NERVOUS SYSTEM ALTERATIONS (NURS 4670) EXAM WITH STANDARDIZED
REVISION QUESTIONS
MULTIPLE CHOICE
1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by
the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min,
and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not
stimulated. Which nursing action is most important to include in this patients plan of care?
a. Frequent neurological assessments
b. Side to side position changes
c. Range of motion to extremities
d. Frequent oropharyngeal suctioning
2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is
144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion
pressure (CPP)?
a. 54 mm Hg
b. 72 mm Hg
c. 90 mm Hg
d. 126 mm
Hg
3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a
CPP of 85 mm Hg. What is the best interpretation by the nurse?
a. Both pressures are high.
b. Both pressures are low.
c. ICP is high; CPP is normal.
d. ICP is high; CPP is low.
4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse
needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene
care, and reposition the patient to the left side. What is the best action by the nurse?
a. Hyperoxygenate during endotracheal suctioning.
b. Elevate the patients head of the bed 30 degrees.
c. Apply bilateral heel protectors after repositioning.
d. Provide rest periods between nursing interventions.
5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the
patients left naris. What is the best nursing action?
,a. Have the patient blow the nose until clear.
b. Insert bilateral cotton nasal packing.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears.
6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at
the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of
15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?
a. Stimulate the patient hourly.
b. Continue to monitor the patient.
c. Elevate the head of the bed.
d. Notify the physician immediately.
7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the
administration of mannitol (Osmitrol), which assessment finding by the nurse requires further
action?
a. ICP of 10 mm Hg
b. CPP of 70 mm Hg
c. GCS score of 5
d. CVP of 2 mm
Hg
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values
indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood
flow?
a. Altered cerebral spinal fluid production and reabsorption
b. Decreased cerebral blood volume due to vessel constriction
c. Increased cerebral blood volume due to vessel dilation
d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is
normal)
8. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional
vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory
rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority
nursing action?
,a. Monitor the patients airway patency.
b. Elevate the head of the patients bed.
c. Increase supplemental oxygen delivery.
d. Support bony prominences with padding.
9. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically
ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the
suction catheter. What is the best interpretation by the nurse?
a. The patient is exhibiting extension posturing.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting purposeful movement.
d. The patient is withdrawing to stimulation.
10. The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon
admission the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also
notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most
appropriate nursing action?
a. Insert bilateral ear plugs.
b. Monitor airway patency.
c. Maintain neutral head position.
d. Apply a small nasal drip pad.
11. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a
blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of
102 F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority
nursing action(s)?
a. Ensure adequate periods of rest between nursing interventions.
b. Insert an oral airway and monitor respiratory rate and depth.
c. Maintain neutral head alignment and avoid extreme hip flexion.
d. Reduce ambient room temperature and administer antipyretics.
12. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The
nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing
action?
, a. Assist the patient to the floor and provide soft head support.
b. Insert a nasogastric tube and connect to continuous wall suction.
c. Open the patients mouth and insert a padded tongue blade.
d. Restrain the patients extremities until the seizure subsides.
13. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury.
Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with
this type of injury?
a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg
b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg
c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm
Hg
14. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine
injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart
rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past
4 hours. What is the best action by the nurse?
a. Administer acetaminophen as ordered for the headache.
b. Assess for a kinked urinary catheter and assess for bowel impaction.
c. Encourage the patient to take slow, deep breaths.
d. Notify the physician of the patients blood pressure.
15. The nurse admits a patient to the emergency department with new onset of slurred speech and right-
sided weakness. What is the priority nursing action?
a. Assess for the presence of a headache.
b. Assess the patients general orientation.
c. Determine the patients drug allergies.
d. Determine the time of symptom onset.
16. Which patient being cared for in the emergency department should the charge nurse evaluate first?
a. A patient with a complete spinal injury at the C5 dermatome level
b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula
c. An alert patient with a subdural bleed who is complaining of a headache
d. An ischemic stroke patient with a blood pressure of 190/100 mm
REVISION QUESTIONS
MULTIPLE CHOICE
1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by
the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min,
and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not
stimulated. Which nursing action is most important to include in this patients plan of care?
a. Frequent neurological assessments
b. Side to side position changes
c. Range of motion to extremities
d. Frequent oropharyngeal suctioning
2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is
144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion
pressure (CPP)?
a. 54 mm Hg
b. 72 mm Hg
c. 90 mm Hg
d. 126 mm
Hg
3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a
CPP of 85 mm Hg. What is the best interpretation by the nurse?
a. Both pressures are high.
b. Both pressures are low.
c. ICP is high; CPP is normal.
d. ICP is high; CPP is low.
4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse
needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene
care, and reposition the patient to the left side. What is the best action by the nurse?
a. Hyperoxygenate during endotracheal suctioning.
b. Elevate the patients head of the bed 30 degrees.
c. Apply bilateral heel protectors after repositioning.
d. Provide rest periods between nursing interventions.
5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the
patients left naris. What is the best nursing action?
,a. Have the patient blow the nose until clear.
b. Insert bilateral cotton nasal packing.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears.
6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at
the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of
15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?
a. Stimulate the patient hourly.
b. Continue to monitor the patient.
c. Elevate the head of the bed.
d. Notify the physician immediately.
7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the
administration of mannitol (Osmitrol), which assessment finding by the nurse requires further
action?
a. ICP of 10 mm Hg
b. CPP of 70 mm Hg
c. GCS score of 5
d. CVP of 2 mm
Hg
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values
indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood
flow?
a. Altered cerebral spinal fluid production and reabsorption
b. Decreased cerebral blood volume due to vessel constriction
c. Increased cerebral blood volume due to vessel dilation
d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is
normal)
8. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional
vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory
rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority
nursing action?
,a. Monitor the patients airway patency.
b. Elevate the head of the patients bed.
c. Increase supplemental oxygen delivery.
d. Support bony prominences with padding.
9. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically
ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the
suction catheter. What is the best interpretation by the nurse?
a. The patient is exhibiting extension posturing.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting purposeful movement.
d. The patient is withdrawing to stimulation.
10. The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon
admission the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also
notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most
appropriate nursing action?
a. Insert bilateral ear plugs.
b. Monitor airway patency.
c. Maintain neutral head position.
d. Apply a small nasal drip pad.
11. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a
blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of
102 F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority
nursing action(s)?
a. Ensure adequate periods of rest between nursing interventions.
b. Insert an oral airway and monitor respiratory rate and depth.
c. Maintain neutral head alignment and avoid extreme hip flexion.
d. Reduce ambient room temperature and administer antipyretics.
12. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The
nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing
action?
, a. Assist the patient to the floor and provide soft head support.
b. Insert a nasogastric tube and connect to continuous wall suction.
c. Open the patients mouth and insert a padded tongue blade.
d. Restrain the patients extremities until the seizure subsides.
13. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury.
Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with
this type of injury?
a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg
b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg
c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm
Hg
14. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine
injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart
rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past
4 hours. What is the best action by the nurse?
a. Administer acetaminophen as ordered for the headache.
b. Assess for a kinked urinary catheter and assess for bowel impaction.
c. Encourage the patient to take slow, deep breaths.
d. Notify the physician of the patients blood pressure.
15. The nurse admits a patient to the emergency department with new onset of slurred speech and right-
sided weakness. What is the priority nursing action?
a. Assess for the presence of a headache.
b. Assess the patients general orientation.
c. Determine the patients drug allergies.
d. Determine the time of symptom onset.
16. Which patient being cared for in the emergency department should the charge nurse evaluate first?
a. A patient with a complete spinal injury at the C5 dermatome level
b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula
c. An alert patient with a subdural bleed who is complaining of a headache
d. An ischemic stroke patient with a blood pressure of 190/100 mm
