QUESTIONS WITH CORRECT ANSWERS AND
RATIONALES
◉ B. CN II and CN III. Answer: The nurse is caring for a patient who
suffered massive head trauma, and suspected increased intracranial
pressure (ICP) from an automobile accident. Which cranial nerves are
most appropriate to check at this time?
A. CN I and CN II
B. CN II and CN III
C. CN III and CN IV
D .CN IV and CN V
◉ D. Pupil changes can be caused by pressure on the ocular nerve..
Answer: When increased ICP is suspected, the nurse performs a
complete neurologic assessment. What does the pupillary response
indicate?
A. High pressure can cause blurred vision.
B. Hemorrhage can cause visual impairment.
C. Pupil dilation is the first sign of increased ICP.
D. Pupil changes can be caused by pressure on the ocular nerve.
◉ D. Touch his nose with his left index finger.. Answer: When rating
a patient using the Glasgow Coma Scale, what would be appropriate
,for the LPN/LVN to ask the patient to do in order to test the patient's
motor response?
A. Roll his eyes in a circle.
B. Take a deep breath and exhale.
C. Describe the view from his window.
D. Touch his nose with his left index finger.
◉ A. Decreasing level of consciousness (LOC). Answer: The nurse is
assessing a patient who has a brain tumor. What assessment finding is
most indicative of increased ICP in this patient?
A. Decreasing level of consciousness (LOC)
B. Elevated temperature
C. Agitation and hostility
D. Increasing blood pressure (BP)
◉ C. "Checking this reflex assesses involuntary muscular
contractions.". Answer: The nurse is assessing the patient's patellar
reflex. The patient asks what the purpose of this exam is. Which
response by the nurse is correct?
A. "I am checking the conscious nerve response in your leg."
B. "This assessment determines your hand-eye coordination."
C. "Checking this reflex assesses involuntary muscular contractions."
D. "The patellar reflex demonstrates large voluntary muscle
coordination."
, ◉ D. Determine whether the patient is able to move his legs and arms.
Answer: The nurse is performing a "neuro check" on a patient who
has demonstrated a decreased LOC. What is the best way to assess the
patient's neuromuscular status?
A. Measure the patient's vital signs.
B. Test the reaction of the patient's pupils to light.
C. Check the patient's response to the stimulus of pinching.
D. Determine whether the patient is able to move his legs and arms
◉ B. "The procedure is safe and painless; you will hear a clicking
noise as the CT machine rotates.". Answer: A patient who is to have
computed tomography (CT scan) of the brain voices concern about
the procedure. The LPN/LVN can best allay the patient's fears by
making which statement?
A. "CT scans use only a small amount of radioactive material injected
into your brain."
B. "The procedure is safe and painless; you will hear a clicking noise
as the CT machine rotates."
C. "You will probably be given something to make you drowsy and
deaden the pain during the CT scan."
C. "CT scanning is a new procedure, and since it involves the brain, I
think the doctor can answer your questions better than I can."
◉ C. White blood cells (WBCs) 100/mm3. Answer: The nurse is
caring for a patient who has undergone a lumbar puncture in order to
run tests on the cerebrospinal fluid (CSF). The nurse knows which
laboratory value is abnormal?