Neuro: We are almost there <3
1. A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the
plan of care?
Answer: Keep the head of the bed elevated to 30 degrees.
2. A patient has been admitted with meningococcal meningitis. Which observation by the nurse
requires action?
Answer: Unlicensed assistive personnel enter the patient’s room without a mask.
3. A patient in the emergency department with sudden- onset right-sided weakness is diagnosed
with an intracerebral hemorrhage. Which information about the patient is most important to
communicate to the health care provider?
Answer: The patient has atrial fibrillation and takes warfarin (Coumadin).
4. Which terms would a nurse use to document abnormal posturing in an adult with a neurological
deficit? SATA
Answer: Decerebrate posturing
Decorticate posturing
5. Which nursing action has the highest priority for a patient who was admitted 16 hours previously
with a C5 spinal cord injury?
Answer: assessment of respiratory rate and effect.
6. When caring for a patient with a new right-sides homonymous hemianopsia resulting from a
stroke, which intervention should the nurse include in the plan of care?
Answer: place objects needed on the patients left side
7. When a 74-year-old patient is seen in the health clinic with new development of a stooped
posture, shuffling gait, and pill rolling- type tremor, the nurse will anticipate teaching the patient
about?
Answer: antiparkinsonian drugs
8. The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
, Answer: Electroencephalography (EEG)
9. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which
parameter should the nurse monitor to determine the medication’s effectiveness?
Answer: Intracranial pressure
10. After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being
monitored with an intraventricular catheter. Which information obtained by the nurse is most
important to communicate to the health care provider?
Answer: temperature 101.6 F
11. A school nurse is called after a student falls down a flight of stairs. The student is breathing, but
unconsciousness. After calling the ambulance, which is the most appropriate action by the
nurse?
Answer: immobilize the neck. Securing the head.
12. A person who stops talking mid-sentence and has a blank stare for 5 seconds would most likely
be experiencing?
Answer: a petit mal seizure
13. A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which
action can the nurse delegate to unlicensed assistive personnel (UPA) who regularly work in the
intensive care unit?
Answer: Check capillary blood glucose level every 6 hours
14. A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when
evaluating for adverse effects of the medication?
Answer: inspect the oral mucosa.
15. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with
pneumonia. Which nursing action will be included in the plan of care?
Answer: assist with active range of motion (ROM)
16. A patient has been admitted with meningococcal meningitis. Which observation by the nurse
requires action?
Answer: Unlicensed assistive personnel enter the patient’s room without a mask.
1. A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the
plan of care?
Answer: Keep the head of the bed elevated to 30 degrees.
2. A patient has been admitted with meningococcal meningitis. Which observation by the nurse
requires action?
Answer: Unlicensed assistive personnel enter the patient’s room without a mask.
3. A patient in the emergency department with sudden- onset right-sided weakness is diagnosed
with an intracerebral hemorrhage. Which information about the patient is most important to
communicate to the health care provider?
Answer: The patient has atrial fibrillation and takes warfarin (Coumadin).
4. Which terms would a nurse use to document abnormal posturing in an adult with a neurological
deficit? SATA
Answer: Decerebrate posturing
Decorticate posturing
5. Which nursing action has the highest priority for a patient who was admitted 16 hours previously
with a C5 spinal cord injury?
Answer: assessment of respiratory rate and effect.
6. When caring for a patient with a new right-sides homonymous hemianopsia resulting from a
stroke, which intervention should the nurse include in the plan of care?
Answer: place objects needed on the patients left side
7. When a 74-year-old patient is seen in the health clinic with new development of a stooped
posture, shuffling gait, and pill rolling- type tremor, the nurse will anticipate teaching the patient
about?
Answer: antiparkinsonian drugs
8. The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
, Answer: Electroencephalography (EEG)
9. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which
parameter should the nurse monitor to determine the medication’s effectiveness?
Answer: Intracranial pressure
10. After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being
monitored with an intraventricular catheter. Which information obtained by the nurse is most
important to communicate to the health care provider?
Answer: temperature 101.6 F
11. A school nurse is called after a student falls down a flight of stairs. The student is breathing, but
unconsciousness. After calling the ambulance, which is the most appropriate action by the
nurse?
Answer: immobilize the neck. Securing the head.
12. A person who stops talking mid-sentence and has a blank stare for 5 seconds would most likely
be experiencing?
Answer: a petit mal seizure
13. A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which
action can the nurse delegate to unlicensed assistive personnel (UPA) who regularly work in the
intensive care unit?
Answer: Check capillary blood glucose level every 6 hours
14. A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when
evaluating for adverse effects of the medication?
Answer: inspect the oral mucosa.
15. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with
pneumonia. Which nursing action will be included in the plan of care?
Answer: assist with active range of motion (ROM)
16. A patient has been admitted with meningococcal meningitis. Which observation by the nurse
requires action?
Answer: Unlicensed assistive personnel enter the patient’s room without a mask.
