NUR 2520 - UNIT I - NERVOUS SYSTEM/ACUTE
INTRACRANIAL PROBLEMS – EXAM QUESTIONS WITH
COMPLETE SOLUTIONS & RATIONALES
1. A patient with a severe traumatic brain injury has an ICP of 22 mm
Hg and a mean arterial pressure (MAP) of 90 mm Hg. What is the
patient's cerebral perfusion pressure (CPP)?
a. 50 mm Hg
b. 58 mm Hg
c. 68 mm Hg
d. 112 mm Hg
Correct Answer: c. 68 mm Hg
Rationale: CPP = MAP - ICP. Therefore, 90 - 22 = 68 mm Hg. Normal CPP
is 60-100 mm Hg. A CPP below 50 is associated with ischemia and poor
neurological outcomes.
2. A patient is exhibiting signs of increased intracranial pressure (ICP).
Which of the following is an early sign of this condition?
a. Fixed, dilated pupils
b. Decerebrate posturing
c. Headache and vomiting
d. Bradycardia and hypertension
Correct Answer: c. Headache and vomiting
Rationale: Headache, often worse in the morning, and vomiting
(without nausea) are classic early signs of increased ICP. Cushing's triad
,(bradycardia, hypertension, and irregular respirations) and abnormal
posturing are late signs. Fixed, dilated pupils indicate uncal herniation.
3. The nurse is caring for a patient with a head injury who is at risk for
increased ICP. Which of the following nursing interventions is a
priority to prevent a rise in ICP?
a. Suction the patient every hour to prevent atelectasis.
b. Keep the patient's neck in a neutral, midline position.
c. Position the patient in a 15-degree Trendelenburg position.
d. Encourage the patient to cough and deep breathe frequently.
Correct Answer: b. Keep the patient's neck in a neutral, midline
position.
Rationale: Keeping the neck in a neutral position promotes venous
drainage from the head. Flexion, extension, or rotation of the neck can
impede jugular venous return, increasing intracranial blood volume and
pressure. Suctioning and coughing can also increase ICP and should be
done only as needed with pre-oxygenation.
4. A patient is brought to the ED after a motor vehicle accident. The
nurse assesses a Glasgow Coma Scale (GCS) score. Which of the
following components is not part of the GCS?
a. Eye opening
b. Motor response
c. Pupillary response
d. Verbal response
Correct Answer: c. Pupillary response
Rationale: The GCS assesses three components: eye opening (E), verbal
response (V), and motor response (M). Pupillary response is a separate
and critical neurological assessment but is not part of the GCS scoring
system.
,5. The nurse is preparing to administer mannitol (Osmitrol) to a
patient with increased ICP. Which of the following assessments is most
important to perform prior to administration?
a. Assess for a headache.
b. Assess for jugular venous distention.
c. Assess for signs of heart failure and fluid overload.
d. Assess the patient's level of consciousness.
Correct Answer: c. Assess for signs of heart failure and fluid overload.
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the brain
into the vascular space. This increases intravascular volume, which can
precipitate or worsen heart failure and pulmonary edema. Therefore,
the nurse must assess for signs of fluid overload (e.g., dyspnea, crackles,
JVD, edema) before and during administration.
6. A 70-year-old patient is post-operative day 1 after a craniotomy for
a brain tumor. Which assessment finding would be of greatest concern
to the nurse?
a. The patient's blood pressure is 110/70 mm Hg.
b. The patient complains of a mild headache.
c. The patient is sleepy but easily aroused.
d. The patient's wound drainage is clear and colorless.
Correct Answer: d. The patient's wound drainage is clear and
colorless.
Rationale: Clear, colorless drainage from a craniotomy site could be
cerebrospinal fluid (CSF) leakage. This indicates a possible dural tear
and increases the risk of meningitis. The nurse should suspect a CSF
leak and notify the healthcare provider. A mild headache and being
sleepy but arousable are expected post-operative findings.
, 7. A patient with a subarachnoid hemorrhage is receiving nimodipine
(Nimotop). What is the purpose of this medication?
a. To prevent seizures.
b. To decrease systemic blood pressure.
c. To reduce cerebral vasospasm.
d. To decrease intracranial pressure.
Correct Answer: c. To reduce cerebral vasospasm.
Rationale: Nimodipine is a calcium channel blocker used specifically to
prevent or reduce cerebral vasospasm, a significant complication
following a subarachnoid hemorrhage. Vasospasm can lead to delayed
cerebral ischemia and stroke.
8. A patient is admitted with a suspected brain tumor. The nurse is
aware that which symptom is most common in patients with a brain
tumor?
a. Seizures
b. Headache
c. Vision changes
d. Personality changes
Correct Answer: b. Headache
Rationale: Headache is the most common and often the first symptom
of a brain tumor. It is typically worse in the morning and may be
accompanied by nausea and vomiting due to increased ICP. While other
symptoms occur, headache is the most frequently reported.
9. The nurse is caring for a patient with a spinal cord injury at the C5
level. Which finding would indicate the development of autonomic
dysreflexia?
a. Hypotension and tachycardia
b. Severe, throbbing headache and bradycardia
INTRACRANIAL PROBLEMS – EXAM QUESTIONS WITH
COMPLETE SOLUTIONS & RATIONALES
1. A patient with a severe traumatic brain injury has an ICP of 22 mm
Hg and a mean arterial pressure (MAP) of 90 mm Hg. What is the
patient's cerebral perfusion pressure (CPP)?
a. 50 mm Hg
b. 58 mm Hg
c. 68 mm Hg
d. 112 mm Hg
Correct Answer: c. 68 mm Hg
Rationale: CPP = MAP - ICP. Therefore, 90 - 22 = 68 mm Hg. Normal CPP
is 60-100 mm Hg. A CPP below 50 is associated with ischemia and poor
neurological outcomes.
2. A patient is exhibiting signs of increased intracranial pressure (ICP).
Which of the following is an early sign of this condition?
a. Fixed, dilated pupils
b. Decerebrate posturing
c. Headache and vomiting
d. Bradycardia and hypertension
Correct Answer: c. Headache and vomiting
Rationale: Headache, often worse in the morning, and vomiting
(without nausea) are classic early signs of increased ICP. Cushing's triad
,(bradycardia, hypertension, and irregular respirations) and abnormal
posturing are late signs. Fixed, dilated pupils indicate uncal herniation.
3. The nurse is caring for a patient with a head injury who is at risk for
increased ICP. Which of the following nursing interventions is a
priority to prevent a rise in ICP?
a. Suction the patient every hour to prevent atelectasis.
b. Keep the patient's neck in a neutral, midline position.
c. Position the patient in a 15-degree Trendelenburg position.
d. Encourage the patient to cough and deep breathe frequently.
Correct Answer: b. Keep the patient's neck in a neutral, midline
position.
Rationale: Keeping the neck in a neutral position promotes venous
drainage from the head. Flexion, extension, or rotation of the neck can
impede jugular venous return, increasing intracranial blood volume and
pressure. Suctioning and coughing can also increase ICP and should be
done only as needed with pre-oxygenation.
4. A patient is brought to the ED after a motor vehicle accident. The
nurse assesses a Glasgow Coma Scale (GCS) score. Which of the
following components is not part of the GCS?
a. Eye opening
b. Motor response
c. Pupillary response
d. Verbal response
Correct Answer: c. Pupillary response
Rationale: The GCS assesses three components: eye opening (E), verbal
response (V), and motor response (M). Pupillary response is a separate
and critical neurological assessment but is not part of the GCS scoring
system.
,5. The nurse is preparing to administer mannitol (Osmitrol) to a
patient with increased ICP. Which of the following assessments is most
important to perform prior to administration?
a. Assess for a headache.
b. Assess for jugular venous distention.
c. Assess for signs of heart failure and fluid overload.
d. Assess the patient's level of consciousness.
Correct Answer: c. Assess for signs of heart failure and fluid overload.
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the brain
into the vascular space. This increases intravascular volume, which can
precipitate or worsen heart failure and pulmonary edema. Therefore,
the nurse must assess for signs of fluid overload (e.g., dyspnea, crackles,
JVD, edema) before and during administration.
6. A 70-year-old patient is post-operative day 1 after a craniotomy for
a brain tumor. Which assessment finding would be of greatest concern
to the nurse?
a. The patient's blood pressure is 110/70 mm Hg.
b. The patient complains of a mild headache.
c. The patient is sleepy but easily aroused.
d. The patient's wound drainage is clear and colorless.
Correct Answer: d. The patient's wound drainage is clear and
colorless.
Rationale: Clear, colorless drainage from a craniotomy site could be
cerebrospinal fluid (CSF) leakage. This indicates a possible dural tear
and increases the risk of meningitis. The nurse should suspect a CSF
leak and notify the healthcare provider. A mild headache and being
sleepy but arousable are expected post-operative findings.
, 7. A patient with a subarachnoid hemorrhage is receiving nimodipine
(Nimotop). What is the purpose of this medication?
a. To prevent seizures.
b. To decrease systemic blood pressure.
c. To reduce cerebral vasospasm.
d. To decrease intracranial pressure.
Correct Answer: c. To reduce cerebral vasospasm.
Rationale: Nimodipine is a calcium channel blocker used specifically to
prevent or reduce cerebral vasospasm, a significant complication
following a subarachnoid hemorrhage. Vasospasm can lead to delayed
cerebral ischemia and stroke.
8. A patient is admitted with a suspected brain tumor. The nurse is
aware that which symptom is most common in patients with a brain
tumor?
a. Seizures
b. Headache
c. Vision changes
d. Personality changes
Correct Answer: b. Headache
Rationale: Headache is the most common and often the first symptom
of a brain tumor. It is typically worse in the morning and may be
accompanied by nausea and vomiting due to increased ICP. While other
symptoms occur, headache is the most frequently reported.
9. The nurse is caring for a patient with a spinal cord injury at the C5
level. Which finding would indicate the development of autonomic
dysreflexia?
a. Hypotension and tachycardia
b. Severe, throbbing headache and bradycardia
