USE FIRST NEURO DYSFUNCTION EXAMS WITH
100% ACCURATE ANSWERS LATEST UPDATED
2025/2026 A COMPLETE SOLUTION RATED A+ FOR
PASS
1. A client is being admitted to the neurologic ICU following an acute
head injury that has resulted in cerebral edema. When planning this
client's care, the nurse would expect to administer what priority
medication? A. Hydrochlorothiazide B. Furosemide C. Mannitol D.
Spironlactone
ANS: C Rationale: Mannitol (an osmotic diuretic) dehydrates brain tissue
and reduces cerebral edema; the other diuretics are not typically used
to lower ICP.
2. The nurse is providing care for a client who is unconscious. What
nursing intervention takes highest priority? A. Maintaining accurate
records of intake and output B. Maintaining a patent airway C. Inserting
a nasogastric (NG) tube as prescribed D. Providing appropriate pain
control
ANS: B Rationale: Airway maintenance is always the top priority in
unconscious clients (airway > breathing > circulation).
3. The nurse is caring for a client in the ICU who has a brain stem
herniation and who is exhibiting an altered level of consciousness.
Monitoring reveals that the client's mean arterial pressure (MAP) is 60
mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is
the nurse's most appropriate action? A. Position the client the high
Fowler position as tolerated. B. Administer osmotic diuretics as
, USE FIRST NEURO DYSFUNCTION EXAMS WITH
100% ACCURATE ANSWERS LATEST UPDATED
2025/2026 A COMPLETE SOLUTION RATED A+ FOR
PASS
prescribed. C. Participate in interventions to increase cerebral perfusion
pressure (CPP). D. Prepare the client for craniotomy.
ANS: C Rationale: CPP = MAP − ICP = 60 − 5 = 55 mm Hg (low);
interventions to increase CPP are needed to prevent irreversible
neurologic damage.
4. The nurse is caring for a client who is postoperative following a
craniotomy. When writing the plan of care, the nurse identifies a
diagnosis of "deficient fluid volume related to fluid restriction and
osmotic diuretic use." What is the nurse's most appropriate
intervention for this diagnosis? A. Change the client's position as
indicated. B. Monitor serum electrolytes. C. Maintain NPO status. D.
Monitor arterial blood gas (ABG) values.
ANS: B Rationale: Monitor serum electrolytes to guide fluid/ electrolyte
management after diuretics and restrictions.
5. A client with a documented history of seizure disorder experiences a
generalized seizure. What nursing action is most appropriate? A.
Restrain the client to prevent injury. B. Open the client's jaws to insert
an oral airway. C. Place client in high Fowler position. D. Loosen the
client's restrictive clothing.
ANS: D Rationale: Loosen restrictive clothing; do not restrain or force
oral devices; place on side to maintain airway and allow drainage.
100% ACCURATE ANSWERS LATEST UPDATED
2025/2026 A COMPLETE SOLUTION RATED A+ FOR
PASS
1. A client is being admitted to the neurologic ICU following an acute
head injury that has resulted in cerebral edema. When planning this
client's care, the nurse would expect to administer what priority
medication? A. Hydrochlorothiazide B. Furosemide C. Mannitol D.
Spironlactone
ANS: C Rationale: Mannitol (an osmotic diuretic) dehydrates brain tissue
and reduces cerebral edema; the other diuretics are not typically used
to lower ICP.
2. The nurse is providing care for a client who is unconscious. What
nursing intervention takes highest priority? A. Maintaining accurate
records of intake and output B. Maintaining a patent airway C. Inserting
a nasogastric (NG) tube as prescribed D. Providing appropriate pain
control
ANS: B Rationale: Airway maintenance is always the top priority in
unconscious clients (airway > breathing > circulation).
3. The nurse is caring for a client in the ICU who has a brain stem
herniation and who is exhibiting an altered level of consciousness.
Monitoring reveals that the client's mean arterial pressure (MAP) is 60
mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is
the nurse's most appropriate action? A. Position the client the high
Fowler position as tolerated. B. Administer osmotic diuretics as
, USE FIRST NEURO DYSFUNCTION EXAMS WITH
100% ACCURATE ANSWERS LATEST UPDATED
2025/2026 A COMPLETE SOLUTION RATED A+ FOR
PASS
prescribed. C. Participate in interventions to increase cerebral perfusion
pressure (CPP). D. Prepare the client for craniotomy.
ANS: C Rationale: CPP = MAP − ICP = 60 − 5 = 55 mm Hg (low);
interventions to increase CPP are needed to prevent irreversible
neurologic damage.
4. The nurse is caring for a client who is postoperative following a
craniotomy. When writing the plan of care, the nurse identifies a
diagnosis of "deficient fluid volume related to fluid restriction and
osmotic diuretic use." What is the nurse's most appropriate
intervention for this diagnosis? A. Change the client's position as
indicated. B. Monitor serum electrolytes. C. Maintain NPO status. D.
Monitor arterial blood gas (ABG) values.
ANS: B Rationale: Monitor serum electrolytes to guide fluid/ electrolyte
management after diuretics and restrictions.
5. A client with a documented history of seizure disorder experiences a
generalized seizure. What nursing action is most appropriate? A.
Restrain the client to prevent injury. B. Open the client's jaws to insert
an oral airway. C. Place client in high Fowler position. D. Loosen the
client's restrictive clothing.
ANS: D Rationale: Loosen restrictive clothing; do not restrain or force
oral devices; place on side to maintain airway and allow drainage.
