NURS 251 EXAM QUESTIONS WITH VERIFIED ANSWERS
A patient with a traumatic brain injury (TBI) complains of feeling unwell with
increasing headaches and vomiting. What is your priority of care?
Notify the doctor immediately.
These manifestations may be early indicators of increased intracranial pressure which
need immediately medical assessment and intervention. Do a set of observations
including neurological observations and continue to vigilantly monitor until medical team
attends.
An unconscious patient is posturing with their arms and legs adducted and arms
hyper-pronated. What type of posture is this?
Decerebrate.
Decerebrate posturing is abnormal. Often the legs are extended straight out and the
feet are plantar flexed. It usually indicated severed damage has been done to the brain.
You are changing the sheets of a patient and notice blood tinged fluid on the
pillow slip, it appears to have a halo around it. What is this?
Cerebrospinal fluid.
This is suggestive of CSF leakage. It can further be tested against a dextrostix to see if
it reacts to glucose, this confirms CSF.
What is the most common cause of secondary brain injuries?
Ischemia.
Secondary injury is the progression of the initial injury (primary injury results from initial
impact). Ischemia is the most common cause of secondary brain injury which then leads
to cerebral hypoxia.
A patient has become unresponsive with a left side facial droop; early diagnosis
is a cerebrovascular accident (CVA). What is the priority nursing care?
Assess and maintain the airway and breathing.
, A stroke may impair patients' ability to swallow. Weakness or lack of coordination with
the tongue and deficit in swallow function may result in choking, excessive drooling,
aspiration or regurgitation.
Risk factors for stroke/CVA are:
Familial history, obesity, sedentary lifestyle, cardiovascular disease, sleep apnoea,
substance abuse, clotting disorders and arrhythmias.
What sort of stroke is the result of a blood clot blocking a large cerebral vessel?
Thrombotic stroke.
Thrombi form in large arteries that bifurcate (split) into narrower lumens. Damaged
areas of brain tissue become oedematous and necrotic. This stroke only affects 1
region of the brain.
Transient ischemic attacks (TIA) are warning signs of an ischemic thrombotic
stroke?
True.
TIA's can cause neurological deficits that could last minutes to hours. Symptoms self-
resolve usually within 24 hours. It is an early warning sign for people to alter their
lifestyle to minimise their risk factors.
The acute treatment for haemorrhagic stroke is Enoxaparin (Clexane) or Heparin?
False.
Never - the last thing you need is for the body to be unable to clot a bleed on the brain.
Intracranial bleed is a deadly complication of oral anticoagulation therapy. Consider a
patient presenting with symptoms of haemorrhagic stroke and they are on warfarin!
When caring for a patient with a spinal injury what is your priority nursing
intervention?
Preventing secondary complications of immobility and altered body functions.
It's also very important to educate the patient on what is happening and to promote self-
care. Always involve the family or support network with the patients consent.
A patient with a traumatic brain injury (TBI) complains of feeling unwell with
increasing headaches and vomiting. What is your priority of care?
Notify the doctor immediately.
These manifestations may be early indicators of increased intracranial pressure which
need immediately medical assessment and intervention. Do a set of observations
including neurological observations and continue to vigilantly monitor until medical team
attends.
An unconscious patient is posturing with their arms and legs adducted and arms
hyper-pronated. What type of posture is this?
Decerebrate.
Decerebrate posturing is abnormal. Often the legs are extended straight out and the
feet are plantar flexed. It usually indicated severed damage has been done to the brain.
You are changing the sheets of a patient and notice blood tinged fluid on the
pillow slip, it appears to have a halo around it. What is this?
Cerebrospinal fluid.
This is suggestive of CSF leakage. It can further be tested against a dextrostix to see if
it reacts to glucose, this confirms CSF.
What is the most common cause of secondary brain injuries?
Ischemia.
Secondary injury is the progression of the initial injury (primary injury results from initial
impact). Ischemia is the most common cause of secondary brain injury which then leads
to cerebral hypoxia.
A patient has become unresponsive with a left side facial droop; early diagnosis
is a cerebrovascular accident (CVA). What is the priority nursing care?
Assess and maintain the airway and breathing.
, A stroke may impair patients' ability to swallow. Weakness or lack of coordination with
the tongue and deficit in swallow function may result in choking, excessive drooling,
aspiration or regurgitation.
Risk factors for stroke/CVA are:
Familial history, obesity, sedentary lifestyle, cardiovascular disease, sleep apnoea,
substance abuse, clotting disorders and arrhythmias.
What sort of stroke is the result of a blood clot blocking a large cerebral vessel?
Thrombotic stroke.
Thrombi form in large arteries that bifurcate (split) into narrower lumens. Damaged
areas of brain tissue become oedematous and necrotic. This stroke only affects 1
region of the brain.
Transient ischemic attacks (TIA) are warning signs of an ischemic thrombotic
stroke?
True.
TIA's can cause neurological deficits that could last minutes to hours. Symptoms self-
resolve usually within 24 hours. It is an early warning sign for people to alter their
lifestyle to minimise their risk factors.
The acute treatment for haemorrhagic stroke is Enoxaparin (Clexane) or Heparin?
False.
Never - the last thing you need is for the body to be unable to clot a bleed on the brain.
Intracranial bleed is a deadly complication of oral anticoagulation therapy. Consider a
patient presenting with symptoms of haemorrhagic stroke and they are on warfarin!
When caring for a patient with a spinal injury what is your priority nursing
intervention?
Preventing secondary complications of immobility and altered body functions.
It's also very important to educate the patient on what is happening and to promote self-
care. Always involve the family or support network with the patients consent.
