1) The school nurse has been called to the football field where player is immobile on the field after landing
awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
*a) Ensure that the player is not moved.
b) Obtain the player's vital signs, if possible.
c) Perform a rapid assessment of the player's range of motion.
d) Assess the player's reflexes.
~ At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck
maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over
determining the patient's vital signs. It would be inappropriate to test ROM or reflexes.
2) The nurse recognizes that a patient with a spinal cord injury (SCI) is at risk for muscle spasticity. How can the
nurse best prevent this complication of an SCI?
a) ensure adequate hydration and keep wrinkle free bed linen
b) support the knees with a pillow when the patient is in bed
*c) perform passive range of motion exercises as ordered
d) administer low dose anticoagulant
~ Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose.
Pillows and sitting upright do not directly address the patient's risk of muscle spasticity. Anticoagulant will not
address spasticity.
Passive range-of-motion exercises and frequent turning and repositioning are helpful, because stiffness tends to
increase spasticity.
3) The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why
autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?
*a) “The sudden increase in blood pressure can rupture a cerebral blood vessel.”
b) “The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state.”
c) “Autonomic dysreflexia causes permanent or temporary damage to delicate nerve fibers that are healing.”
d) “The sudden, severe headache increases muscle tone and can cause further nerve damage.”
~ The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP.
Autonomic dysreflexia does not directly cause nerve damage.
4) The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of
what are the cardinal signs of brain death? Select all that apply.
a) Absence of verbal response
*b) Apnea
*c) Coma
*d) Absence of brain stem reflexes(only 1 answer not a SATA)
e) Absence of deep tendon reflexes
~ The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes,
and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death. When
a patient has sustained a severe head injury incompatible with life, the patient is a potential organ donor. The nurse
may assist in the clinical examination for determination of brain death and in the process of organ procurement.
Adjunctive tests, such as cerebral blood flow studies, electroencephalogram (EEG), transcranial Doppler, and
brainstem auditory-evoked potential, are often used to confirm brain death. The health care team provides
information to the family and assists them with the decision-making process about end-of-life care.
5) The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury.
Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain
compression, increased ICP and causing possible brain stem damage?
*a) Hyperthermia
b) Absent bowel sounds
c) Hypotension
d) Decreased urine output
,~ Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening
pulse pressure. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic
demands of the brain and may indicate brain stem damage. The bradycardia, hypertension, and bradypnea
associated with this deterioration are known as Cushing’s triad, which is a grave sign. At this point, herniation of
the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated. Preventing a
temperature elevation is critical, because fever increases cerebral metabolism and the rate at which cerebral edema
forms.
6) The emergency room nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at
home. What physical assessment finding is suggestive of a basilar skull fracture?
a) Bradycardia
b) Grey Turner's sign
*c) Battle's sign changed to periorbital ecchymosis
d) Unilateral facial numbness
~ An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture.
Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.
7) Paramedics have brought an intubated patient to the emergency department following a head injury due to
acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Which of the following is most
appropriate nursing intervention the nurse would include in the plan of care?
a) Keep the head of the bed (HOB) flat at all times.
b) Teach the patient to perform the Valsalva maneuver.
*c) Administer benzodiazepines as prescribed.
d) Perform oral care every 8 hour shift.
~ If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do
not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited
basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes
increased ICP.
8) A patient with spinal cord injury has a nursing diagnosis of impaired mobility. The nurse recognizes the increased
risk of developing deep vein thrombosis (DVT). Which of the following would be included most appropriate
nursing intervention to prevent a DVT from occurring?
a) Placing the patient on a fluid restriction as ordered
*b) Initiating anticoagulation within 72 hours of injury as ordered
c) Administering an antifibrinolyic agent as ordered
d) Monitoring vital signs and accurate intake and output
~ It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility.
Anticoagulation should be initiated within 72 hours of injury and continued for at least 3 months. The use of lmw
heparin or low-dose unfractionated heparin may be followed by long-term oral anticoagulation (warfarin).
Additional measures such as range-of-motion exercises, antiembolism stockings, and adequate hydration are
important preventive measures.
9) A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
*a) Flaccid extremities
b) Positive Babinski's reflex
c) Diarrhea
d) Spasticity of arms and legs
~ During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are
absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski's
reflex, hyperreflexia, and spasticity of all four extremities.
10) A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4.
When developing the plan of care, what aspect of the patient's neurologic and functional status should the nurse
consider?
, a) The patient will be unable to use an electric wheelchair.
b) The patient will be unable to swallow food.
c) The patient will be continent of urine, but incontinent of bowel.
*d) The patient will require full assistance for all aspects of elimination.
~ Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but is able to
swallow. The patient will be capable of using an electric wheelchair.
11) When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible
secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing
interventions would the nurse most likely initiate if the patient developed SIADH?
*a) Fluid restriction
b) Transfusion of platelets
c) Transfusion of fresh frozen plasma (FFP)
d) Electrolyte restriction
~ The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH
requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.
12) What should the nurse suspect when hourly assessment on a patient postcraniotomy exhibits a urine output from
a catheter of 1,500 mL for two consecutive hours?
a) Cushing syndrome with hyponatremia
b) Syndrome of inappropriate antidiuretic hormone (SIADH) with decreased serum osmolarity
c) Adrenal crisis with hyperglycemia
*d) Diabetes insipidus with decreased urine specific gravity
~ Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery.
Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the
result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum
sodium concentration becomes dilute.
13) The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in
this patient's treatment?
a) Computed tomography (CT) scan
*b) Lumbar puncture
c) Magnetic resonance imaging (MRI)
d) Venous Doppler studies
~ A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal of fluid
and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT,
MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.
14) The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the
nurse's first action when assessing this patient?
*a) Assessing the patient's verbal response
b) Assessing the patient's ability to follow complex commands
c) Assessing the patient's judgment
d) Assessing the patient's response to pain
~ Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining
the patient's orientation to time, person, and place. In most cases, this assessment will precede each of the other
listed assessments, even though each may be indicated.
15) The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care,
the nurse identifies a diagnosis of “deficient fluid volume related to fluid restriction and osmotic diuretic use.” What
would be an appropriate intervention for this diagnosis?
a) Keep the head of bed at 30 degree.
*b) Monitor serum electrolytes and osmolality.
c) Maintain NPO status.
awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
*a) Ensure that the player is not moved.
b) Obtain the player's vital signs, if possible.
c) Perform a rapid assessment of the player's range of motion.
d) Assess the player's reflexes.
~ At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck
maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over
determining the patient's vital signs. It would be inappropriate to test ROM or reflexes.
2) The nurse recognizes that a patient with a spinal cord injury (SCI) is at risk for muscle spasticity. How can the
nurse best prevent this complication of an SCI?
a) ensure adequate hydration and keep wrinkle free bed linen
b) support the knees with a pillow when the patient is in bed
*c) perform passive range of motion exercises as ordered
d) administer low dose anticoagulant
~ Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose.
Pillows and sitting upright do not directly address the patient's risk of muscle spasticity. Anticoagulant will not
address spasticity.
Passive range-of-motion exercises and frequent turning and repositioning are helpful, because stiffness tends to
increase spasticity.
3) The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why
autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?
*a) “The sudden increase in blood pressure can rupture a cerebral blood vessel.”
b) “The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state.”
c) “Autonomic dysreflexia causes permanent or temporary damage to delicate nerve fibers that are healing.”
d) “The sudden, severe headache increases muscle tone and can cause further nerve damage.”
~ The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP.
Autonomic dysreflexia does not directly cause nerve damage.
4) The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of
what are the cardinal signs of brain death? Select all that apply.
a) Absence of verbal response
*b) Apnea
*c) Coma
*d) Absence of brain stem reflexes(only 1 answer not a SATA)
e) Absence of deep tendon reflexes
~ The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes,
and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death. When
a patient has sustained a severe head injury incompatible with life, the patient is a potential organ donor. The nurse
may assist in the clinical examination for determination of brain death and in the process of organ procurement.
Adjunctive tests, such as cerebral blood flow studies, electroencephalogram (EEG), transcranial Doppler, and
brainstem auditory-evoked potential, are often used to confirm brain death. The health care team provides
information to the family and assists them with the decision-making process about end-of-life care.
5) The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury.
Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain
compression, increased ICP and causing possible brain stem damage?
*a) Hyperthermia
b) Absent bowel sounds
c) Hypotension
d) Decreased urine output
,~ Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening
pulse pressure. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic
demands of the brain and may indicate brain stem damage. The bradycardia, hypertension, and bradypnea
associated with this deterioration are known as Cushing’s triad, which is a grave sign. At this point, herniation of
the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated. Preventing a
temperature elevation is critical, because fever increases cerebral metabolism and the rate at which cerebral edema
forms.
6) The emergency room nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at
home. What physical assessment finding is suggestive of a basilar skull fracture?
a) Bradycardia
b) Grey Turner's sign
*c) Battle's sign changed to periorbital ecchymosis
d) Unilateral facial numbness
~ An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture.
Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.
7) Paramedics have brought an intubated patient to the emergency department following a head injury due to
acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Which of the following is most
appropriate nursing intervention the nurse would include in the plan of care?
a) Keep the head of the bed (HOB) flat at all times.
b) Teach the patient to perform the Valsalva maneuver.
*c) Administer benzodiazepines as prescribed.
d) Perform oral care every 8 hour shift.
~ If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do
not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited
basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes
increased ICP.
8) A patient with spinal cord injury has a nursing diagnosis of impaired mobility. The nurse recognizes the increased
risk of developing deep vein thrombosis (DVT). Which of the following would be included most appropriate
nursing intervention to prevent a DVT from occurring?
a) Placing the patient on a fluid restriction as ordered
*b) Initiating anticoagulation within 72 hours of injury as ordered
c) Administering an antifibrinolyic agent as ordered
d) Monitoring vital signs and accurate intake and output
~ It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility.
Anticoagulation should be initiated within 72 hours of injury and continued for at least 3 months. The use of lmw
heparin or low-dose unfractionated heparin may be followed by long-term oral anticoagulation (warfarin).
Additional measures such as range-of-motion exercises, antiembolism stockings, and adequate hydration are
important preventive measures.
9) A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
*a) Flaccid extremities
b) Positive Babinski's reflex
c) Diarrhea
d) Spasticity of arms and legs
~ During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are
absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski's
reflex, hyperreflexia, and spasticity of all four extremities.
10) A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4.
When developing the plan of care, what aspect of the patient's neurologic and functional status should the nurse
consider?
, a) The patient will be unable to use an electric wheelchair.
b) The patient will be unable to swallow food.
c) The patient will be continent of urine, but incontinent of bowel.
*d) The patient will require full assistance for all aspects of elimination.
~ Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but is able to
swallow. The patient will be capable of using an electric wheelchair.
11) When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible
secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing
interventions would the nurse most likely initiate if the patient developed SIADH?
*a) Fluid restriction
b) Transfusion of platelets
c) Transfusion of fresh frozen plasma (FFP)
d) Electrolyte restriction
~ The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH
requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.
12) What should the nurse suspect when hourly assessment on a patient postcraniotomy exhibits a urine output from
a catheter of 1,500 mL for two consecutive hours?
a) Cushing syndrome with hyponatremia
b) Syndrome of inappropriate antidiuretic hormone (SIADH) with decreased serum osmolarity
c) Adrenal crisis with hyperglycemia
*d) Diabetes insipidus with decreased urine specific gravity
~ Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery.
Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the
result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum
sodium concentration becomes dilute.
13) The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in
this patient's treatment?
a) Computed tomography (CT) scan
*b) Lumbar puncture
c) Magnetic resonance imaging (MRI)
d) Venous Doppler studies
~ A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal of fluid
and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT,
MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.
14) The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the
nurse's first action when assessing this patient?
*a) Assessing the patient's verbal response
b) Assessing the patient's ability to follow complex commands
c) Assessing the patient's judgment
d) Assessing the patient's response to pain
~ Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining
the patient's orientation to time, person, and place. In most cases, this assessment will precede each of the other
listed assessments, even though each may be indicated.
15) The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care,
the nurse identifies a diagnosis of “deficient fluid volume related to fluid restriction and osmotic diuretic use.” What
would be an appropriate intervention for this diagnosis?
a) Keep the head of bed at 30 degree.
*b) Monitor serum electrolytes and osmolality.
c) Maintain NPO status.
