NUR 004 EXAM SCRIPT 2 2026 QUESTIONS
WITH SOLUTIONS GRADED A+
◉ Head injuries- open vs. closed. Which has the highest risk for
infection. Answer: Open: penetration to the skull *high risk for
infection
Closed: no penetration to the skill
◉ T/F: You can remove a collar off of a cervical spine injury patient
when they come to the ER. Answer: False! Never remove a stabilizer
collar until orders allow
◉ What is the earliest indication of neuro trauma?. Answer: Level of
consciousness
◉ Level of consciousness- full consciousness. Answer: Child is awake
and alert, oriented to time, place, and person age-appropriately
◉ Level of consciousness- confused. Answer: Child is disorientated,
alert but responds inappropriately to questions
◉ Level of consciousness- obtunded. Answer: Child has limited
responses to the environment and falls asleep unless stimulated
,◉ Level of consciousness- stupor. Answer: Child only responds only
to vigorous stimulation
◉ Level of consciousness- coma. Answer: Child cannot be aroused,
even with painful stimuli
◉ What is the Glascow Coma Scale? What does a lower score
indicate?. Answer: Assessment tool used to determine level of
consciousness and suggest proper tools + interventions to be used
The lower the score is, the worse the LOC is
◉ Early signs of increased intracranial pressure- infants (6). Answer:
Bulging fontanelles
Weak sutures
Increased head circumference
Dilated scalp veins
High-pitched cry
Sun-setting eyes
◉ Early signs of increased intracranial pressure- children (6).
Answer: Headache
, N/V
Blurred and/or dizzy vision
Lethargy
Changes in LOC
Irritability
◉ Late changes of increased intracranial pressure (5). Answer:
Lower LOC
Decreased motor and sensory responses
Bradycardia
Irregular respirations (children vs. infants)
Cheyne-stokes respiration
◉ Ocular motor function- Sunset eyes. Answer: Sclera can be seen
between upper eyelids and the iris, the lower part of the eye is
covered by the lower eyelid *appears to be looking down
◉ Ocular motor function-Doll's eye maneuver. Answer: Abnormal
neurological response when eyes move with the head when turned
◉ Ocular motor function- neurosurgical emergency that needs to be
immediately reported. Answer: Sudden presence of fixed and dilated
pupils
WITH SOLUTIONS GRADED A+
◉ Head injuries- open vs. closed. Which has the highest risk for
infection. Answer: Open: penetration to the skull *high risk for
infection
Closed: no penetration to the skill
◉ T/F: You can remove a collar off of a cervical spine injury patient
when they come to the ER. Answer: False! Never remove a stabilizer
collar until orders allow
◉ What is the earliest indication of neuro trauma?. Answer: Level of
consciousness
◉ Level of consciousness- full consciousness. Answer: Child is awake
and alert, oriented to time, place, and person age-appropriately
◉ Level of consciousness- confused. Answer: Child is disorientated,
alert but responds inappropriately to questions
◉ Level of consciousness- obtunded. Answer: Child has limited
responses to the environment and falls asleep unless stimulated
,◉ Level of consciousness- stupor. Answer: Child only responds only
to vigorous stimulation
◉ Level of consciousness- coma. Answer: Child cannot be aroused,
even with painful stimuli
◉ What is the Glascow Coma Scale? What does a lower score
indicate?. Answer: Assessment tool used to determine level of
consciousness and suggest proper tools + interventions to be used
The lower the score is, the worse the LOC is
◉ Early signs of increased intracranial pressure- infants (6). Answer:
Bulging fontanelles
Weak sutures
Increased head circumference
Dilated scalp veins
High-pitched cry
Sun-setting eyes
◉ Early signs of increased intracranial pressure- children (6).
Answer: Headache
, N/V
Blurred and/or dizzy vision
Lethargy
Changes in LOC
Irritability
◉ Late changes of increased intracranial pressure (5). Answer:
Lower LOC
Decreased motor and sensory responses
Bradycardia
Irregular respirations (children vs. infants)
Cheyne-stokes respiration
◉ Ocular motor function- Sunset eyes. Answer: Sclera can be seen
between upper eyelids and the iris, the lower part of the eye is
covered by the lower eyelid *appears to be looking down
◉ Ocular motor function-Doll's eye maneuver. Answer: Abnormal
neurological response when eyes move with the head when turned
◉ Ocular motor function- neurosurgical emergency that needs to be
immediately reported. Answer: Sudden presence of fixed and dilated
pupils
