NSG 223 Neuro Review Practice Exam
Questions and Answers with Verified
Solutions | Latest Updated 2026
The emergency room (ER) nurse ANS: A, C Rationale: Fractures of the base
is of the
caring for a client who has been skull tend to traverse the paranasal sinus
brought in by of the
ambulance after sustaining a fall at frontal bone or the middle ear located in
home. What physical assessment the
finding(s) are temporal bone. Therefore, they frequently
suggestive of a basilar skull produce
fracture? hemorrhage from the nose (epistaxis),
Select all that apply pharynx, or
A. Epistaxis ears, and blood may appear under the
B. Swelling of the tongue and lips conjunctiva.
C. Bruising over the mastoid An area of ecchymosis (bruising) may be
D. Unilateral facial numbness seen over
E. Severe back pain the mastoid (Battle sign). Pain is usually
localized to
the area of injury and swelling of the
tongue and
lips may have been the result of direct
impact of
the face due to the fall or an anaphylactic
reaction
of some type. Numbness on one side of
the face is
not a typical finding in basilar skull
fractures.
,A client is brought to the trauma ANS: B Rationale: If endotracheal
center by ambulance after intubation is
sustaining necessary, extreme care is taken to avoid
a high cervical flexing or
spinal cord injury 11/2 hours ago. extending the client's neck, which can
Endotracheal intubation has been result in
deemed necessary extension of a cervical injury. Intubation
and the nurse is preparing to does not
assist. directly cause autonomic dysreflexia and
What nursing diagnosis should the the threat
nurse associate to skin integrity is not a primary concern.
with this procedure? Intubation
A. Risk for impaired skin integrity does not carry the potential to cause
B. Risk for injury suffocation.
C. Risk for autonomic dysreflexia
D. Risk for suffocation
A nurse is caring for a critically ill ANS: B Rationale: Autonomic dysreflexia
client with autonomic dysreflexia. is
What clinical characterized by a pounding headache,
manifestations would the nurse profuse
expect in this client? sweating, nasal congestion, piloerection
A. Respiratory distress and (goose
projectile bumps), bradycardia, and hypertension. It
vomiting occurs in
B. Bradycardia and hypertension cord lesions above T6 after spinal shock
C. Tachycardia and agitation has
D. Third-spacing and hyperthermia resolved; it does not result in vomiting,
tachycardia,
or third-spacing.
,The nurse is caring for a client with ANS: A Rationale: Signs of increasing ICP
increased intracranial pressure include
(ICP) slowing of the heart rate (bradycardia),
caused by a increasing
traumatic brain injury. Which of the systolic BP, and widening pulse pressure.
following clinical manifestations As brain
would suggest that compression increases, respirations
the client may be experiencing become rapid,
increased brain compression BP may decrease, and the pulse slows
causing further. A
brain stem damage? rapid rise in body temperature is regarded
A. Hyperthermia as
B. Tachycardia unfavorable. Hyperthermia increases the
C. Hypertension metabolic
D. Bradypnea demands of the brain and may indicate
brain stem
damage.
, A client is brought to the ED by ANS: C Rationale: An epidural hematoma
family after falling off the roof. The is
care team suspects considered an extreme emergency.
an epidural hematoma, prompting Marked
the nurse to anticipate for which neurological deficit or respiratory arrest
priority can occur
intervention? within minutes. Treatment consists of
A. Insertion of an intracranial making an
monitoring device opening through the skull to decrease ICP
B. Treatment with emergently, remove the clot, and control
antihypertensives the
C. Making openings in the skull bleeding. Antihypertensive medications
D. Administration of anticoagulant would not
therapy be a priority. Anticoagulant therapy should
not be
prescribed for a client who has a cranial
bleed. This
could further increase bleeding activity.
Insertion
of an intracranial monitoring device may be
done
during the surgery, but is not priority for
this client.
Questions and Answers with Verified
Solutions | Latest Updated 2026
The emergency room (ER) nurse ANS: A, C Rationale: Fractures of the base
is of the
caring for a client who has been skull tend to traverse the paranasal sinus
brought in by of the
ambulance after sustaining a fall at frontal bone or the middle ear located in
home. What physical assessment the
finding(s) are temporal bone. Therefore, they frequently
suggestive of a basilar skull produce
fracture? hemorrhage from the nose (epistaxis),
Select all that apply pharynx, or
A. Epistaxis ears, and blood may appear under the
B. Swelling of the tongue and lips conjunctiva.
C. Bruising over the mastoid An area of ecchymosis (bruising) may be
D. Unilateral facial numbness seen over
E. Severe back pain the mastoid (Battle sign). Pain is usually
localized to
the area of injury and swelling of the
tongue and
lips may have been the result of direct
impact of
the face due to the fall or an anaphylactic
reaction
of some type. Numbness on one side of
the face is
not a typical finding in basilar skull
fractures.
,A client is brought to the trauma ANS: B Rationale: If endotracheal
center by ambulance after intubation is
sustaining necessary, extreme care is taken to avoid
a high cervical flexing or
spinal cord injury 11/2 hours ago. extending the client's neck, which can
Endotracheal intubation has been result in
deemed necessary extension of a cervical injury. Intubation
and the nurse is preparing to does not
assist. directly cause autonomic dysreflexia and
What nursing diagnosis should the the threat
nurse associate to skin integrity is not a primary concern.
with this procedure? Intubation
A. Risk for impaired skin integrity does not carry the potential to cause
B. Risk for injury suffocation.
C. Risk for autonomic dysreflexia
D. Risk for suffocation
A nurse is caring for a critically ill ANS: B Rationale: Autonomic dysreflexia
client with autonomic dysreflexia. is
What clinical characterized by a pounding headache,
manifestations would the nurse profuse
expect in this client? sweating, nasal congestion, piloerection
A. Respiratory distress and (goose
projectile bumps), bradycardia, and hypertension. It
vomiting occurs in
B. Bradycardia and hypertension cord lesions above T6 after spinal shock
C. Tachycardia and agitation has
D. Third-spacing and hyperthermia resolved; it does not result in vomiting,
tachycardia,
or third-spacing.
,The nurse is caring for a client with ANS: A Rationale: Signs of increasing ICP
increased intracranial pressure include
(ICP) slowing of the heart rate (bradycardia),
caused by a increasing
traumatic brain injury. Which of the systolic BP, and widening pulse pressure.
following clinical manifestations As brain
would suggest that compression increases, respirations
the client may be experiencing become rapid,
increased brain compression BP may decrease, and the pulse slows
causing further. A
brain stem damage? rapid rise in body temperature is regarded
A. Hyperthermia as
B. Tachycardia unfavorable. Hyperthermia increases the
C. Hypertension metabolic
D. Bradypnea demands of the brain and may indicate
brain stem
damage.
, A client is brought to the ED by ANS: C Rationale: An epidural hematoma
family after falling off the roof. The is
care team suspects considered an extreme emergency.
an epidural hematoma, prompting Marked
the nurse to anticipate for which neurological deficit or respiratory arrest
priority can occur
intervention? within minutes. Treatment consists of
A. Insertion of an intracranial making an
monitoring device opening through the skull to decrease ICP
B. Treatment with emergently, remove the clot, and control
antihypertensives the
C. Making openings in the skull bleeding. Antihypertensive medications
D. Administration of anticoagulant would not
therapy be a priority. Anticoagulant therapy should
not be
prescribed for a client who has a cranial
bleed. This
could further increase bleeding activity.
Insertion
of an intracranial monitoring device may be
done
during the surgery, but is not priority for
this client.
