©Jason McConnel 2025 ALL RIGHTS RESERVED.
Acute Intracranial Problems. Exam
Questions With Correct Answers A+
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of
the ventriculostomy system being used for intracranial pressure monitoring. Which response by
the nurse is best?
a. "This type of monitoring system is complex and it is managed by skilled staff."
b. "The monitoring system helps show whether blood flow to the brain is adequate."
c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion
pressure."
d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid
drainage." - Answer✔b. "The monitoring system helps show whether blood flow to the brain is
adequate."
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and
respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern
to the nurse?
a. Blood pressure 154/68, pulse 56, respirations 12
b. Blood pressure 134/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30 - Answer✔a. Blood pressure 154/68, pulse
56, respirations 12
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and
flexion of the arms, the nurse reports the response as
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing. - Answer✔c. decorticate posturing.
1|Page
, ©Jason McConnel 2025 ALL RIGHTS RESERVED.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which
parameter should the nurse monitor to determine the medication's effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit - Answer✔c. Intracranial pressure
A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to push away a
painful stimulus. The nurse records the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15. - Answer✔b. 11.
An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a
head injury. The patient's spouse and teenage children stay at the patient's side and ask many
questions about the treatment being given. What action is best for the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the patient and briefly explain all procedures to them.
c. Refer the family members to the hospital counseling service to deal with their anxiety.
d. Call the family's pastor or spiritual advisor to take them to the chapel while care is given. -
Answer✔b. Allow the family to stay with the patient and briefly explain all procedures to them.
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the
plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods. - Answer✔c. Keep the head of the bed
elevated to 30 degrees.
A 20-year-old male patient is admitted with a head injury after a collision while playing football.
After noting that the patient has developed clear nasal drainage, which action should the nurse
take?
a. Have the patient gently blow the nose.
2|Page
Acute Intracranial Problems. Exam
Questions With Correct Answers A+
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of
the ventriculostomy system being used for intracranial pressure monitoring. Which response by
the nurse is best?
a. "This type of monitoring system is complex and it is managed by skilled staff."
b. "The monitoring system helps show whether blood flow to the brain is adequate."
c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion
pressure."
d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid
drainage." - Answer✔b. "The monitoring system helps show whether blood flow to the brain is
adequate."
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and
respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern
to the nurse?
a. Blood pressure 154/68, pulse 56, respirations 12
b. Blood pressure 134/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30 - Answer✔a. Blood pressure 154/68, pulse
56, respirations 12
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and
flexion of the arms, the nurse reports the response as
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing. - Answer✔c. decorticate posturing.
1|Page
, ©Jason McConnel 2025 ALL RIGHTS RESERVED.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which
parameter should the nurse monitor to determine the medication's effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit - Answer✔c. Intracranial pressure
A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to push away a
painful stimulus. The nurse records the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15. - Answer✔b. 11.
An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a
head injury. The patient's spouse and teenage children stay at the patient's side and ask many
questions about the treatment being given. What action is best for the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the patient and briefly explain all procedures to them.
c. Refer the family members to the hospital counseling service to deal with their anxiety.
d. Call the family's pastor or spiritual advisor to take them to the chapel while care is given. -
Answer✔b. Allow the family to stay with the patient and briefly explain all procedures to them.
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the
plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods. - Answer✔c. Keep the head of the bed
elevated to 30 degrees.
A 20-year-old male patient is admitted with a head injury after a collision while playing football.
After noting that the patient has developed clear nasal drainage, which action should the nurse
take?
a. Have the patient gently blow the nose.
2|Page
