NSG 3280 Unit 5 Neurological Practice Questions & Answers
Question
1. A patient suffered severe global ischemia following a myocardial infarction (MI).
The nurse understands that the resulting generalized brain edema is primarily due
to which cellular mechanism?
A. Increased vessel pressure causing a midline shift (vasogenic edema)
B. Cellular energy failure leading to decreased ATP and subsequent Na+
accumulation inside the cell
C. Excessive influx of water and Ca+ into the cells due to increased glutamate
D. Compression of the cerebral vessels causing secondary interstitial edema
Answer: B
Rationale: Intracellular edema (cytotoxic edema), often associated with global
ischemia (like an MI), occurs when cellular energy fails, decreasing ATP
production. This leads to Na+ accumulation within the cell, which attracts water,
causing generalized brain edema and increased ICP. Option A describes interstitial
(vasogenic) edema. Options C describes cell damage related to glutamate
following ischemia. Option D is a potential complication of severe cytotoxic
edema, not the primary mechanism.
Question 2
A patient's Intracranial Pressure (ICP) monitor reading has been consistently
above 22 mmHg for the past 10 minutes. The nurse recognizes that this finding
indicates:
A. The patient is compensating via the Monroe-Kellie doctrine, as this slight
increase is manageable.
B. Brain impairment is occurring due to sustained compression.
,C. The patient is experiencing a temporary, slight increase in ICP typical of a
sneeze or laugh.
D. The CSF component is decreasing to offset the increased pressure.
Answer: B
Rationale: Brain impairment occurs when ICP is sustained above 22 mmHg for
more than 5 minutes due to compression. While the Monroe-Kellie doctrine
explains how the brain, CSF, and blood compensate, that compliance is limited. An
ICP > 22 mmHg sustained for > 5 minutes is defined as causing impairment.
Question 3
A nurse is preparing a presentation on the Monroe-Kellie doctrine. The nurse
should include that the three main cranial components whose volume must
remain relatively constant are:
A. Brain, Neurons, and Arterial Blood
B. Brain tissue, Venous Sinuses, and CSF
C. Brain, Cerebral Spinal Fluid (CSF), and Blood
D. Dura Mater, Pia Mater, and Arachnoid Membrane
Answer: C
Rationale: The Monroe-Kellie doctrine states that the three main components of
the cranium are the brain, CSF (cerebral spinal fluid), and blood. Intracranial
compliance means if one component increases, the others must decrease to
compensate.
Question 4
A patient presents to the Emergency Department following a fall. Which finding
would the nurse recognize as the MOST sensitive indicator of increasing
intracranial pressure (ICP)?
,A. Worsening headache
B. Increased drowsiness
C. Onset of Cushing’s Triad
D. Hypotension
Answer: B
Rationale: A change in the Level of Consciousness (LOC), often manifesting as
increased drowsiness, is cited as the MOST sensitive change indicating increasing
ICP. Headache, slow pupillary response, and Cushing's Triad are also clinical
manifestations, but Cushing's Triad is usually a late sign.
Question 5 (SATA) The nurse assesses a patient and identifies Cushing's Triad. The
nurse understands this is a sympathetic nervous system reaction to increased ICP
in an attempt to maintain cerebral perfusion. Which findings are components of
Cushing’s Triad?
A. Decreased blood pressure (BP)
B. Increased respiratory rate
C. Increased systolic blood pressure (BP)
D. Decreased heart rate (HR)
E. Respiratory changes
Answer: C, D, E
Rationale: Cushing’s Triad includes increased BP, decreased HR, and respiratory
changes.
, Question 6
The nurse is performing a neurological assessment on an unresponsive patient.
Upon checking the cranial nerve reflexes, the patient exhibits fixed and dilated
pupils. The nurse should immediately conclude that this sign indicates:
A. Early pressure on Cranial Nerve (CN) III due to midbrain displacement.
B. An issue localized to the Pons.
C. The presence of significant opioid drug effects.
D. Poor brain perfusion.
Answer: D
Rationale: Fixed and dilated pupils are a clinical manifestation of poor brain
perfusion. Mild dilation with a decreased or absent response suggests increased
pressure on CN III. Small (pinpoint) pupils suggest a Pons issue or drug effects.
Question 7
When testing the Oculovestibular Reflex using the Doll’s Eyes Test, the nurse
turns the patient's head to the right. A normal response is documented if the
patient's eyes: A. Deviate toward the side of the head movement (right).
B. Stay midline, appearing "painted on".
C. Move opposite the direction of head movement (left).
D. Blinked
Answer: C
Rationale: A normal response to the Doll’s Eyes Test is for the eyes to move
opposite the direction of head movement. This adjustment allows the object
fixation on the retina even when the head is moving. An absent response is when
the eyes stay midline.
Question
1. A patient suffered severe global ischemia following a myocardial infarction (MI).
The nurse understands that the resulting generalized brain edema is primarily due
to which cellular mechanism?
A. Increased vessel pressure causing a midline shift (vasogenic edema)
B. Cellular energy failure leading to decreased ATP and subsequent Na+
accumulation inside the cell
C. Excessive influx of water and Ca+ into the cells due to increased glutamate
D. Compression of the cerebral vessels causing secondary interstitial edema
Answer: B
Rationale: Intracellular edema (cytotoxic edema), often associated with global
ischemia (like an MI), occurs when cellular energy fails, decreasing ATP
production. This leads to Na+ accumulation within the cell, which attracts water,
causing generalized brain edema and increased ICP. Option A describes interstitial
(vasogenic) edema. Options C describes cell damage related to glutamate
following ischemia. Option D is a potential complication of severe cytotoxic
edema, not the primary mechanism.
Question 2
A patient's Intracranial Pressure (ICP) monitor reading has been consistently
above 22 mmHg for the past 10 minutes. The nurse recognizes that this finding
indicates:
A. The patient is compensating via the Monroe-Kellie doctrine, as this slight
increase is manageable.
B. Brain impairment is occurring due to sustained compression.
,C. The patient is experiencing a temporary, slight increase in ICP typical of a
sneeze or laugh.
D. The CSF component is decreasing to offset the increased pressure.
Answer: B
Rationale: Brain impairment occurs when ICP is sustained above 22 mmHg for
more than 5 minutes due to compression. While the Monroe-Kellie doctrine
explains how the brain, CSF, and blood compensate, that compliance is limited. An
ICP > 22 mmHg sustained for > 5 minutes is defined as causing impairment.
Question 3
A nurse is preparing a presentation on the Monroe-Kellie doctrine. The nurse
should include that the three main cranial components whose volume must
remain relatively constant are:
A. Brain, Neurons, and Arterial Blood
B. Brain tissue, Venous Sinuses, and CSF
C. Brain, Cerebral Spinal Fluid (CSF), and Blood
D. Dura Mater, Pia Mater, and Arachnoid Membrane
Answer: C
Rationale: The Monroe-Kellie doctrine states that the three main components of
the cranium are the brain, CSF (cerebral spinal fluid), and blood. Intracranial
compliance means if one component increases, the others must decrease to
compensate.
Question 4
A patient presents to the Emergency Department following a fall. Which finding
would the nurse recognize as the MOST sensitive indicator of increasing
intracranial pressure (ICP)?
,A. Worsening headache
B. Increased drowsiness
C. Onset of Cushing’s Triad
D. Hypotension
Answer: B
Rationale: A change in the Level of Consciousness (LOC), often manifesting as
increased drowsiness, is cited as the MOST sensitive change indicating increasing
ICP. Headache, slow pupillary response, and Cushing's Triad are also clinical
manifestations, but Cushing's Triad is usually a late sign.
Question 5 (SATA) The nurse assesses a patient and identifies Cushing's Triad. The
nurse understands this is a sympathetic nervous system reaction to increased ICP
in an attempt to maintain cerebral perfusion. Which findings are components of
Cushing’s Triad?
A. Decreased blood pressure (BP)
B. Increased respiratory rate
C. Increased systolic blood pressure (BP)
D. Decreased heart rate (HR)
E. Respiratory changes
Answer: C, D, E
Rationale: Cushing’s Triad includes increased BP, decreased HR, and respiratory
changes.
, Question 6
The nurse is performing a neurological assessment on an unresponsive patient.
Upon checking the cranial nerve reflexes, the patient exhibits fixed and dilated
pupils. The nurse should immediately conclude that this sign indicates:
A. Early pressure on Cranial Nerve (CN) III due to midbrain displacement.
B. An issue localized to the Pons.
C. The presence of significant opioid drug effects.
D. Poor brain perfusion.
Answer: D
Rationale: Fixed and dilated pupils are a clinical manifestation of poor brain
perfusion. Mild dilation with a decreased or absent response suggests increased
pressure on CN III. Small (pinpoint) pupils suggest a Pons issue or drug effects.
Question 7
When testing the Oculovestibular Reflex using the Doll’s Eyes Test, the nurse
turns the patient's head to the right. A normal response is documented if the
patient's eyes: A. Deviate toward the side of the head movement (right).
B. Stay midline, appearing "painted on".
C. Move opposite the direction of head movement (left).
D. Blinked
Answer: C
Rationale: A normal response to the Doll’s Eyes Test is for the eyes to move
opposite the direction of head movement. This adjustment allows the object
fixation on the retina even when the head is moving. An absent response is when
the eyes stay midline.
