BSN Week 5 Quiz: Neurological & Fluid/Electrolyte Balance
2026|Galen
1. A nurse is assessing a patient with a Glasgow Coma Scale (GCS) score of 7.
Which action is the highest priority for the nurse?
A. Monitor urine output hourly
B. Assess peripheral pulses
C. Prepare for endotracheal intubation
D. Perform a range of motion assessment
Answer: C
Rationale: A GCS score of 8 or less typically indicates a need for airway protection via
intubation (‘Less than 8, intubate’).
2. Which of the following is considered the earliest sign of increased intracranial
pressure (ICP)?
A. Change in level of consciousness (LOC)
B. Fixed and dilated pupils
C. Cushing’s triad
D. Decerebrate posturing
Answer: A
Rationale: Alteration in LOC is the most sensitive and earliest indicator of neurological
deterioration and increased ICP.
,3. A patient is receiving Mannitol for cerebral edema. Which finding indicates
the medication is effective?
A. Increased blood pressure
B. Decreased pulse rate
C. Increased urine output
D. Decreased body temperature
Answer: C
Rationale: Mannitol is an osmotic diuretic that draws fluid from the brain tissue into the
vascular space, resulting in increased urine output.
4. The nurse observes a patient with their arms adducted and flexed on the
chest, with wrists and fingers flexed. How should the nurse document this?
A. Decerebrate posturing
B. Decorticate posturing
C. Flaccid paralysis
D. Clonic activity
Answer: B
Rationale: Decorticate posturing involves internal rotation and adduction of arms with
flexion of elbows and wrists, indicating damage to the corticospinal tract.
5. Which clinical manifestation is part of Cushing’s Triad, signaling late-stage
increased ICP?
A. Tachycardia
B. Hypotension
C. Widened pulse pressure
D. Tachypnea
Answer: C
Rationale: Cushing’s Triad consists of bradycardia, hypertension with a widened pulse
pressure, and irregular respirations.
, 6. A patient with a T6 spinal cord injury reports a severe headache and has a BP
of 190/100. What is the nurse’s first action?
A. Administer PRN antihypertensives
B. Place the patient in a high-Fowler’s position
C. Notify the provider immediately
D. Check for bladder distension
Answer: B
Rationale: The symptoms suggest autonomic dysreflexia. The first priority is to sit the
patient up to utilize orthostatic pressure to lower BP.
7. Which electrolyte imbalance is most closely associated with Trousseau’s and
Chvostek’s signs?
A. Hypokalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Answer: B
Rationale: Hypocalcemia increases neuromuscular excitability, leading to positive
Chvostek’s (facial twitch) and Trousseau’s (carpal spasm) signs.
8. An ECG shows peaked T-waves and a widened QRS complex. Which
electrolyte abnormality should the nurse suspect?
A. Hypokalemia
B. Hypermagnesemia
C. Hypocalcemia
D. Hyperkalemia
Answer: D
Rationale: Hyperkalemia (high potassium) significantly impacts cardiac conduction,
presenting as peaked T-waves and potential cardiac arrest.
2026|Galen
1. A nurse is assessing a patient with a Glasgow Coma Scale (GCS) score of 7.
Which action is the highest priority for the nurse?
A. Monitor urine output hourly
B. Assess peripheral pulses
C. Prepare for endotracheal intubation
D. Perform a range of motion assessment
Answer: C
Rationale: A GCS score of 8 or less typically indicates a need for airway protection via
intubation (‘Less than 8, intubate’).
2. Which of the following is considered the earliest sign of increased intracranial
pressure (ICP)?
A. Change in level of consciousness (LOC)
B. Fixed and dilated pupils
C. Cushing’s triad
D. Decerebrate posturing
Answer: A
Rationale: Alteration in LOC is the most sensitive and earliest indicator of neurological
deterioration and increased ICP.
,3. A patient is receiving Mannitol for cerebral edema. Which finding indicates
the medication is effective?
A. Increased blood pressure
B. Decreased pulse rate
C. Increased urine output
D. Decreased body temperature
Answer: C
Rationale: Mannitol is an osmotic diuretic that draws fluid from the brain tissue into the
vascular space, resulting in increased urine output.
4. The nurse observes a patient with their arms adducted and flexed on the
chest, with wrists and fingers flexed. How should the nurse document this?
A. Decerebrate posturing
B. Decorticate posturing
C. Flaccid paralysis
D. Clonic activity
Answer: B
Rationale: Decorticate posturing involves internal rotation and adduction of arms with
flexion of elbows and wrists, indicating damage to the corticospinal tract.
5. Which clinical manifestation is part of Cushing’s Triad, signaling late-stage
increased ICP?
A. Tachycardia
B. Hypotension
C. Widened pulse pressure
D. Tachypnea
Answer: C
Rationale: Cushing’s Triad consists of bradycardia, hypertension with a widened pulse
pressure, and irregular respirations.
, 6. A patient with a T6 spinal cord injury reports a severe headache and has a BP
of 190/100. What is the nurse’s first action?
A. Administer PRN antihypertensives
B. Place the patient in a high-Fowler’s position
C. Notify the provider immediately
D. Check for bladder distension
Answer: B
Rationale: The symptoms suggest autonomic dysreflexia. The first priority is to sit the
patient up to utilize orthostatic pressure to lower BP.
7. Which electrolyte imbalance is most closely associated with Trousseau’s and
Chvostek’s signs?
A. Hypokalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Answer: B
Rationale: Hypocalcemia increases neuromuscular excitability, leading to positive
Chvostek’s (facial twitch) and Trousseau’s (carpal spasm) signs.
8. An ECG shows peaked T-waves and a widened QRS complex. Which
electrolyte abnormality should the nurse suspect?
A. Hypokalemia
B. Hypermagnesemia
C. Hypocalcemia
D. Hyperkalemia
Answer: D
Rationale: Hyperkalemia (high potassium) significantly impacts cardiac conduction,
presenting as peaked T-waves and potential cardiac arrest.
