,Question 1
A nurse is caring for a client who is post procedure following lumbar puncture and reports a
throbbing headache when sitting upright. Which of the following actions should the nurse take?
(Select all that apply)
Choices:
a.) Use the Glasgow Coma Scale when assessing the client
b.) Assist the client to a supine position
c.) Administer an opioid medications
d.) Encourage the client to increase fluid intake
e.) Instruct the client to perform deep breathing and coughing exercises
Correct Answer: b, c, d
Rationale: A post-lumbar puncture headache is often caused by CSF leakage. Supine
position reduces CSF pressure, opioids relieve pain, and increased fluid intake helps restore
CSF volume. GCS is not indicated for this type of headache, and deep breathing exercises
do not address the cause.
Question 2
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular
catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of
the following complications related to the ventriculostomy?
Choices:
a.) Headache
b.) Infection
c.) Aphasia
d.) Hypertension
Correct Answer: b
Rationale: The primary complication of an intraventricular catheter is infection
(ventriculitis or meningitis) due to the invasive nature of the device penetrating the central
nervous system.
,Question 3
A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma
Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his
extremities when pain is applied. Which of the following GCS scores should the nurse
document?
Choices:
a.) E2+V3+M5 = 10
b.) E3+V4+M4 = 11
c.) E4+V5+M6 = 15
d.) E2+V2+M4 = 8
Correct Answer: b
Rationale: Eye opening to speech = E3. Incoherent speech = V4. Movement to pain
(withdrawal) = M4. Total = 3+4+4 = 11.
Question 4
A nurse is developing a plan of care for a client who is scheduled for a cerebral angiography with
contrast media. Which of the following statements by the client should the nurse report to the
provider? (Select all that apply)
Choices:
a.) "I think I might be pregnant."
b.) "I take warfarin."
c.) "I take antihypertensive medication."
d.) "I am allergic to shrimp."
e.) "I ate a light breakfast this morning."
Correct Answer: a, b, d, e
Rationale: Pregnancy (radiation risk), warfarin (bleeding risk), shellfish allergy (contrast
reaction risk), and eating before procedure (aspiration risk) should all be reported.
Antihypertensive medication is typically continued.
, Question 5
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the
next day. Which of the following information should the nurse include in the teaching?
Choices:
a.) "Do not wash your hair the morning of the procedure."
b.) "Try to stay awake most of the night prior to the procedure."
c.) "The procedure will take approximately 15 minutes."
d.) "You will need to lie flat for 4 hours after the procedure."
Correct Answer: b
Rationale: Sleep deprivation can increase the likelihood of seizure activity during an EEG.
The patient is often instructed to stay awake the night before. The procedure takes longer
than 15 minutes, and the other statements are incorrect.
Question 6
A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to
have a seizure." Which of the following actions should the nurse implement?
Choices:
a.) provide privacy
b.) Ease the client to the floor if standing
c.) Move furniture away from the client
d.) Loosen the client's clothing
e.) Protect the client's head with padding
f.) Restrain the client
Correct Answer: a, b, c, d, e
Rationale: All actions except restraint are appropriate. Restraining a client during a
seizure can cause injury. The nurse should provide privacy, ease the client to the floor,
move furniture, loosen clothing, and protect the head.
A nurse is caring for a client who is post procedure following lumbar puncture and reports a
throbbing headache when sitting upright. Which of the following actions should the nurse take?
(Select all that apply)
Choices:
a.) Use the Glasgow Coma Scale when assessing the client
b.) Assist the client to a supine position
c.) Administer an opioid medications
d.) Encourage the client to increase fluid intake
e.) Instruct the client to perform deep breathing and coughing exercises
Correct Answer: b, c, d
Rationale: A post-lumbar puncture headache is often caused by CSF leakage. Supine
position reduces CSF pressure, opioids relieve pain, and increased fluid intake helps restore
CSF volume. GCS is not indicated for this type of headache, and deep breathing exercises
do not address the cause.
Question 2
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular
catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of
the following complications related to the ventriculostomy?
Choices:
a.) Headache
b.) Infection
c.) Aphasia
d.) Hypertension
Correct Answer: b
Rationale: The primary complication of an intraventricular catheter is infection
(ventriculitis or meningitis) due to the invasive nature of the device penetrating the central
nervous system.
,Question 3
A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma
Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his
extremities when pain is applied. Which of the following GCS scores should the nurse
document?
Choices:
a.) E2+V3+M5 = 10
b.) E3+V4+M4 = 11
c.) E4+V5+M6 = 15
d.) E2+V2+M4 = 8
Correct Answer: b
Rationale: Eye opening to speech = E3. Incoherent speech = V4. Movement to pain
(withdrawal) = M4. Total = 3+4+4 = 11.
Question 4
A nurse is developing a plan of care for a client who is scheduled for a cerebral angiography with
contrast media. Which of the following statements by the client should the nurse report to the
provider? (Select all that apply)
Choices:
a.) "I think I might be pregnant."
b.) "I take warfarin."
c.) "I take antihypertensive medication."
d.) "I am allergic to shrimp."
e.) "I ate a light breakfast this morning."
Correct Answer: a, b, d, e
Rationale: Pregnancy (radiation risk), warfarin (bleeding risk), shellfish allergy (contrast
reaction risk), and eating before procedure (aspiration risk) should all be reported.
Antihypertensive medication is typically continued.
, Question 5
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the
next day. Which of the following information should the nurse include in the teaching?
Choices:
a.) "Do not wash your hair the morning of the procedure."
b.) "Try to stay awake most of the night prior to the procedure."
c.) "The procedure will take approximately 15 minutes."
d.) "You will need to lie flat for 4 hours after the procedure."
Correct Answer: b
Rationale: Sleep deprivation can increase the likelihood of seizure activity during an EEG.
The patient is often instructed to stay awake the night before. The procedure takes longer
than 15 minutes, and the other statements are incorrect.
Question 6
A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to
have a seizure." Which of the following actions should the nurse implement?
Choices:
a.) provide privacy
b.) Ease the client to the floor if standing
c.) Move furniture away from the client
d.) Loosen the client's clothing
e.) Protect the client's head with padding
f.) Restrain the client
Correct Answer: a, b, c, d, e
Rationale: All actions except restraint are appropriate. Restraining a client during a
seizure can cause injury. The nurse should provide privacy, ease the client to the floor,
move furniture, loosen clothing, and protect the head.
