NSG 4100 Exam 4 Final EXAM WITH QUESTIONS AND CORRECT
VERIFIED ANSWERS AND RATINALES GRADED A+
SECTION 1: NEUROLOGICAL DISORDERS & EMERGENCIES
(Questions 1-30)
Question 1
A nurse is caring for a client with a traumatic brain injury. Which assessment finding is the
earliest indicator of worsening neurological status?
A) Pupil size changing from 5mm to 9mm
B) Decreased heart rate
C) Increased blood pressure
D) Confusion and restlessness
Correct Answer: A
Rationale: A pupil size changing from 5mm to 9mm is a sign of worsening condition and increased
intracranial pressure (ICP). Early signs of increased ICP include changes in level of consciousness,
pupillary changes, and vital sign changes (Cushing's triad: hypertension, bradycardia, irregular
respirations). Pupillary changes indicate brainstem compression and require immediate intervention.
Question 2
Which position is BEST for a patient who is at risk for increased intracranial pressure?
A) Supine
B) Trendelenburg
C) Semi-Fowler's
D) Prone
Correct Answer: C
Rationale: Semi-Fowler's position (head of bed elevated 30-45 degrees) is the optimal position for
patients at risk for increased ICP. This position promotes venous drainage from the head, reducing
,cerebral edema and ICP. Supine and Trendelenburg positions increase ICP, and prone is
contraindicated.
Question 3
A patient is post-operative following a craniotomy using the supratentorial approach. How should
the nurse best position the patient?
A) Position the patient supine
B) Maintain HOB elevated at 30-45 degrees
C) Position the patient prone
D) Maintain bed in Trendelenburg position
Correct Answer: B
Rationale: After a supratentorial craniotomy, the head of the bed should be elevated 30-45 degrees to
promote venous drainage and reduce cerebral edema. This position helps maintain optimal cerebral
perfusion pressure and minimizes the risk of increased ICP.
Question 4
A patient is S/P craniotomy for tumor removal. Which finding is indicative of a complication?
A) Client states he feels a lot of drainage at the back of his throat
B) Eyes that are swollen post-op
C) Mild headache
D) Temperature of 99.2°F
Correct Answer: A
Rationale: Drainage at the back of the throat after craniotomy may indicate a cerebrospinal fluid (CSF)
leak through the surgical site. CSF leaks can lead to meningitis and require immediate intervention. Post-
operative eye swelling (B) is a normal finding after craniotomy.
Question 5
The nurse is admitting a client to the neurological ICU following a transsphenoidal
hypophysectomy. Which data warrants immediate intervention?
,A) Client is alert to name but unable to tell nurse the location
B) Client has output of 2500 mL since surgery and intake of 1000 mL
C) Client vital signs are T 97.6°F, P 88, RR 22, BP 130/80
D) Client has 3 cm of dark red drainage on turban dressing
Correct Answer: B
Rationale: A urine output of 2500 mL with intake of only 1000 mL suggests diabetes insipidus (DI), a
complication of pituitary surgery. DI results from decreased antidiuretic hormone (ADH) and can lead to
severe dehydration and hypernatremia. Immediate intervention is required to prevent complications.
Question 6
Which of the following is indicative of worsening condition in a patient with increased ICP?
A) Pupil size 3mm bilaterally
B) Blood pressure 110/70
C) Pupil size changing from 5 to 9mm
D) Heart rate 72
Correct Answer: C
Rationale: Pupil size changing from 5 to 9mm (unilateral or bilateral dilation) is a sign of worsening
neurological status and increased ICP. This indicates brainstem compression and is a medical
emergency requiring immediate intervention.
Question 7
A nurse is caring for a client with a head injury. Which of the following situations needs
intervention by the nurse?
A) The client's spouse reads aloud to the client
B) The client's spouse turns on the TV for 3 hours in the evening
C) The client sleeps for 2 hours
D) The client's room is kept dark
Correct Answer: B
Rationale: Patients with head injuries require low stimulation environments to prevent increased ICP.
Extended television viewing (3 hours) provides excessive sensory stimulation that can increase ICP.
Activities should be limited to short periods and the environment should be quiet and calm.
, Question 8
The nurse is caring for clients in the emergency department. Which client should the nurse
assess FIRST?
A) The client with a subdural hematoma
B) The client with an epidural hematoma
C) The client with a concussion
D) The client with a skull fracture
Correct Answer: B
Rationale: An epidural hematoma results from bleeding between the dura and the inner surface of the
skull and is an active arterial bleed. This is a medical emergency that requires immediate surgical
intervention. Epidural hematomas can rapidly expand and cause brain herniation.
Question 9
Which of the following are early signs of increased ICP? (Select all that apply)
A) Kussmaul respirations
B) Weakness in one extremity
C) Pupil dilation
D) Decreased level of consciousness
Correct Answer: A, B, D
Rationale: Early signs of increased ICP include Kussmaul respirations (irregular breathing pattern),
weakness in one extremity (indicating motor changes), and decreased level of consciousness. Pupil
dilation (C) is typically a later sign indicating brainstem compression.
Question 10
A patient with a spinal cord injury at C4 would be expected to have which of the following?
A) Full range of motion
B) Quadriplegia
C) Paraplegia
D) Ability to breathe independently
Correct Answer: B
VERIFIED ANSWERS AND RATINALES GRADED A+
SECTION 1: NEUROLOGICAL DISORDERS & EMERGENCIES
(Questions 1-30)
Question 1
A nurse is caring for a client with a traumatic brain injury. Which assessment finding is the
earliest indicator of worsening neurological status?
A) Pupil size changing from 5mm to 9mm
B) Decreased heart rate
C) Increased blood pressure
D) Confusion and restlessness
Correct Answer: A
Rationale: A pupil size changing from 5mm to 9mm is a sign of worsening condition and increased
intracranial pressure (ICP). Early signs of increased ICP include changes in level of consciousness,
pupillary changes, and vital sign changes (Cushing's triad: hypertension, bradycardia, irregular
respirations). Pupillary changes indicate brainstem compression and require immediate intervention.
Question 2
Which position is BEST for a patient who is at risk for increased intracranial pressure?
A) Supine
B) Trendelenburg
C) Semi-Fowler's
D) Prone
Correct Answer: C
Rationale: Semi-Fowler's position (head of bed elevated 30-45 degrees) is the optimal position for
patients at risk for increased ICP. This position promotes venous drainage from the head, reducing
,cerebral edema and ICP. Supine and Trendelenburg positions increase ICP, and prone is
contraindicated.
Question 3
A patient is post-operative following a craniotomy using the supratentorial approach. How should
the nurse best position the patient?
A) Position the patient supine
B) Maintain HOB elevated at 30-45 degrees
C) Position the patient prone
D) Maintain bed in Trendelenburg position
Correct Answer: B
Rationale: After a supratentorial craniotomy, the head of the bed should be elevated 30-45 degrees to
promote venous drainage and reduce cerebral edema. This position helps maintain optimal cerebral
perfusion pressure and minimizes the risk of increased ICP.
Question 4
A patient is S/P craniotomy for tumor removal. Which finding is indicative of a complication?
A) Client states he feels a lot of drainage at the back of his throat
B) Eyes that are swollen post-op
C) Mild headache
D) Temperature of 99.2°F
Correct Answer: A
Rationale: Drainage at the back of the throat after craniotomy may indicate a cerebrospinal fluid (CSF)
leak through the surgical site. CSF leaks can lead to meningitis and require immediate intervention. Post-
operative eye swelling (B) is a normal finding after craniotomy.
Question 5
The nurse is admitting a client to the neurological ICU following a transsphenoidal
hypophysectomy. Which data warrants immediate intervention?
,A) Client is alert to name but unable to tell nurse the location
B) Client has output of 2500 mL since surgery and intake of 1000 mL
C) Client vital signs are T 97.6°F, P 88, RR 22, BP 130/80
D) Client has 3 cm of dark red drainage on turban dressing
Correct Answer: B
Rationale: A urine output of 2500 mL with intake of only 1000 mL suggests diabetes insipidus (DI), a
complication of pituitary surgery. DI results from decreased antidiuretic hormone (ADH) and can lead to
severe dehydration and hypernatremia. Immediate intervention is required to prevent complications.
Question 6
Which of the following is indicative of worsening condition in a patient with increased ICP?
A) Pupil size 3mm bilaterally
B) Blood pressure 110/70
C) Pupil size changing from 5 to 9mm
D) Heart rate 72
Correct Answer: C
Rationale: Pupil size changing from 5 to 9mm (unilateral or bilateral dilation) is a sign of worsening
neurological status and increased ICP. This indicates brainstem compression and is a medical
emergency requiring immediate intervention.
Question 7
A nurse is caring for a client with a head injury. Which of the following situations needs
intervention by the nurse?
A) The client's spouse reads aloud to the client
B) The client's spouse turns on the TV for 3 hours in the evening
C) The client sleeps for 2 hours
D) The client's room is kept dark
Correct Answer: B
Rationale: Patients with head injuries require low stimulation environments to prevent increased ICP.
Extended television viewing (3 hours) provides excessive sensory stimulation that can increase ICP.
Activities should be limited to short periods and the environment should be quiet and calm.
, Question 8
The nurse is caring for clients in the emergency department. Which client should the nurse
assess FIRST?
A) The client with a subdural hematoma
B) The client with an epidural hematoma
C) The client with a concussion
D) The client with a skull fracture
Correct Answer: B
Rationale: An epidural hematoma results from bleeding between the dura and the inner surface of the
skull and is an active arterial bleed. This is a medical emergency that requires immediate surgical
intervention. Epidural hematomas can rapidly expand and cause brain herniation.
Question 9
Which of the following are early signs of increased ICP? (Select all that apply)
A) Kussmaul respirations
B) Weakness in one extremity
C) Pupil dilation
D) Decreased level of consciousness
Correct Answer: A, B, D
Rationale: Early signs of increased ICP include Kussmaul respirations (irregular breathing pattern),
weakness in one extremity (indicating motor changes), and decreased level of consciousness. Pupil
dilation (C) is typically a later sign indicating brainstem compression.
Question 10
A patient with a spinal cord injury at C4 would be expected to have which of the following?
A) Full range of motion
B) Quadriplegia
C) Paraplegia
D) Ability to breathe independently
Correct Answer: B
