Question 1

When a nurse asks a patient\'s name, the patient replies with the name of the town where the hospital is located. When asked what day it is, he replies \"house.\" Shown a hairbrush and asked to name it, he replies \"dog.\" What other step(s) should the nurse take to evaluate the patient\'s language functioning?

Accepted Answer

Ask the patient to raise one arm slowly

Question 2

Which of the following should the nurse perform immediately after insertion of the monitoring device is completed?

Accepted Answer

Assess neurologic status and compare to assessment before insertion

Question 3

A nurse is assessing an awake and alert patient who can move all extremities using the GCS. The eye opening score is 4. The nurse is now proceeding to assess motor score. What techniques could the nurse use to assess the patient\'s motor response?

Accepted Answer

WRONG Ask the patient, \"show me your thumb.\" Ask the patient, \"stick out your tongue.\" Ask the patient, \"wiggle your toes and hold up your thumb.\" ALSO WRONG: grasp patient\'s hand and ask \"squeeze my fingers.\"; ask the patient, \"wiggle your toes and hold up your thumb.\"

Question 4

A patient is admitted after having tonic-clonic movements and is postictal. The outpatient head CT scan without contrast done three days ago was negative. Which of the following diagnostic tests should the nurse anticipate?

Accepted Answer

WRONG EMG/NCS; MRA

Question 5

In determining LOC, a nurse finds that a trauma patient is not alert and does not respond to loud questions or statements. What should be the nurse\'s next step?

Accepted Answer

Assess a central pain stimulus response

Question 6

Your patient with a traumatic brain injury is receiving IV NS at 125 mL/hr, is intubated, and has a GCS of E 1, M 2, V 1 T = 4 T, with the trend in vital signs as shown. You notify the provider of the changes. What treatment do you anticipate will be ordered?

Accepted Answer

Intravenous osmotic agent

Question 7

A patient with a head injury is admitted. He has become increasingly lethargic, and his pupils are now unequal, with the right pupil smaller than the left. Which of the following nursing actions has the highest priority?

Accepted Answer

Call the provider

Question 8

Which of the following patients should the nurse anticipate as most likely to develop hyponatremia and hyposmolality? A patient:

Accepted Answer

Two days post severe traumatic brain injury

Question 9

A patient sustains a stroke affecting the left hemisphere. The patient is speaking in single words that don\'t make sense in terms of the questions asked, and is unable to name objects correctly. The patient is unable to follow simple commands. The nurse should anticipate the speech therapist documenting this patient as having:

Accepted Answer

Receptive asphasia

Question 10

A skier who collided with a tree is admitted for head injury and placed in a cervical collar. What potential cause of increased ICP should the nurse observe for?

Accepted Answer

Compression of jugular veins due to...

Question 11

While preparing a patient for lumbar puncture, which of the following items are included in patient teaching?

Accepted Answer

We can measure CSF pressure You will lie on your side with your knees pulled up... CSF can be tested...

Question 12

Checking the uvula before and while the patient is saying \"Aah\" to see if it remains midline and doesn\'t deviate is a technique used to assess which of the following cranial nerves?

Accepted Answer

Vagus nerve

Question 13

A patient with a massive cerebral hemorrhage is admitted. The patient is comatose. Pupils have become dilated and no longer react to light. The breathing pattern has become irregular. Vital signs: BP 170/66 (101), HR 40 and irregular, RR 16 and irregular. Administration of which of the following should the nurse anticipate?

Accepted Answer

Mannitol

Question 14

What intracranial factors can decrease the brain\'s supply of oxygenated blood?

Accepted Answer

Thrombosis Vasospasm Hypocapnia... Vessels compressed by elevated ICP

Question 15

A patient with a lumbar drain has a visible blood clot occluding the tubing. The blockage is proximal to the stopcock port nearest the insertion site. Which of the following actions should the nurse implement?

Accepted Answer

Notify the provider than the system may need to be flushed

Question 16

You are caring for an unconscious patient with TBI from a MVC. His alcohol and toxicology screen are negative, he has no facial fracture and he\'s not receiving pain or sedation medication....

Accepted Answer

Abnormal flexor posturing

Question 17

Which of the following patients is most likely to receive cerebral angiography? A patient:

Accepted Answer

With a suspected brain anerysm

Question 18

A patient with seizures was started on phenytoin three days ago and is receiving ongoing monitoring of serum drug levels. What other antiepileptic medications should receive serum drug level monitoring?

Accepted Answer

Phenobarbital Valproic acid

Question 19

Upon performing a comprehensive neurologic exam on a patient experiencing alcohol withdrawal, a nurse evaluates the patient\'s communication ability and orientation. What other functions should the nurse examine?

Accepted Answer

LOC Pupil size and reactivity Motor function

Question 20

A preoperative patient for brain tumor biopsy surgery reports nausea and has become increasingly drowsy. What further assessments do you need to perform before calling the provider?

Accepted Answer

Pupillary assessment Motor function BP measurement

Question 21

A nurse observes that a patient with a traumatic brain injury with a midline shift has changed from sinus tachycardia to sinus bradycardia. What oher signs and symptoms indicate brain herniation?

Accepted Answer

Systolic hypertension with widening pulse pressure Changes in respiration progressing to apnea

Question 22

A nurse finds that a patient does not move spontaneously or follow commands. To assess the patient\'s motor function, the nurse applies a central pain stimulus, without response. what is the nurse\'s next step?

Accepted Answer

Apply peripheral pain stimulus

Question 23

A patient with a history of brain tumor is being evaluated for polymyositis. What tests should the nurse anticipate for this patient?

Accepted Answer

WRONG: Electromyography Nerve conduction studies

Question 24

What should the nurse do to assess orientation in a patient who is post-cardiopulmonary bypass?

Accepted Answer

Ask the patient what day... Ask the patient why he or she is in the hospital... Ask the patient\'s name and where he or she is located

Question 25

A patient is admitted following a drug overdose. The patient does not open eyes upon verbal request but localizes to a trapezius muscle squeeze without opening eyes. The nurse should document the patient\'s mental status as:

Accepted Answer

Responsive to painful stimuli

Question 26

Which signs and symptoms of brain herniation should the nurse be alert for when a patient with a hemorrhagic stroke develops apnea?

Accepted Answer

Decreased pupil reactivity; Systolic hypertension with widening pulse pressure; Onset of bradycardia

Question 27

After evaluating a post-stroke patient\'s LOC, a nurse should complete the patient\'s neurologic exam by evaluating which other functions?

Accepted Answer

Motor function Pupil size and reacitivity Orientation and basic communication

Question 28

Which of the following may result in a decreased supply of oxygen to the brain?

Accepted Answer

Hypotension

Question 29

Your patient blinks and can move eyes up and down. Respirations are irregular with periods of apnea; gag reflex and motor movement of extremities are absent. What is your highest priority intervention?

Accepted Answer

Secure the airway

Question 30

A patient is admitted after sustaining traumatic brain injury in a motorcycle crash. The patient\'s GCS score on admission is E 2, M 3, V 1T = 6T. Which of the following should the nurse perform to prepare the patient for ICP monitoring?

Accepted Answer

Reassess the patient\'s neurologic status

Question 31

Which of the following central pain stimuli should the nurse use to assess motor function in a patient who is unconscious and who has facial fractures?

Accepted Answer

Apply trapezius squeeze

Question 32

In assessing an unconscious patient, deficits in which cranial nerves reflexes can indicate brainstem compression

Accepted Answer

WRONG Pupil reactivity to light Corneal reflex Cough reflex

Question 33

A patient with a large brain tumor is admitted. She initially reported a headache and suddenly became unresponsive to all stimuli. Pupils are no longer reactive to light. The heart rate is decreasing, and the SBP is elevated with a widened pulse pressure. The provider has been notified and is on the way to the bedside. Which of the following is immediately indicated to temporarily reduce increased ICP?

Accepted Answer

Hyperventilate the patient

Question 34

What vital sign assessments herald impending brainstem herniation?

Accepted Answer

Increased SBP with widening pulse pressure, changes in respirations, and bradycardia

Question 35

A trauma patient\'s brain injury has been monitored non-invasively. The provider orders set-up for invasive monitoring. What monitoring methods should the nurse expect?

Accepted Answer

Intraparenchymal Intraventricular

Question 36

In a patient with a subarachnoid hemorrhage, what is the purpose of a transcranial Doppler (TCD) test?

Accepted Answer

Measure blood velocity to assess for vasospasm

Question 37

A patient with a traumatic brain injury was reported to have a seizure lasting approximately 20 seconds while being transported to the hospital and admitted. After CT scan, which diagnostic test should the nurse anticipate to be ordered?

Accepted Answer

EEG

Question 38

A patient is admitted with a subarachnoid hemorrhage. She is restless and agitated, and complaining of an ongoing headache 10/10. Which of the following symptoms requires an immediate call to the provider?

Accepted Answer

Unresponsiveness...

Question 39

You patient has a sudden onset loss of motor and sensory function of the left arm and leg. The neurologist suspects a stroke, and the patient has gone to CT for evaluation. Which assessment techniques could be used by the provider and nurse to provide ongoing assessment of the stroke symptoms of the patient?

Accepted Answer

WRONG NIHSS GCS FOUR score; also wrong: mNIHSS, GCS; also wrong: NIHSS, mNIHHS, GCS

Question 40

A patient is admitted with a head injury from falling off a motorcycle while not wearing a helmet. The patient is very drowsy and can be aroused with verbal stimuli. He is able to follow commands but unable to name common objects (pen and fork) shown to him...

Accepted Answer

Expressive asphasia

Question 41

A patient is admitted after an unwitnessed cardiac arrest at home. What criterion is anticipated as part of the decision-making process to support declaration of death by neurologic criteria?

Accepted Answer

The PaCO2 increases to 68 when off ventilator for 8 minutes

Question 42

A patient underwent surgery for a brain tumor develops obstructive hydrocephalus. What intervention should the nurse expect?

Accepted Answer

WRONG: Insertion of subdural drain; repeat lumbar punctures

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