253 - NEURO QUESTIONS (51-100 WITH
RATIONALES AND STRATEGIES) EXAM
COMPREHENSIVE QUESTIONS AND
CORRECT ANSWERS!!
The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which
client complaint would indicate the need to notify the health care provider (HCP)?
1.Backache
2.Headache
3.Neck stiffness
4.Feelings of fatigue - ANSWER - 3.
Headache is relatively common after the procedure, but neck stiffness, especially on flexion,
and pain should be reported because they signal meningeal irritation. The client also is
monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors,
and hallucinations. Feelings of fatigue may be normal, and back discomfort may be owing to the
positions required for the procedure.
*Focus on the subject, the finding indicating the need to notify the HCP. Recalling that
meningeal irritation is a complication and that neck stiffness is a characteristic sign will direct
you to the correct option.
The nurse caring for a client with a head injury is monitoring for signs of increased intracranial
pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal
fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of
which condition?
1.Normal condition
2.Increased pressure
3.Borderline situation
4.Compensating condition - ANSWER - 1.
,The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal
range.
*Focus on the subject, normal intracranial pressure. Knowledge about normal intracranial
pressure is needed to answer this question. Recalling that the normal pressure is 5 to 10 mm Hg
will direct you to the correct option.
The nurse in the neurological unit is monitoring a client for signs of increased intracranial
pressure (ICP). The nurse reviews the assessment findings for the client and notes
documentation of the presence of Cushing's reflex. The nurse determines that the presence of
this reflex is obtained by assessing which item?
1.Blood pressure
2.Motor response
3.Pupillary response
4.Level of consciousness - ANSWER - 1.
Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic
pressure rises faster than diastolic pressure) and bradycardia. Options 2, 3, and 4 are unrelated
to monitoring for Cushing's reflex.
* Use knowledge regarding Cushing's reflex and the ABCs-airway, breathing, and circulation-to
assist in directing you to the correct option.
The nurse is assisting the neurologist in performing an assessment on a client who is
unconscious after sustaining a head injury. The nurse understands that the neurologist would
avoid performing the oculocephalic response (doll's-eyes maneuver) if which condition is
present in the client?
1.Dilated pupils
2.Lumbar trauma
3.A cervical cord injury
4.Altered level of consciousness - ANSWER - 3.
In an unconscious client, eye movements are an indication of brainstem activity and are tested
by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the
opposite direction when the head is turned. Abnormal responses include movement of the eyes
in the same direction as that for the head and maintenance of a midline position of the eyes
, when the head is turned. An abnormal response indicates a disruption in the processing of
information through the brainstem. Contraindications to performing this test include cervical-
level spinal cord injuries and severely increased intracranial pressure.
* Focus on the subject, contraindication to performing the oculocephalic response. Visualize
this maneuver and recall that with a cervical injury, the head is not turned but maintained in a
midline position.
The nurse is performing the oculocephalic response (doll's-eyes maneuver) test on an
unconscious client. The nurse turns the client's head and notes movement of the eyes in the
same direction as for the head. How should the nurse document these findings?
1.Normal
2.Abnormal
3.Insignificant
4.Inconclusive - ANSWER - 2.
In an unconscious client, eye movements are an indication of brainstem activity and are tested
by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the
opposite direction when the head is turned. Abnormal responses include movement of the eyes
in the same direction as for the head and maintenance of a midline position of the eyes when
the head is turned. An abnormal response indicates a disruption in the processing of
information through the brainstem.
* Eliminate options 3 and 4 first because they are comparable or alike findings. Regarding the
remaining choices, it is necessary to know that the assessment finding noted in the question is
an abnormal response.
The nurse is performing a neurological assessment on a client and is assessing the function of
cranial nerves III, IV, and VI. Assessment of which aspect of function by the nurse will yield the
best information about these cranial nerves?
1.Eye movements
2.Response to verbal stimuli
3.Affect, feelings, or emotions
4.Insight, judgment, and planning - ANSWER - 1.
RATIONALES AND STRATEGIES) EXAM
COMPREHENSIVE QUESTIONS AND
CORRECT ANSWERS!!
The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which
client complaint would indicate the need to notify the health care provider (HCP)?
1.Backache
2.Headache
3.Neck stiffness
4.Feelings of fatigue - ANSWER - 3.
Headache is relatively common after the procedure, but neck stiffness, especially on flexion,
and pain should be reported because they signal meningeal irritation. The client also is
monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors,
and hallucinations. Feelings of fatigue may be normal, and back discomfort may be owing to the
positions required for the procedure.
*Focus on the subject, the finding indicating the need to notify the HCP. Recalling that
meningeal irritation is a complication and that neck stiffness is a characteristic sign will direct
you to the correct option.
The nurse caring for a client with a head injury is monitoring for signs of increased intracranial
pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal
fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of
which condition?
1.Normal condition
2.Increased pressure
3.Borderline situation
4.Compensating condition - ANSWER - 1.
,The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal
range.
*Focus on the subject, normal intracranial pressure. Knowledge about normal intracranial
pressure is needed to answer this question. Recalling that the normal pressure is 5 to 10 mm Hg
will direct you to the correct option.
The nurse in the neurological unit is monitoring a client for signs of increased intracranial
pressure (ICP). The nurse reviews the assessment findings for the client and notes
documentation of the presence of Cushing's reflex. The nurse determines that the presence of
this reflex is obtained by assessing which item?
1.Blood pressure
2.Motor response
3.Pupillary response
4.Level of consciousness - ANSWER - 1.
Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic
pressure rises faster than diastolic pressure) and bradycardia. Options 2, 3, and 4 are unrelated
to monitoring for Cushing's reflex.
* Use knowledge regarding Cushing's reflex and the ABCs-airway, breathing, and circulation-to
assist in directing you to the correct option.
The nurse is assisting the neurologist in performing an assessment on a client who is
unconscious after sustaining a head injury. The nurse understands that the neurologist would
avoid performing the oculocephalic response (doll's-eyes maneuver) if which condition is
present in the client?
1.Dilated pupils
2.Lumbar trauma
3.A cervical cord injury
4.Altered level of consciousness - ANSWER - 3.
In an unconscious client, eye movements are an indication of brainstem activity and are tested
by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the
opposite direction when the head is turned. Abnormal responses include movement of the eyes
in the same direction as that for the head and maintenance of a midline position of the eyes
, when the head is turned. An abnormal response indicates a disruption in the processing of
information through the brainstem. Contraindications to performing this test include cervical-
level spinal cord injuries and severely increased intracranial pressure.
* Focus on the subject, contraindication to performing the oculocephalic response. Visualize
this maneuver and recall that with a cervical injury, the head is not turned but maintained in a
midline position.
The nurse is performing the oculocephalic response (doll's-eyes maneuver) test on an
unconscious client. The nurse turns the client's head and notes movement of the eyes in the
same direction as for the head. How should the nurse document these findings?
1.Normal
2.Abnormal
3.Insignificant
4.Inconclusive - ANSWER - 2.
In an unconscious client, eye movements are an indication of brainstem activity and are tested
by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the
opposite direction when the head is turned. Abnormal responses include movement of the eyes
in the same direction as for the head and maintenance of a midline position of the eyes when
the head is turned. An abnormal response indicates a disruption in the processing of
information through the brainstem.
* Eliminate options 3 and 4 first because they are comparable or alike findings. Regarding the
remaining choices, it is necessary to know that the assessment finding noted in the question is
an abnormal response.
The nurse is performing a neurological assessment on a client and is assessing the function of
cranial nerves III, IV, and VI. Assessment of which aspect of function by the nurse will yield the
best information about these cranial nerves?
1.Eye movements
2.Response to verbal stimuli
3.Affect, feelings, or emotions
4.Insight, judgment, and planning - ANSWER - 1.
