NSG 4100 FINAL EXAM
Section 1: Neurological Emergencies (Increased ICP & Traumatic Brain
Injury)
1. A patient is admitted with a traumatic brain injury (TBI). The nurse
assesses a Glasgow Coma Scale (GCS) score of 12 (Eye opening to pain,
Confused conversation, Obeys commands). Two hours later, the patient’s
pupils are fixed and dilated. What is the priority nursing action?
a) Administer Mannitol as prescribed
b) Reassess the GCS in 15 minutes
c) Document the findings as a normal progression
d) Lower the head of the bed to 0 degrees
Correct Answer: a) Administer Mannitol as prescribed
Rationale: A GCS drop coupled with pupillary changes (fixed/dilated)
indicates increased intracranial pressure (ICP) and potential uncal herniation.
Mannitol is an osmotic diuretic used to reduce cerebral edema. Lowering the head
of bed (HOB) would increase ICP . This is a medical emergency requiring
immediate intervention, not just reassessment.
2. The nurse is caring for a patient at risk for increased ICP. Which
positioning intervention is most appropriate?
a) Supine with head of bed flat to promote perfusion
b) Lateral position with head turned to the side to facilitate oral suctioning
c) Semi-Fowlers (30-45 degrees) with head maintained in a midline neutral
position
d) Trendelenburg position to enhance venous return
Correct Answer: c) Semi-Fowlers (30-45 degrees) with head maintained in a
midline neutral position
Rationale: Semi-Fowlers positioning promotes venous drainage from the brain,
reducing ICP . Keeping the head in a midline neutral position prevents jugular
compression, which would impede outflow and raise ICP. Extreme head rotation or
flat positioning is contraindicated .
,3. A patient with a closed head injury suddenly develops a widened pulse
pressure, bradycardia, and irregular respirations. The nurse recognizes this
as:
a) Neurogenic shock
b) Cushing’s Triad
c) Spinal shock
d) Autonomic Dysreflexia
Correct Answer: b) Cushing’s Triad
Rationale: Cushing’s Triad (hypertension with widened pulse pressure,
bradycardia, and irregular respirations) is a late, ominous sign of increased ICP
indicating brainstem compression . It requires immediate intervention to prevent
herniation.
4. The nurse is assessing a patient who sustained a head injury in a motorcycle
accident. Initially, the patient was decorticate. Now, the patient extends the
upper and lower extremities in response to painful stimuli. What does this
change indicate?
a) Improved neurological status
b) Development of a spinal cord injury
c) Worsening ICP and brainstem involvement
d) A normal response to painful stimuli
Correct Answer: c) Worsening ICP and brainstem involvement
Rationale: Decorticate posturing (flexion) indicates damage to the cerebral
hemispheres. Progression to decerebrate posturing (extension) indicates
deterioration and damage to the midbrain/brainstem . This is a sign of worsening
ICP and requires immediate intervention.
5. A patient is 4 hours post-craniotomy. The blood pressure changes from
130/70 to 142/72, and the patient is becoming restless. Which statement is true
regarding this scenario?
a) This indicates a developing complication
b) This is expected post-operative pain
c) The nurse should increase the head of bed
d) The nurse should administer a sedative immediately
Correct Answer: a) This indicates a developing complication
Rationale: Post-craniotomy, increasing blood pressure and restlessness can indicate
rising ICP or potential intracranial hemorrhage . While pain can cause restlessness,
, the change in BP warrants immediate notification of the provider rather than
independent administration of sedatives which could mask neurological
assessment.
6. An elderly man with a TBI fell off a ladder yesterday. The nurse assesses
swelling of the optic nerve (papilledema). What does this finding indicate?
a) A worsening condition related to increased ICP
b) An allergic reaction to the pain medication
c) A pre-existing ocular condition
d) Improvement in cerebral perfusion
Correct Answer: a) A worsening condition related to increased ICP
Rationale: Papilledema (swelling of the optic disc) is a direct sign of increased
intracranial pressure transmitted through the optic nerve sheath . It is a late sign
and indicates sustained high pressure.
Section 2: Seizure Disorders & Status Epilepticus
7. A patient is admitted with a brain abscess. The nurse understands that the
most common causative organisms of brain abscesses are:
a) Viruses
b) Fungi
c) Parasites
d) Bacteria
Correct Answer: d) Bacteria
Rationale: While viral encephalitis is common, brain abscesses are most
frequently caused by bacterial pathogens (such
as Streptococcus and Staphylococcus) that spread from contiguous sites (ears,
sinuses) or via hematogenous spread . The statement "viruses are the most
common" regarding brain abscesses is false .
8. A patient with a seizure disorder is brought to the emergency department in
active convulsive status epilepticus. What is the nurse’s priority intervention?
a) Establish IV access and administer lorazepam
b) Place a tongue blade in the mouth to prevent aspiration
c) Obtain a stat CT scan
d) Restrain the patient to prevent injury
Section 1: Neurological Emergencies (Increased ICP & Traumatic Brain
Injury)
1. A patient is admitted with a traumatic brain injury (TBI). The nurse
assesses a Glasgow Coma Scale (GCS) score of 12 (Eye opening to pain,
Confused conversation, Obeys commands). Two hours later, the patient’s
pupils are fixed and dilated. What is the priority nursing action?
a) Administer Mannitol as prescribed
b) Reassess the GCS in 15 minutes
c) Document the findings as a normal progression
d) Lower the head of the bed to 0 degrees
Correct Answer: a) Administer Mannitol as prescribed
Rationale: A GCS drop coupled with pupillary changes (fixed/dilated)
indicates increased intracranial pressure (ICP) and potential uncal herniation.
Mannitol is an osmotic diuretic used to reduce cerebral edema. Lowering the head
of bed (HOB) would increase ICP . This is a medical emergency requiring
immediate intervention, not just reassessment.
2. The nurse is caring for a patient at risk for increased ICP. Which
positioning intervention is most appropriate?
a) Supine with head of bed flat to promote perfusion
b) Lateral position with head turned to the side to facilitate oral suctioning
c) Semi-Fowlers (30-45 degrees) with head maintained in a midline neutral
position
d) Trendelenburg position to enhance venous return
Correct Answer: c) Semi-Fowlers (30-45 degrees) with head maintained in a
midline neutral position
Rationale: Semi-Fowlers positioning promotes venous drainage from the brain,
reducing ICP . Keeping the head in a midline neutral position prevents jugular
compression, which would impede outflow and raise ICP. Extreme head rotation or
flat positioning is contraindicated .
,3. A patient with a closed head injury suddenly develops a widened pulse
pressure, bradycardia, and irregular respirations. The nurse recognizes this
as:
a) Neurogenic shock
b) Cushing’s Triad
c) Spinal shock
d) Autonomic Dysreflexia
Correct Answer: b) Cushing’s Triad
Rationale: Cushing’s Triad (hypertension with widened pulse pressure,
bradycardia, and irregular respirations) is a late, ominous sign of increased ICP
indicating brainstem compression . It requires immediate intervention to prevent
herniation.
4. The nurse is assessing a patient who sustained a head injury in a motorcycle
accident. Initially, the patient was decorticate. Now, the patient extends the
upper and lower extremities in response to painful stimuli. What does this
change indicate?
a) Improved neurological status
b) Development of a spinal cord injury
c) Worsening ICP and brainstem involvement
d) A normal response to painful stimuli
Correct Answer: c) Worsening ICP and brainstem involvement
Rationale: Decorticate posturing (flexion) indicates damage to the cerebral
hemispheres. Progression to decerebrate posturing (extension) indicates
deterioration and damage to the midbrain/brainstem . This is a sign of worsening
ICP and requires immediate intervention.
5. A patient is 4 hours post-craniotomy. The blood pressure changes from
130/70 to 142/72, and the patient is becoming restless. Which statement is true
regarding this scenario?
a) This indicates a developing complication
b) This is expected post-operative pain
c) The nurse should increase the head of bed
d) The nurse should administer a sedative immediately
Correct Answer: a) This indicates a developing complication
Rationale: Post-craniotomy, increasing blood pressure and restlessness can indicate
rising ICP or potential intracranial hemorrhage . While pain can cause restlessness,
, the change in BP warrants immediate notification of the provider rather than
independent administration of sedatives which could mask neurological
assessment.
6. An elderly man with a TBI fell off a ladder yesterday. The nurse assesses
swelling of the optic nerve (papilledema). What does this finding indicate?
a) A worsening condition related to increased ICP
b) An allergic reaction to the pain medication
c) A pre-existing ocular condition
d) Improvement in cerebral perfusion
Correct Answer: a) A worsening condition related to increased ICP
Rationale: Papilledema (swelling of the optic disc) is a direct sign of increased
intracranial pressure transmitted through the optic nerve sheath . It is a late sign
and indicates sustained high pressure.
Section 2: Seizure Disorders & Status Epilepticus
7. A patient is admitted with a brain abscess. The nurse understands that the
most common causative organisms of brain abscesses are:
a) Viruses
b) Fungi
c) Parasites
d) Bacteria
Correct Answer: d) Bacteria
Rationale: While viral encephalitis is common, brain abscesses are most
frequently caused by bacterial pathogens (such
as Streptococcus and Staphylococcus) that spread from contiguous sites (ears,
sinuses) or via hematogenous spread . The statement "viruses are the most
common" regarding brain abscesses is false .
8. A patient with a seizure disorder is brought to the emergency department in
active convulsive status epilepticus. What is the nurse’s priority intervention?
a) Establish IV access and administer lorazepam
b) Place a tongue blade in the mouth to prevent aspiration
c) Obtain a stat CT scan
d) Restrain the patient to prevent injury
