ICP/head injury NCLEX style questions and answers 2025
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the
nurse expect in this patient?
A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia - ansB
Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion,
piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock
has resolved; it does not result in vomiting, tachycardia, or third-spacing
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to
gauge what aspect of the patients status?
A) Reflex activity
B) Level of consciousness
C) Cognitive ability
D) Sensory involvement - ansB
The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response,
and best motor response.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted
to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The
nurse should gauge the patients LOC on the results of what diagnostic tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination - ansB
LOC is assessed d based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor
response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull,
an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the
,volume of the others. Cranial nerve function and the mental status examination would be part of the
neurologic examination for this patient, but would not be the priority in evaluating LOC.
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the
patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death.
These indications include which of the following?
A) Hemiplegia
B) Dry mucous membranes
C) Signs of internal bleeding
D) Loss of brain stem reflexes - ansD
Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of
approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none
of these is a common sign of impending death.
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing
assessment best addresses this complication?
A) Vigilant monitoring of fluid balance
B) Continuous BP monitoring
C) Serial arterial blood gases (ABGs)
D) Monitoring of the patients airway for patency - ansA
Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to
replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this
patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this
patient?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal muscles
D) Urinary retention related to inability to void spontaneously - ansC
, A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury
will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing
diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing
patterns.
A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse
notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should
the nurse suspect?
A) Epidural hemorrhage
B) Hypertensive emergency
C) Spinal shock
D) Hypovolemia - ansC
In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia,
hemorrhage, and hypertension do not cause this sudden change in neurologic function
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral
edema. When planning this patients care, the nurse would expect to administer what priority medication?
A) Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix)
C) Mannitol (Osmitrol)
D) Spirolactone (Aldactone) - ansC
The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts
by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and hydrochlorothiazide are
diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when
the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe
headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare
for which priority intervention?
A) Insertion of an intracranial monitoring device
B) Treatment with antihypertensives
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the
nurse expect in this patient?
A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia - ansB
Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion,
piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock
has resolved; it does not result in vomiting, tachycardia, or third-spacing
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to
gauge what aspect of the patients status?
A) Reflex activity
B) Level of consciousness
C) Cognitive ability
D) Sensory involvement - ansB
The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response,
and best motor response.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted
to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The
nurse should gauge the patients LOC on the results of what diagnostic tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination - ansB
LOC is assessed d based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor
response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull,
an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the
,volume of the others. Cranial nerve function and the mental status examination would be part of the
neurologic examination for this patient, but would not be the priority in evaluating LOC.
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the
patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death.
These indications include which of the following?
A) Hemiplegia
B) Dry mucous membranes
C) Signs of internal bleeding
D) Loss of brain stem reflexes - ansD
Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of
approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none
of these is a common sign of impending death.
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing
assessment best addresses this complication?
A) Vigilant monitoring of fluid balance
B) Continuous BP monitoring
C) Serial arterial blood gases (ABGs)
D) Monitoring of the patients airway for patency - ansA
Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to
replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this
patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this
patient?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal muscles
D) Urinary retention related to inability to void spontaneously - ansC
, A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury
will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing
diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing
patterns.
A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse
notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should
the nurse suspect?
A) Epidural hemorrhage
B) Hypertensive emergency
C) Spinal shock
D) Hypovolemia - ansC
In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia,
hemorrhage, and hypertension do not cause this sudden change in neurologic function
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral
edema. When planning this patients care, the nurse would expect to administer what priority medication?
A) Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix)
C) Mannitol (Osmitrol)
D) Spirolactone (Aldactone) - ansC
The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts
by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and hydrochlorothiazide are
diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when
the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe
headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare
for which priority intervention?
A) Insertion of an intracranial monitoring device
B) Treatment with antihypertensives
