Below is Exam 3 covering content: Neurological disorders (TBI, ICP, meningitis, stroke,
seizures), spinal cord injuries, neuromuscular disorders, burns, and endocrine disorders.
Neurological & Increased Intracranial Pressure
1. The nurse is caring for a patient with a traumatic brain injury (TBI). Which
finding should the nurse recognize as the earliest sign of neurologic deterioration?
A) Fixed pupils
B) Decreased level of consciousness
C) Decerebrate posturing
D) Cushing's triad
Answer: B
A change in level of consciousness (LOC) is the earliest indicator of neurologic
deterioration and must be reported immediately. It reflects changes in cerebral perfusion
and intracranial pressure before other signs appear .
2. A patient with a head injury has the following vital signs: P 56, R 14, BP 166/52
mm Hg. What does this indicate?
A) Normal vital signs
B) Cushing's triad indicating increased ICP
C) Hypovolemic shock
D) Sepsis
,Answer: B
Cushing's triad consists of bradycardia, hypertension with widened pulse pressure, and
irregular respirations. This is a late sign of increased intracranial pressure and requires
immediate intervention .
3. A patient has a Glasgow Coma Scale (GCS) score of 6. How should the nurse
interpret this finding?
A) Mild neurologic impairment
B) Moderate neurologic impairment
C) Patient is comatose
D) Normal neurologic status
Answer: C
A GCS score of 7 or less indicates coma and reflects severe neurologic dysfunction
requiring immediate intervention. GCS 13-15 is mild, 9-12 is moderate .
4. The nurse observes abnormal flexion of the patient's arms, wrists, and fingers
with plantar flexion of the legs. How should this finding be documented?
A) Decerebrate posturing
B) Flaccid paralysis
C) Decorticate posturing
D) Hemiparesis
Answer: C
Decorticate (flexor) posturing is characterized by flexion of the arms, wrists, and fingers
with internal rotation and plantar flexion of the legs. It indicates damage to the
corticospinal tracts .
5. A patient with a basilar skull fracture is suspected of having a CSF leak. Which
assessment finding supports this suspicion?
,A) Bloody drainage from ear
B) Halo sign on absorbent pad
C) Yellow nasal mucus
D) Clear sputum
Answer: B
CSF leakage can be identified by the halo sign, which appears as a clear or yellowish ring
surrounding a spot of blood on an absorbent pad. CSF contains glucose and is positive on
a glucose test strip .
6. The nurse is caring for a patient with a closed head injury who is receiving
mechanical ventilation and is at risk for developing increased ICP. Which action
should the nurse take?
A) Perform passive ROM to the patient's hips and knees
B) Log roll the patient during turning and repositioning
C) Elevate the foot of the patient's bed
D) Notify the charge nurse if PaCO₂ decreases from 39 to 35 mm Hg
Answer: B
Log rolling maintains spinal alignment and prevents sudden movement that could
increase ICP. Hip flexion should be avoided, and head of bed should be elevated 30-45
degrees .
7. The nurse is caring for a patient who sustained a closed head injury. Which
intervention should be included in the plan of care to prevent increased ICP?
A) Cluster all care activities together to minimize disturbance
B) Maintain the head in a flexed position
C) Provide a quiet environment by limiting visitors
D) Keep hips in a flexed position
Answer: C
A quiet environment with minimal stimulation helps prevent increases in ICP. Clustering
care activities should be avoided as multiple stimuli can dramatically elevate ICP. The
head should remain in a midline, neutral position .
, 8. A patient 24 hours post-craniotomy reports a headache rated 8/10. Which
action should the nurse take first?
A) Administer prescribed pain medication
B) Perform a neurological assessment
C) Notify the provider
D) Apply a cold compress
Answer: B
Severe headache after craniotomy may indicate increased ICP. A neurological assessment
should be performed first to evaluate for other signs of deterioration before administering
medication .
9. Which assessment finding is associated with Cushing's triad, indicating
increased ICP?
A) Tachycardia and hypotension
B) Widened pulse pressure and bradycardia
C) Fever and tachypnea
D) Narrowed pulse pressure and tachycardia
Answer: B
Cushing's triad includes severe hypertension with widened pulse pressure, bradycardia,
and irregular respirations. This is a late, ominous sign of increased ICP .
10. A patient with a TBI has a change in BP from 110/58 to 134/40 mm Hg. What
should the nurse do?
A) Document the finding as normal
B) Notify the provider immediately
C) Increase IV fluids
D) Administer antihypertensives
seizures), spinal cord injuries, neuromuscular disorders, burns, and endocrine disorders.
Neurological & Increased Intracranial Pressure
1. The nurse is caring for a patient with a traumatic brain injury (TBI). Which
finding should the nurse recognize as the earliest sign of neurologic deterioration?
A) Fixed pupils
B) Decreased level of consciousness
C) Decerebrate posturing
D) Cushing's triad
Answer: B
A change in level of consciousness (LOC) is the earliest indicator of neurologic
deterioration and must be reported immediately. It reflects changes in cerebral perfusion
and intracranial pressure before other signs appear .
2. A patient with a head injury has the following vital signs: P 56, R 14, BP 166/52
mm Hg. What does this indicate?
A) Normal vital signs
B) Cushing's triad indicating increased ICP
C) Hypovolemic shock
D) Sepsis
,Answer: B
Cushing's triad consists of bradycardia, hypertension with widened pulse pressure, and
irregular respirations. This is a late sign of increased intracranial pressure and requires
immediate intervention .
3. A patient has a Glasgow Coma Scale (GCS) score of 6. How should the nurse
interpret this finding?
A) Mild neurologic impairment
B) Moderate neurologic impairment
C) Patient is comatose
D) Normal neurologic status
Answer: C
A GCS score of 7 or less indicates coma and reflects severe neurologic dysfunction
requiring immediate intervention. GCS 13-15 is mild, 9-12 is moderate .
4. The nurse observes abnormal flexion of the patient's arms, wrists, and fingers
with plantar flexion of the legs. How should this finding be documented?
A) Decerebrate posturing
B) Flaccid paralysis
C) Decorticate posturing
D) Hemiparesis
Answer: C
Decorticate (flexor) posturing is characterized by flexion of the arms, wrists, and fingers
with internal rotation and plantar flexion of the legs. It indicates damage to the
corticospinal tracts .
5. A patient with a basilar skull fracture is suspected of having a CSF leak. Which
assessment finding supports this suspicion?
,A) Bloody drainage from ear
B) Halo sign on absorbent pad
C) Yellow nasal mucus
D) Clear sputum
Answer: B
CSF leakage can be identified by the halo sign, which appears as a clear or yellowish ring
surrounding a spot of blood on an absorbent pad. CSF contains glucose and is positive on
a glucose test strip .
6. The nurse is caring for a patient with a closed head injury who is receiving
mechanical ventilation and is at risk for developing increased ICP. Which action
should the nurse take?
A) Perform passive ROM to the patient's hips and knees
B) Log roll the patient during turning and repositioning
C) Elevate the foot of the patient's bed
D) Notify the charge nurse if PaCO₂ decreases from 39 to 35 mm Hg
Answer: B
Log rolling maintains spinal alignment and prevents sudden movement that could
increase ICP. Hip flexion should be avoided, and head of bed should be elevated 30-45
degrees .
7. The nurse is caring for a patient who sustained a closed head injury. Which
intervention should be included in the plan of care to prevent increased ICP?
A) Cluster all care activities together to minimize disturbance
B) Maintain the head in a flexed position
C) Provide a quiet environment by limiting visitors
D) Keep hips in a flexed position
Answer: C
A quiet environment with minimal stimulation helps prevent increases in ICP. Clustering
care activities should be avoided as multiple stimuli can dramatically elevate ICP. The
head should remain in a midline, neutral position .
, 8. A patient 24 hours post-craniotomy reports a headache rated 8/10. Which
action should the nurse take first?
A) Administer prescribed pain medication
B) Perform a neurological assessment
C) Notify the provider
D) Apply a cold compress
Answer: B
Severe headache after craniotomy may indicate increased ICP. A neurological assessment
should be performed first to evaluate for other signs of deterioration before administering
medication .
9. Which assessment finding is associated with Cushing's triad, indicating
increased ICP?
A) Tachycardia and hypotension
B) Widened pulse pressure and bradycardia
C) Fever and tachypnea
D) Narrowed pulse pressure and tachycardia
Answer: B
Cushing's triad includes severe hypertension with widened pulse pressure, bradycardia,
and irregular respirations. This is a late, ominous sign of increased ICP .
10. A patient with a TBI has a change in BP from 110/58 to 134/40 mm Hg. What
should the nurse do?
A) Document the finding as normal
B) Notify the provider immediately
C) Increase IV fluids
D) Administer antihypertensives
