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ATI ADULT MEDICAL SURGICAL NURSING – UNIT 2 Neurologic
System 120 Questions with Rationales
SECTION 1: NEUROLOGIC ASSESSMENT & DIAGNOSTIC
PROCEDURES
1. A nurse is assessing a client's level of consciousness using the
Glasgow Coma Scale (GCS). The client opens eyes to pain,
makes incomprehensible sounds, and withdraws from painful
stimuli. What is the GCS score?
A. 6
B. 7
C. 8
D. 9
Answer: C
Rationale: Eye opening to pain = 2; incomprehensible sounds =
2; withdrawal to pain = 4. Total = 8.
2. Which of the following is the earliest indicator of a change in
neurologic status?
A. Pupil size
B. Level of consciousness
C. Motor strength
D. Vital signs
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Answer: B
Rationale: A change in level of consciousness is the earliest and
most sensitive indicator of neurologic deterioration.
3. A nurse is assessing a client's pupils. Which finding indicates
increased intracranial pressure?
A. Bilateral constricted pupils
B. Unilateral dilated, nonreactive pupil
C. Bilateral pinpoint pupils
D. Equal, reactive pupils
Answer: B
Rationale: A unilateral dilated nonreactive pupil suggests
compression of cranial nerve III from increased ICP/herniation.
4. Which of the following is a component of the Glasgow Coma
Scale?
A. Pupil response
B. Eye opening, verbal response, motor response
C. Deep tendon reflexes
D. Sensory function
Answer: B
Rationale: GCS assesses eye opening, verbal response, and
motor response.
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5. A nurse is preparing a client for a lumbar puncture. Which
instruction is appropriate?
A. "You will lie supine during the procedure."
B. "You will be positioned with your knees drawn to your chest."
C. "You will be in a sitting position only."
D. "You will be standing."
Answer: B
Rationale: For lumbar puncture, the client is positioned in
lateral recumbent with knees drawn up or sitting leaning
forward to open the intervertebral spaces.
6. After a lumbar puncture, the nurse should instruct the client
to:
A. Sit upright immediately
B. Lie flat for several hours to prevent headache
C. Ambulate frequently
D. Increase fluid restriction
Answer: B
Rationale: Lying flat reduces the risk of post-lumbar puncture
headache from CSF leakage.
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7. A nurse is assessing a client for meningeal irritation. Which
finding indicates a positive Kernig's sign?
A. Flexion of the neck causes hip and knee flexion
B. Inability to extend the knee when the hip is flexed
C. Dorsiflexion of the foot causes calf pain
D. Nuchal rigidity only
Answer: B
Rationale: Kernig's sign is positive when the knee cannot be
fully extended with the hip flexed due to meningeal irritation.
Nuchal rigidity and Brudzinski's sign are also meningeal signs.
8. A client is scheduled for an electroencephalogram (EEG).
Which instruction should the nurse provide?
A. "You may drink coffee before the test."
B. "Wash your hair and avoid using hair products."
C. "Take a sedative before the test."
D. "You will be NPO for 12 hours."
Answer: B
Rationale: For EEG, the client should have clean hair without
products to ensure electrode contact. Caffeine and sedatives
may alter results; NPO not required.
ATI ADULT MEDICAL SURGICAL NURSING – UNIT 2 Neurologic
System 120 Questions with Rationales
SECTION 1: NEUROLOGIC ASSESSMENT & DIAGNOSTIC
PROCEDURES
1. A nurse is assessing a client's level of consciousness using the
Glasgow Coma Scale (GCS). The client opens eyes to pain,
makes incomprehensible sounds, and withdraws from painful
stimuli. What is the GCS score?
A. 6
B. 7
C. 8
D. 9
Answer: C
Rationale: Eye opening to pain = 2; incomprehensible sounds =
2; withdrawal to pain = 4. Total = 8.
2. Which of the following is the earliest indicator of a change in
neurologic status?
A. Pupil size
B. Level of consciousness
C. Motor strength
D. Vital signs
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Answer: B
Rationale: A change in level of consciousness is the earliest and
most sensitive indicator of neurologic deterioration.
3. A nurse is assessing a client's pupils. Which finding indicates
increased intracranial pressure?
A. Bilateral constricted pupils
B. Unilateral dilated, nonreactive pupil
C. Bilateral pinpoint pupils
D. Equal, reactive pupils
Answer: B
Rationale: A unilateral dilated nonreactive pupil suggests
compression of cranial nerve III from increased ICP/herniation.
4. Which of the following is a component of the Glasgow Coma
Scale?
A. Pupil response
B. Eye opening, verbal response, motor response
C. Deep tendon reflexes
D. Sensory function
Answer: B
Rationale: GCS assesses eye opening, verbal response, and
motor response.
, Page |3
5. A nurse is preparing a client for a lumbar puncture. Which
instruction is appropriate?
A. "You will lie supine during the procedure."
B. "You will be positioned with your knees drawn to your chest."
C. "You will be in a sitting position only."
D. "You will be standing."
Answer: B
Rationale: For lumbar puncture, the client is positioned in
lateral recumbent with knees drawn up or sitting leaning
forward to open the intervertebral spaces.
6. After a lumbar puncture, the nurse should instruct the client
to:
A. Sit upright immediately
B. Lie flat for several hours to prevent headache
C. Ambulate frequently
D. Increase fluid restriction
Answer: B
Rationale: Lying flat reduces the risk of post-lumbar puncture
headache from CSF leakage.
, Page |4
7. A nurse is assessing a client for meningeal irritation. Which
finding indicates a positive Kernig's sign?
A. Flexion of the neck causes hip and knee flexion
B. Inability to extend the knee when the hip is flexed
C. Dorsiflexion of the foot causes calf pain
D. Nuchal rigidity only
Answer: B
Rationale: Kernig's sign is positive when the knee cannot be
fully extended with the hip flexed due to meningeal irritation.
Nuchal rigidity and Brudzinski's sign are also meningeal signs.
8. A client is scheduled for an electroencephalogram (EEG).
Which instruction should the nurse provide?
A. "You may drink coffee before the test."
B. "Wash your hair and avoid using hair products."
C. "Take a sedative before the test."
D. "You will be NPO for 12 hours."
Answer: B
Rationale: For EEG, the client should have clean hair without
products to ensure electrode contact. Caffeine and sedatives
may alter results; NPO not required.
