught by repetition and by
using memory aids that provide recurrent alerts to facilitate retention of information.
This would help the client to learn new information and recall it when needed.
Clients with slower processing time should be provided with sufficient time to
respond to questions or directions. Allowing adequate time for processing helps
differentiate normal findings from neurologic deterioration. Clients with decreased
coordination should be instructed to hold handrails when ambulating to provide
support and prevent falls.
, For what clinical manifestations should the nurse assess a Irritability
client during the first few hours of the alcohol withdrawal? Tachycardia
Increasing anxiety
Alcohol is a central nervous system depressant; irritability and increasing anxiety
reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia is
one of the early sign of withdrawal; it results from autonomic overactivity.
Hallucinations are not early signs of alcohol withdrawal; they usually do not occur
before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of
withdrawal that may be seen during alcohol withdrawal delirium; they result from
autonomic overactivity.
The nurse is conducting a neurologic assessment on a Midbrain
client brought to the emergency room after a motor vehicle
accident. While assessing the client's response to pain, the Decorticate posturing[1][2][3] is a sign of significant deterioration in a client's
client pulls his arms upward and inward. The nurse neurologic status and is manifested by rigid flexing of elbows and wrists. This can
recognizes that this response represents an injury to what represent an injury to the midbrain. Damage to the frontal lobe would affect motor
part of the brain? function, problem solving, spontaneity, memory, language, initiation, judgment,
impulse control, and social and sexual behavior. The pons (which is part of the
brainstem) and brainstem help control breathing and heart rate, vision, hearing,
sweating, blood pressure, digestion, alertness, sleep, and sense of balance.
Damage to this area would manifest itself as abnormal responses in the above
listed areas.
A client admitted with the diagnosis of subarachnoid Vascular spasms
hemorrhage exhibits aphasia and hemiparesis. The nurse
concludes that these neurologic deficits are caused In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in
primarily by which response? turn contributes to the ischemia responsible for the neurologic deficits. The volume
of blood loss is not great enough to significantly alter the oxygen-carrying capability
of the remaining blood supply. Although prolonged ischemia may cause necrosis,
many of the manifestations of cerebral ischemia are reversed as pressure
diminishes, and there may be no permanent damage. Severe electrolyte imbalance
may cause generalized weakness; however, hemiparesis and aphasia are not the
result of electrolyte loss.
To begin the administration of total parenteral nutrition Auscultate the lungs to evaluate breath sounds.
(TPN), a client has a right subclavian central venous
access device inserted. Immediately after insertion of the The most significant and life-threatening complication of insertion of a subclavian
catheter, what is the priority nursing action? catheter is a pneumothorax because of the proximity of the subclavian vein and the
apex of the upper lobe of the lung; a client's respiratory status always is the priority.
Although a chest x-ray may be done before TPN is begun, it is not the priority
immediately after insertion of the catheter. A baseline blood glucose level should be
obtained before insertion of the catheter. After TPN is started, routine monitoring of
blood glucose levels is important. Although assessing for a neurologic deficit should
be done eventually, it is not the priority at this time.
The client's serum sodium is 123 mEq/L (123 mmol/L). Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.
Which prescription should the nurse question?
Because one-half NS is a hypotonic solution, it is contraindicated. It would actually
compound the issue instead of correcting the hyponatremia. Treatment for
hyponatremia can include restricting fluid intake and increasing sodium intake either
via oral intake or, in severe cases, intravenous fluids. The presence of
hyponatremia, as well as correction of hyponatremia if done too quickly, can cause
fluid shifts in the brain, resulting in altered mental status. Therefore it is important for
the nurse to assess for neurologic changes.
A group of clients is admitted with neurologic injury after Disability assessment is a part of the primary survey that is done to assess the level
hiking at high altitude. The nurse is assessing using the of consciousness that may occur due to a neurologic injury. In the mnemonic "
"AVPU" mnemonic. Which type of emergency assessment AVPU," A indicates alert, V indicates response to voice, P stands for response to
is the nurse performing? pain, and U indicates unresponsive. Exposure assessment is one of the priorities of
a primary survey, which involves removing clothing for a complete assessment and
preventing hypothermia using heat devices. Breathing assessment involves
checking breath sounds and respiratory effort. Circulation assessment is performed
in a primary survey to monitor blood pressure and pulse.
2026 | Study Guide,
Practice Questions,
Answers, Rationales &
Exam Review
| Complete Ethics Study
Guide
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,After a 4-year-old child undergoes craniotomy the nurse Motor function is part of a neurologic assessment and provides information about
performs a neurologic assessment that includes level of cerebral function. Blood pressure and temperature are not direct measures of
consciousness, pupillary activity, and reflex activity. What neurologic status. Head circumference provides information as to skeletal
else should the nurse include in this assessment development and brain growth, not neurologic data. A change in head
circumference as a result of increased intracranial pressure is not expected in a 4-
year-old whose cranial bones are fused.
A 12-year-old child is admitted to the hospital for Assessing the level of consciousness every hour. Evidence of a subdural
observation after sustaining a head injury. Twelve hours hemorrhage may take hours or days to develop; a diminishing level of
after the injury the child has none of the signs or symptoms consciousness is an early indication of neurological damage.
of a head injury. What is the nurse's priority intervention at
this time
What interventions should the nurse implement when Providing frequent oral care
caring for a client with syndrome of inappropriate Instituting fall risk precautions
antidiuretic hormone Monitoring for and reporting neurologic changes
The excess production of antidiuretic hormone associated with SIADH leads to
increased water reabsorption by the kidneys. Increased water reabsorption results
in decreased urinary output, increased intravascular fluid volume, serum
hypoosmolality, and dilutional hyponatremia. Because treatment includes restricting
fluids, frequent oral care is provided to increase client comfort. Fall risk precautions
are instituted to protect the client from injury that might occur as a result of
neurologic changes associated with declining serum sodium. The nurse monitors for
and reports changes in neurologic status resulting from cerebral edema and
hyponatremia. Immediate treatment goals are to restore normal fluid balance and
normal serum osmolality. Fluids are restricted to no more than 1000 mL and to no
more than 500 mL for the client with severe hyponatremia. Treatment of SIADH
includes placing the bed flat or elevating the head of the bed no more than 10
degrees. This position promotes venous return to the heart, which increases left
ventricular filling pressure. Increasing left ventricular filling pressure stimulates
osmoreceptors to send a message to the pituitary (via the hypothalamus) that
antidiuretic hormone release should be decreased.
A nurse is assessing sudden changes in the neurologic The Glasgow Coma Scale (GCS) assigns a numeric score for each of the areas of
status of different clients after an earthquake. Which client the client's neurologic status. The lower the score of the GCS, the lower the client's
should require endotracheal intubation and mechanical neurologic function. Client 3 is opening the eyes on pain, so the score is 2. The
ventilation? client shows abnormal flexion motor response, which has a score of 3, and the
verbal response is incomprehensible, scoring 2. Therefore, the total score is
2+3+2=7. A score equal to or below 8 indicates a need for endotracheal intubation
and mechanical ventilation. Client 1 will have a GCS score of 12. Client 2 will have
a GCS score of 13. Client 4 will have a GCS score of 9.
A nurse is assessing the level of consciousness of four GCS again
different clients. Which client would have the lowest
neurologic function?
The registered nurse is teaching a coworker about the care "Clients with decreased sensory perception of touch should be carefully monitored
to be taken in clients with neurologic changes associated for infection."
with aging. Which statement made by the coworker
indicates the nurse needs to intervene? Decreased sensory perception is a neurological change associated with aging.
Clients with this change should be instructed to reduce the risks associated with
falling. Therefore, the nurse should intervene to correct this misconception. All the
other statements are correct and require no follow up. Clients with an increased risk
for infections due to structural deterioration of microglia should be monitored for
infections. Clients with recent memory loss should be taught by repetition and by
using memory aids that provide recurrent alerts to facilitate retention of information.
This would help the client to learn new information and recall it when needed.
Clients with slower processing time should be provided with sufficient time to
respond to questions or directions. Allowing adequate time for processing helps
differentiate normal findings from neurologic deterioration. Clients with decreased
coordination should be instructed to hold handrails when ambulating to provide
support and prevent falls.
, For what clinical manifestations should the nurse assess a Irritability
client during the first few hours of the alcohol withdrawal? Tachycardia
Increasing anxiety
Alcohol is a central nervous system depressant; irritability and increasing anxiety
reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia is
one of the early sign of withdrawal; it results from autonomic overactivity.
Hallucinations are not early signs of alcohol withdrawal; they usually do not occur
before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of
withdrawal that may be seen during alcohol withdrawal delirium; they result from
autonomic overactivity.
The nurse is conducting a neurologic assessment on a Midbrain
client brought to the emergency room after a motor vehicle
accident. While assessing the client's response to pain, the Decorticate posturing[1][2][3] is a sign of significant deterioration in a client's
client pulls his arms upward and inward. The nurse neurologic status and is manifested by rigid flexing of elbows and wrists. This can
recognizes that this response represents an injury to what represent an injury to the midbrain. Damage to the frontal lobe would affect motor
part of the brain? function, problem solving, spontaneity, memory, language, initiation, judgment,
impulse control, and social and sexual behavior. The pons (which is part of the
brainstem) and brainstem help control breathing and heart rate, vision, hearing,
sweating, blood pressure, digestion, alertness, sleep, and sense of balance.
Damage to this area would manifest itself as abnormal responses in the above
listed areas.
A client admitted with the diagnosis of subarachnoid Vascular spasms
hemorrhage exhibits aphasia and hemiparesis. The nurse
concludes that these neurologic deficits are caused In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in
primarily by which response? turn contributes to the ischemia responsible for the neurologic deficits. The volume
of blood loss is not great enough to significantly alter the oxygen-carrying capability
of the remaining blood supply. Although prolonged ischemia may cause necrosis,
many of the manifestations of cerebral ischemia are reversed as pressure
diminishes, and there may be no permanent damage. Severe electrolyte imbalance
may cause generalized weakness; however, hemiparesis and aphasia are not the
result of electrolyte loss.
To begin the administration of total parenteral nutrition Auscultate the lungs to evaluate breath sounds.
(TPN), a client has a right subclavian central venous
access device inserted. Immediately after insertion of the The most significant and life-threatening complication of insertion of a subclavian
catheter, what is the priority nursing action? catheter is a pneumothorax because of the proximity of the subclavian vein and the
apex of the upper lobe of the lung; a client's respiratory status always is the priority.
Although a chest x-ray may be done before TPN is begun, it is not the priority
immediately after insertion of the catheter. A baseline blood glucose level should be
obtained before insertion of the catheter. After TPN is started, routine monitoring of
blood glucose levels is important. Although assessing for a neurologic deficit should
be done eventually, it is not the priority at this time.
The client's serum sodium is 123 mEq/L (123 mmol/L). Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.
Which prescription should the nurse question?
Because one-half NS is a hypotonic solution, it is contraindicated. It would actually
compound the issue instead of correcting the hyponatremia. Treatment for
hyponatremia can include restricting fluid intake and increasing sodium intake either
via oral intake or, in severe cases, intravenous fluids. The presence of
hyponatremia, as well as correction of hyponatremia if done too quickly, can cause
fluid shifts in the brain, resulting in altered mental status. Therefore it is important for
the nurse to assess for neurologic changes.
A group of clients is admitted with neurologic injury after Disability assessment is a part of the primary survey that is done to assess the level
hiking at high altitude. The nurse is assessing using the of consciousness that may occur due to a neurologic injury. In the mnemonic "
"AVPU" mnemonic. Which type of emergency assessment AVPU," A indicates alert, V indicates response to voice, P stands for response to
is the nurse performing? pain, and U indicates unresponsive. Exposure assessment is one of the priorities of
a primary survey, which involves removing clothing for a complete assessment and
preventing hypothermia using heat devices. Breathing assessment involves
checking breath sounds and respiratory effort. Circulation assessment is performed
in a primary survey to monitor blood pressure and pulse.
