CNS- Sensory and Motor Disorders NR 507
Questions correct answers (Already graded A+)
Exam 2025/2026 Chamberlain College of Nursing
1. The nurse is caring for a patient brought to the emergency
department after an automobile accident. The patient is fully
conscious. For what early signs of increased intracranial
pressure (ICP) should the nurse be alert?
a. Bradycardia
b. Hypothermia
c. Pinpoint pupils
d. Decreased level of consciousness
D. Decreased level of consciousness
Initial symptoms of increased ICP include restlessness,
irritability, and decreased level of consciousness, because
cerebral cortex function is impaired. If not intubated, the
patient may hyperventilate, causing vasoconstriction as the
body attempts to compensate. As the pressure increases, the
oculomotor nerve may be compressed on the side of the
impairment.
2. The vital signs for a client with a possible head injury were
on admission: blood pressure 128/72 mm Hg, pulse 90
beats/min, and respirations 66 breaths/min. Which vital sign
assessment conducted four hours later most likely indicates
the presence of increased intracranial pressure (ICP)?
,a. Blood pressure 172/68 mm Hg, pulse 42 beats/min,
respirations 10 breaths/min
b. Blood pressure 160/90 mm Hg, pulse 112 beats/min,
respirations 16 breaths/min
c. Blood pressure 130/72 mm Hg, pulse 50 beats/min,
respirations 24 breaths/min
d. Blood pressure 100/70 mm Hg, pulse 120 beats/min,
respirations 30 breaths/min
A. Blood pressure 172/68 mm Hg, pulse 42 beats/min,
respirations 10 breaths/min
Vital sign changes are a late indication of increasing ICP.
Cushing’s response is a classic late sign of increased ICP.
Cushing’s response (or Cushing’s triad) is characterized by
bradycardia, bradypnea, and arterial hypertension (increasing
systolic blood pressure while diastolic blood pressure remains
the same), resulting in widening pulse pressure.
3. A patient who was in an industrial accident has had a
sudden increase in intracranial pressure and is being prepared
for placement of an emergency subarachnoid bolt. Which
action should the nurse make a priority at this time?
a. Find out how the accident happened.
b. Ensure the patient is bathed before surgery.
c. Have the patients next of kin sign a consent form.
d. Send the patients belongings home with a family member.
,C. Have the patients next of kin sign a consent form
The patient is unlikely to be able to sign a consent form, and it
must be signed for surgery to begin
4. A patient with a severe headache due to viral meningitis
requests an opioid analgesic. What explanation about opioids
should the nurse provide?
a. Opioid analgesics increase intracranial pressure.
b. Opioid analgesics are used as a last resort for headaches.
c. Opioid analgesics are contraindicated in patients with
meningitis.
d. Acetaminophen (Tylenol) is more effective in treating
meningitis-related headaches.
B. Opioid analgesics are used as a last resort for headaches
Opioids are habit forming and are used only as a last resort for
headaches.
5. The nurse concludes that a patients meningitis is improving.
What activity did the patient perform for the nurse to come to
this conclusion?
a. Dorsiflex both feet.
b. Sit up and drink water.
c. Touch the chin to the chest.
d. Maintain a side-lying position in bed.
C. Touch the chin to the chest
, Ability to touch the chin to the chest indicates improvement in
nuchal rigidity
6. The nurse is assisting with teaching a patient about tension
headaches. Which explanation of tension headaches should
the nurse provide?
a. Tension headaches result from release of pain mediators in
the periphery.
b. Tension headaches are caused by stress, which causes
cerebral vessel constriction.
c. Tension headaches are a result of stress and sustained
muscle contraction of the head and neck.
d. Tension headaches are caused by blood sugar fluctuations
that result from excessive stress.
C. Tension headaches are a result of stress and sustained
muscle contraction of the head and neck
Persistent contraction of the scalp, facial, cervical, and upper
thoracic muscles can cause tension headaches. A cycle of
muscle tension, muscle tenderness, and further muscle tension
is established.
7. The nurse is determining care for a patient with acute
migraine headaches. What should the nurse teach the patient
to do first in order to determine a plan of care for the
headaches?
a. Keep a headache diary.
b. Avoid sugar and caffeine.
Questions correct answers (Already graded A+)
Exam 2025/2026 Chamberlain College of Nursing
1. The nurse is caring for a patient brought to the emergency
department after an automobile accident. The patient is fully
conscious. For what early signs of increased intracranial
pressure (ICP) should the nurse be alert?
a. Bradycardia
b. Hypothermia
c. Pinpoint pupils
d. Decreased level of consciousness
D. Decreased level of consciousness
Initial symptoms of increased ICP include restlessness,
irritability, and decreased level of consciousness, because
cerebral cortex function is impaired. If not intubated, the
patient may hyperventilate, causing vasoconstriction as the
body attempts to compensate. As the pressure increases, the
oculomotor nerve may be compressed on the side of the
impairment.
2. The vital signs for a client with a possible head injury were
on admission: blood pressure 128/72 mm Hg, pulse 90
beats/min, and respirations 66 breaths/min. Which vital sign
assessment conducted four hours later most likely indicates
the presence of increased intracranial pressure (ICP)?
,a. Blood pressure 172/68 mm Hg, pulse 42 beats/min,
respirations 10 breaths/min
b. Blood pressure 160/90 mm Hg, pulse 112 beats/min,
respirations 16 breaths/min
c. Blood pressure 130/72 mm Hg, pulse 50 beats/min,
respirations 24 breaths/min
d. Blood pressure 100/70 mm Hg, pulse 120 beats/min,
respirations 30 breaths/min
A. Blood pressure 172/68 mm Hg, pulse 42 beats/min,
respirations 10 breaths/min
Vital sign changes are a late indication of increasing ICP.
Cushing’s response is a classic late sign of increased ICP.
Cushing’s response (or Cushing’s triad) is characterized by
bradycardia, bradypnea, and arterial hypertension (increasing
systolic blood pressure while diastolic blood pressure remains
the same), resulting in widening pulse pressure.
3. A patient who was in an industrial accident has had a
sudden increase in intracranial pressure and is being prepared
for placement of an emergency subarachnoid bolt. Which
action should the nurse make a priority at this time?
a. Find out how the accident happened.
b. Ensure the patient is bathed before surgery.
c. Have the patients next of kin sign a consent form.
d. Send the patients belongings home with a family member.
,C. Have the patients next of kin sign a consent form
The patient is unlikely to be able to sign a consent form, and it
must be signed for surgery to begin
4. A patient with a severe headache due to viral meningitis
requests an opioid analgesic. What explanation about opioids
should the nurse provide?
a. Opioid analgesics increase intracranial pressure.
b. Opioid analgesics are used as a last resort for headaches.
c. Opioid analgesics are contraindicated in patients with
meningitis.
d. Acetaminophen (Tylenol) is more effective in treating
meningitis-related headaches.
B. Opioid analgesics are used as a last resort for headaches
Opioids are habit forming and are used only as a last resort for
headaches.
5. The nurse concludes that a patients meningitis is improving.
What activity did the patient perform for the nurse to come to
this conclusion?
a. Dorsiflex both feet.
b. Sit up and drink water.
c. Touch the chin to the chest.
d. Maintain a side-lying position in bed.
C. Touch the chin to the chest
, Ability to touch the chin to the chest indicates improvement in
nuchal rigidity
6. The nurse is assisting with teaching a patient about tension
headaches. Which explanation of tension headaches should
the nurse provide?
a. Tension headaches result from release of pain mediators in
the periphery.
b. Tension headaches are caused by stress, which causes
cerebral vessel constriction.
c. Tension headaches are a result of stress and sustained
muscle contraction of the head and neck.
d. Tension headaches are caused by blood sugar fluctuations
that result from excessive stress.
C. Tension headaches are a result of stress and sustained
muscle contraction of the head and neck
Persistent contraction of the scalp, facial, cervical, and upper
thoracic muscles can cause tension headaches. A cycle of
muscle tension, muscle tenderness, and further muscle tension
is established.
7. The nurse is determining care for a patient with acute
migraine headaches. What should the nurse teach the patient
to do first in order to determine a plan of care for the
headaches?
a. Keep a headache diary.
b. Avoid sugar and caffeine.
