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Neurological Questions and Correct
Answers/ Latest Update / Already Graded
The nurse is assessing the motor function of an unconscious client.
The nurse should plan to use which technique to test the client's
peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle
Ans: 2. Nail bed pressure
Motor testing in the unconscious client can be done onl y by
testing response to painful stimuli. Nail bed pressure tests a
basic peripheral response. Cerebral responses to pain are tested
using a sternal rub, placing upward pressure on the orbital rim,
or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is caring for the client with increased intracranial pressure.
The nurse would note which trend in vital signs if the intracranial
pressure is rising?
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1. Increasing temperature, increasing pulse, increasing respirations,
decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations,
decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure
Ans: 2. Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure
A change in vital signs may be a late sign of increa sed
intracranial pressure. Trends include increasing temperature
and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may occur.
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations
in intracranial pressure if the nurse observes the client doing which
activity?
1. Blowing the nose
2. Isometric exercises
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3. Coughing vigorously
4. Exhaling during repositioning
Ans: 4. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal
pressures cause an indirect elevation of the intracranial
pressure. Some of these activities include isometric exercises,
Valsalva's maneuver, coughing, sneezing, and blow ing the nose.
Exhaling during activities such as repositioning or pulling up in
bed, opens the glottis, which prevents intrathoracic pressure
from rising.
A client has clear fluid leaking from the nose following a basilar skull
fracture. Which finding would alert the nurse that cerebrospinal fluid is
present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose.
Ans: 4. Fluid separates into concentric rings and tests positive
for glucose.
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Leakage of cerebrospinal fluid (CSF) from the ears or nose may
accompany basilar skull fracture. CSF can be distinguished fro m
other body fluids because the drainage will separate into
bloody and yellow concentric rings on dressing material, called
a halo sign. The fluid also tests positive for glucose.
A client with a spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse should avoid which measure to minimize the risk
of occurrence?
1. Strict adherence to a bowel retraining program
2. Keeping the linen wrinkle-free under the client
3. Preventing unnecessary pressure on the lower limbs
4. Limiting bladder catheterization to once every 12 hours
Ans: 4. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a
distended bladder. Straight catheterization should be done
every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and Foley catheters should be checked frequently
to prevent kinks in the tubing. Constipation and fecal impaction
are other causes, so maintaining bowel regularity is important.
Other causes include stimulation of the skin from tactile,
All rights reserved © 2025/ 2026 |
Neurological Questions and Correct
Answers/ Latest Update / Already Graded
The nurse is assessing the motor function of an unconscious client.
The nurse should plan to use which technique to test the client's
peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle
Ans: 2. Nail bed pressure
Motor testing in the unconscious client can be done onl y by
testing response to painful stimuli. Nail bed pressure tests a
basic peripheral response. Cerebral responses to pain are tested
using a sternal rub, placing upward pressure on the orbital rim,
or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is caring for the client with increased intracranial pressure.
The nurse would note which trend in vital signs if the intracranial
pressure is rising?
All rights reserved © 2025/ 2026 |
, Page |2
1. Increasing temperature, increasing pulse, increasing respirations,
decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations,
decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure
Ans: 2. Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure
A change in vital signs may be a late sign of increa sed
intracranial pressure. Trends include increasing temperature
and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may occur.
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations
in intracranial pressure if the nurse observes the client doing which
activity?
1. Blowing the nose
2. Isometric exercises
All rights reserved © 2025/ 2026 |
, Page |3
3. Coughing vigorously
4. Exhaling during repositioning
Ans: 4. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal
pressures cause an indirect elevation of the intracranial
pressure. Some of these activities include isometric exercises,
Valsalva's maneuver, coughing, sneezing, and blow ing the nose.
Exhaling during activities such as repositioning or pulling up in
bed, opens the glottis, which prevents intrathoracic pressure
from rising.
A client has clear fluid leaking from the nose following a basilar skull
fracture. Which finding would alert the nurse that cerebrospinal fluid is
present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose.
Ans: 4. Fluid separates into concentric rings and tests positive
for glucose.
All rights reserved © 2025/ 2026 |
, Page |4
Leakage of cerebrospinal fluid (CSF) from the ears or nose may
accompany basilar skull fracture. CSF can be distinguished fro m
other body fluids because the drainage will separate into
bloody and yellow concentric rings on dressing material, called
a halo sign. The fluid also tests positive for glucose.
A client with a spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse should avoid which measure to minimize the risk
of occurrence?
1. Strict adherence to a bowel retraining program
2. Keeping the linen wrinkle-free under the client
3. Preventing unnecessary pressure on the lower limbs
4. Limiting bladder catheterization to once every 12 hours
Ans: 4. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a
distended bladder. Straight catheterization should be done
every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and Foley catheters should be checked frequently
to prevent kinks in the tubing. Constipation and fecal impaction
are other causes, so maintaining bowel regularity is important.
Other causes include stimulation of the skin from tactile,
All rights reserved © 2025/ 2026 |
