Rasmussen University NUR 2243 Module 7 (pdf) | 2026/2027 | Prof
Nursing Skills I Q&A | Nursing
1. Which of the following best describes the Monro-Kellie doctrine?
A) The brain can expand indefinitely to accommodate increased volume
B) The total volume of the intracranial contents (brain, blood, and CSF)
remains constant, and an increase in one must be compensated by a
decrease in another
C) Intracranial pressure is directly proportional to the patient's age
D) The skull is flexible and can expand to accommodate swelling
Correct Answer: The total volume of the intracranial contents (brain, blood,
and CSF) remains constant, and an increase in one must be compensated by
a decrease in another
Rationale: The Monro-Kellie doctrine states that the cranial compartment is
incompressible, and the total volume of its contents (brain tissue, blood, and
cerebrospinal fluid) must remain constant. An increase in any one
component necessitates a compensatory decrease in another to maintain
normal intracranial pressure. Failure of this compensation leads to increased
ICP.
2. A nurse is assessing a client with a suspected increase in intracranial
pressure. Which assessment finding is the earliest and most sensitive
indicator of this condition?
A) Pupillary dilation
B) Bradycardia and hypertension
C) Changes in level of consciousness
D) Decerebrate posturing
Correct Answer: Changes in level of consciousness
,Rationale: Changes in level of consciousness (LOC), such as restlessness,
confusion, and lethargy, are the earliest and most sensitive indicators of
increased ICP. Pupillary changes, abnormal posturing, and Cushing's triad
(bradycardia, hypertension, irregular respirations) are late signs.
3. A client with increased intracranial pressure exhibits a blood pressure of
180/100 mm Hg, a heart rate of 50 beats per minute, and irregular
respirations. The nurse recognizes this as:
A) Cushing's triad
B) Kernig's sign
C) Brudzinski's sign
D) Battle's sign
Correct Answer: Cushing's triad
Rationale: Cushing's triad—hypertension, bradycardia, and irregular
respirations—is a late and ominous sign of increased ICP, indicating brain
herniation is imminent. It requires immediate intervention. Kernig's and
Brudzinski's signs are associated with meningitis, and Battle's sign indicates
a basilar skull fracture.
4. A client has a Glasgow Coma Scale (GCS) score of 15. The nurse interprets
this score as:
A) The client is comatose
B) The client is critically ill with a poor prognosis
C) The client is fully alert and oriented
D) The client has a moderate neurological deficit
Correct Answer: The client is fully alert and oriented
,Rationale: The GCS is a standardized tool used to assess a client's level of
consciousness. The highest possible score is 15, indicating the client is fully
alert, oriented, and able to follow commands. A score of 8 or less generally
indicates a coma.
5. A client opens eyes only to painful stimuli, makes incomprehensible
sounds, and demonstrates abnormal flexion (decorticate posturing) to pain.
What is this client's GCS score?
A) 6
B) 7
C) 8
D) 9
Correct Answer: 7
Rationale: The GCS evaluates eye opening (1-4), verbal response (1-5), and
motor response (1-6). Opening eyes to pain = 2 points, incomprehensible
sounds = 2 points, and abnormal flexion = 3 points. The total score of 7
indicates severe neurological impairment.
6. A nurse is preparing a client for a lumbar puncture. Which action is most
important for the nurse to take?
A) Place the client in a supine position
B) Have the client void to empty the bladder
C) Administer a sedative
D) Ensure the client is NPO for 8 hours
Correct Answer: Have the client void to empty the bladder
, Rationale: Before a lumbar puncture, the client should void to empty the
bladder and prevent discomfort during the procedure. The client is positioned
in a lateral recumbent (fetal) position, not supine. NPO status is not typically
required.
7. After a lumbar puncture, the nurse should place the client in which
position?
A) Supine
B) Prone
C) Flat (supine)
D) High Fowler's
Correct Answer: Flat (supine)
Rationale: After a lumbar puncture, the client should lie flat (supine) to
prevent a post-procedure headache from cerebrospinal fluid (CSF) leakage.
This position helps maintain CSF pressure and reduce the risk of a spinal
headache.
8. A nurse is assessing a client after a lumbar puncture. Which finding should
be reported to the provider immediately?
A) Clear cerebrospinal fluid
B) Headache that is relieved by lying flat
C) Blood-tinged cerebrospinal fluid
D) Slight discomfort at the insertion site
Correct Answer: Blood-tinged cerebrospinal fluid
Rationale: Blood-tinged CSF after a lumbar puncture may indicate trauma or
bleeding and should be reported immediately. Clear CSF is a normal finding.
Nursing Skills I Q&A | Nursing
1. Which of the following best describes the Monro-Kellie doctrine?
A) The brain can expand indefinitely to accommodate increased volume
B) The total volume of the intracranial contents (brain, blood, and CSF)
remains constant, and an increase in one must be compensated by a
decrease in another
C) Intracranial pressure is directly proportional to the patient's age
D) The skull is flexible and can expand to accommodate swelling
Correct Answer: The total volume of the intracranial contents (brain, blood,
and CSF) remains constant, and an increase in one must be compensated by
a decrease in another
Rationale: The Monro-Kellie doctrine states that the cranial compartment is
incompressible, and the total volume of its contents (brain tissue, blood, and
cerebrospinal fluid) must remain constant. An increase in any one
component necessitates a compensatory decrease in another to maintain
normal intracranial pressure. Failure of this compensation leads to increased
ICP.
2. A nurse is assessing a client with a suspected increase in intracranial
pressure. Which assessment finding is the earliest and most sensitive
indicator of this condition?
A) Pupillary dilation
B) Bradycardia and hypertension
C) Changes in level of consciousness
D) Decerebrate posturing
Correct Answer: Changes in level of consciousness
,Rationale: Changes in level of consciousness (LOC), such as restlessness,
confusion, and lethargy, are the earliest and most sensitive indicators of
increased ICP. Pupillary changes, abnormal posturing, and Cushing's triad
(bradycardia, hypertension, irregular respirations) are late signs.
3. A client with increased intracranial pressure exhibits a blood pressure of
180/100 mm Hg, a heart rate of 50 beats per minute, and irregular
respirations. The nurse recognizes this as:
A) Cushing's triad
B) Kernig's sign
C) Brudzinski's sign
D) Battle's sign
Correct Answer: Cushing's triad
Rationale: Cushing's triad—hypertension, bradycardia, and irregular
respirations—is a late and ominous sign of increased ICP, indicating brain
herniation is imminent. It requires immediate intervention. Kernig's and
Brudzinski's signs are associated with meningitis, and Battle's sign indicates
a basilar skull fracture.
4. A client has a Glasgow Coma Scale (GCS) score of 15. The nurse interprets
this score as:
A) The client is comatose
B) The client is critically ill with a poor prognosis
C) The client is fully alert and oriented
D) The client has a moderate neurological deficit
Correct Answer: The client is fully alert and oriented
,Rationale: The GCS is a standardized tool used to assess a client's level of
consciousness. The highest possible score is 15, indicating the client is fully
alert, oriented, and able to follow commands. A score of 8 or less generally
indicates a coma.
5. A client opens eyes only to painful stimuli, makes incomprehensible
sounds, and demonstrates abnormal flexion (decorticate posturing) to pain.
What is this client's GCS score?
A) 6
B) 7
C) 8
D) 9
Correct Answer: 7
Rationale: The GCS evaluates eye opening (1-4), verbal response (1-5), and
motor response (1-6). Opening eyes to pain = 2 points, incomprehensible
sounds = 2 points, and abnormal flexion = 3 points. The total score of 7
indicates severe neurological impairment.
6. A nurse is preparing a client for a lumbar puncture. Which action is most
important for the nurse to take?
A) Place the client in a supine position
B) Have the client void to empty the bladder
C) Administer a sedative
D) Ensure the client is NPO for 8 hours
Correct Answer: Have the client void to empty the bladder
, Rationale: Before a lumbar puncture, the client should void to empty the
bladder and prevent discomfort during the procedure. The client is positioned
in a lateral recumbent (fetal) position, not supine. NPO status is not typically
required.
7. After a lumbar puncture, the nurse should place the client in which
position?
A) Supine
B) Prone
C) Flat (supine)
D) High Fowler's
Correct Answer: Flat (supine)
Rationale: After a lumbar puncture, the client should lie flat (supine) to
prevent a post-procedure headache from cerebrospinal fluid (CSF) leakage.
This position helps maintain CSF pressure and reduce the risk of a spinal
headache.
8. A nurse is assessing a client after a lumbar puncture. Which finding should
be reported to the provider immediately?
A) Clear cerebrospinal fluid
B) Headache that is relieved by lying flat
C) Blood-tinged cerebrospinal fluid
D) Slight discomfort at the insertion site
Correct Answer: Blood-tinged cerebrospinal fluid
Rationale: Blood-tinged CSF after a lumbar puncture may indicate trauma or
bleeding and should be reported immediately. Clear CSF is a normal finding.
