CVA NCLEX PRACTICE EXAM
CVA NCLEX PRACTICE EXAM 1 Complete
Questions And Correct Detailed Answers with
Rationales Graded A+ Guaranteed Pass
A patient with bacterial meningitis has photophobia and severe neck stiffness. Which nursing
intervention is priority?
a. Provide a dark, quiet room with a cool cloth over eyes
b. Place the patient in high Fowler’s position
c. Administer diuretics to reduce ICP
d. Use bright light for orientation
a. Provide a dark, quiet room with a cool cloth over eyes
Rationale: Reducing environmental stimuli decreases pain and photophobia.
Bright lights (d) worsen symptoms; diuretics (c) are not first-line comfort care.
Which cerebrospinal fluid (CSF) finding best supports bacterial meningitis?
a. Clear fluid with lymphocytosis
A+ TEST BANK 1
, CVA NCLEX PRACTICE EXAM
b. Cloudy, purulent fluid with neutrophils
c. Yellow fluid with high protein
d. Pink-tinged fluid with low glucose
b. Cloudy, purulent fluid with neutrophils
Rationale: Bacterial meningitis produces cloudy CSF, elevated protein, low glucose, and
neutrophilic predominance. Viral infections show clear CSF with lymphocytes.
What is the normal range for intracranial pressure (ICP) in an adult patient?
a. 0–5 mmHg
b. 5–15 mmHg
c. 15–25 mmHg
d. 25–30 mmHg
b. 5–15 mmHg
Rationale: Normal ICP is 5–15 mmHg. Sustained pressure ≥20 mmHg is abnormal and requires
immediate intervention to prevent ischemia and brain death.
A patient with traumatic brain injury has a sustained ICP of 22 mmHg. What is the nurse’s
priority action?
a. Continue monitoring for changes in mental status
b. Document findings and reassess in 1 hour
c. Notify the healthcare provider immediately
d. Place the patient in the Trendelenburg position
c. Notify the healthcare provider immediately
Rationale: Sustained ICP ≥20 mmHg is life-threatening and requires urgent intervention.
Trendelenburg worsens ICP, and delaying care risks ischemia and brain death.
According to the Monro-Kellie Doctrine, which components must remain in balance within the
skull?
a. Brain tissue, cerebrospinal fluid (CSF), cerebral blood
b. Brain tissue, oxygen, electrolytes
c. Cerebral arteries, jugular veins, CSF
A+ TEST BANK 2
, CVA NCLEX PRACTICE EXAM
d. Skull, meninges, cerebral tissue
a. Brain tissue, cerebrospinal fluid (CSF), cerebral blood
Rationale: The Monro-Kellie Doctrine states that the skull is a closed space containing brain
tissue, blood, and CSF. If one increases, the others must decrease or ICP rises.
Which cerebral perfusion pressure (CPP) value is considered the minimum to maintain adequate
brain perfusion?
a. 40 mmHg
b. 50 mmHg
c. 60 mmHg
d. 70 mmHg
c. 60 mmHg
Rationale: Normal CPP is 60–100 mmHg. A CPP <60 leads to cerebral ischemia, while maintaining
CPP ≥60 ensures adequate oxygen and glucose delivery to the brain.
Which assessment finding is part of Cushing’s Triad?
a. Hypertension with widened pulse pressure
b. Tachycardia with weak pulse
c. Bradypnea with shallow respirations
d. Hypotension with tachypnea
a. Hypertension with widened pulse pressure
Rationale: Cushing’s Triad includes systolic hypertension with widened pulse pressure (>60
mmHg), bradycardia with bounding pulse, and irregular respirations.
A patient’s pupillary exam shows a fixed, dilated left pupil. What does this most likely indicate?
a. Oculomotor nerve compression from increased ICP
b. Optic nerve impairment
c. Normal aging change
d. Early seizure activity
a. Oculomotor nerve compression from increased ICP
A+ TEST BANK 3
, CVA NCLEX PRACTICE EXAM
Rationale: Compression of cranial nerve III (oculomotor) from rising ICP causes fixed, dilated
pupils. It is an ominous late sign of brain herniation.
What type of posturing is shown when a patient exhibits abnormal flexion of the arms to the
chest?
a. Decerebrate posturing
b. Decorticate posturing
c. Opisthotonic posturing
d. Flaccid posturing
b. Decorticate posturing
Rationale:
Decorticate posturing = flexion of arms toward the core.
Decerebrate = extension.
Opisthotonic = rigid arching.
Flaccid = no motor response.
Which diagnostic study is the priority for evaluating suspected head trauma with possible bleed?
a. MRI with contrast
b. CT scan without contrast
c. PET scan
d. Lumbar puncture
b. CT scan without contrast
Rationale: CT without contrast is the rapid, best test for acute head injury and bleed. Lumbar
puncture is contraindicated in suspected ↑ ICP due to herniation risk.
What is the normal brain tissue oxygen pressure (PbtO₂)?
a. 10–20 mmHg
b. 20–40 mmHg
c. 40–60 mmHg
d. 60–80 mmHg
A+ TEST BANK 4
CVA NCLEX PRACTICE EXAM 1 Complete
Questions And Correct Detailed Answers with
Rationales Graded A+ Guaranteed Pass
A patient with bacterial meningitis has photophobia and severe neck stiffness. Which nursing
intervention is priority?
a. Provide a dark, quiet room with a cool cloth over eyes
b. Place the patient in high Fowler’s position
c. Administer diuretics to reduce ICP
d. Use bright light for orientation
a. Provide a dark, quiet room with a cool cloth over eyes
Rationale: Reducing environmental stimuli decreases pain and photophobia.
Bright lights (d) worsen symptoms; diuretics (c) are not first-line comfort care.
Which cerebrospinal fluid (CSF) finding best supports bacterial meningitis?
a. Clear fluid with lymphocytosis
A+ TEST BANK 1
, CVA NCLEX PRACTICE EXAM
b. Cloudy, purulent fluid with neutrophils
c. Yellow fluid with high protein
d. Pink-tinged fluid with low glucose
b. Cloudy, purulent fluid with neutrophils
Rationale: Bacterial meningitis produces cloudy CSF, elevated protein, low glucose, and
neutrophilic predominance. Viral infections show clear CSF with lymphocytes.
What is the normal range for intracranial pressure (ICP) in an adult patient?
a. 0–5 mmHg
b. 5–15 mmHg
c. 15–25 mmHg
d. 25–30 mmHg
b. 5–15 mmHg
Rationale: Normal ICP is 5–15 mmHg. Sustained pressure ≥20 mmHg is abnormal and requires
immediate intervention to prevent ischemia and brain death.
A patient with traumatic brain injury has a sustained ICP of 22 mmHg. What is the nurse’s
priority action?
a. Continue monitoring for changes in mental status
b. Document findings and reassess in 1 hour
c. Notify the healthcare provider immediately
d. Place the patient in the Trendelenburg position
c. Notify the healthcare provider immediately
Rationale: Sustained ICP ≥20 mmHg is life-threatening and requires urgent intervention.
Trendelenburg worsens ICP, and delaying care risks ischemia and brain death.
According to the Monro-Kellie Doctrine, which components must remain in balance within the
skull?
a. Brain tissue, cerebrospinal fluid (CSF), cerebral blood
b. Brain tissue, oxygen, electrolytes
c. Cerebral arteries, jugular veins, CSF
A+ TEST BANK 2
, CVA NCLEX PRACTICE EXAM
d. Skull, meninges, cerebral tissue
a. Brain tissue, cerebrospinal fluid (CSF), cerebral blood
Rationale: The Monro-Kellie Doctrine states that the skull is a closed space containing brain
tissue, blood, and CSF. If one increases, the others must decrease or ICP rises.
Which cerebral perfusion pressure (CPP) value is considered the minimum to maintain adequate
brain perfusion?
a. 40 mmHg
b. 50 mmHg
c. 60 mmHg
d. 70 mmHg
c. 60 mmHg
Rationale: Normal CPP is 60–100 mmHg. A CPP <60 leads to cerebral ischemia, while maintaining
CPP ≥60 ensures adequate oxygen and glucose delivery to the brain.
Which assessment finding is part of Cushing’s Triad?
a. Hypertension with widened pulse pressure
b. Tachycardia with weak pulse
c. Bradypnea with shallow respirations
d. Hypotension with tachypnea
a. Hypertension with widened pulse pressure
Rationale: Cushing’s Triad includes systolic hypertension with widened pulse pressure (>60
mmHg), bradycardia with bounding pulse, and irregular respirations.
A patient’s pupillary exam shows a fixed, dilated left pupil. What does this most likely indicate?
a. Oculomotor nerve compression from increased ICP
b. Optic nerve impairment
c. Normal aging change
d. Early seizure activity
a. Oculomotor nerve compression from increased ICP
A+ TEST BANK 3
, CVA NCLEX PRACTICE EXAM
Rationale: Compression of cranial nerve III (oculomotor) from rising ICP causes fixed, dilated
pupils. It is an ominous late sign of brain herniation.
What type of posturing is shown when a patient exhibits abnormal flexion of the arms to the
chest?
a. Decerebrate posturing
b. Decorticate posturing
c. Opisthotonic posturing
d. Flaccid posturing
b. Decorticate posturing
Rationale:
Decorticate posturing = flexion of arms toward the core.
Decerebrate = extension.
Opisthotonic = rigid arching.
Flaccid = no motor response.
Which diagnostic study is the priority for evaluating suspected head trauma with possible bleed?
a. MRI with contrast
b. CT scan without contrast
c. PET scan
d. Lumbar puncture
b. CT scan without contrast
Rationale: CT without contrast is the rapid, best test for acute head injury and bleed. Lumbar
puncture is contraindicated in suspected ↑ ICP due to herniation risk.
What is the normal brain tissue oxygen pressure (PbtO₂)?
a. 10–20 mmHg
b. 20–40 mmHg
c. 40–60 mmHg
d. 60–80 mmHg
A+ TEST BANK 4
