1. An 18-year-old client is admitted with a closed head
injury sustained in a MVA. His intracranial pressure
(ICP) shows an upward trend. Which intervention
should the nurse perform first?
A. Reposition the client to avoid neck flexion.
B. Administer 1 g Mannitol IV as ordered.
C. Increase the ventilator’s respiratory rate to 20
breaths/minute.
D. Administer 100 mg of pentobarbital IV as ordered.
2. A client with a subarachnoid hemorrhage is
prescribed a 1,000-mg loading dose of Dilantin IV.
Which consideration is most important when
administering this dose?
A. Therapeutic drug levels should be maintained
between 20 to 30 mg/ml.
B. Rapid Dilantin administration can cause
cardiac arrhythmias.
C. Dilantin should be mixed in dextrose in water
before administration.
D. Dilantin should be administered through an IV
catheter in the client’s hand.
3. A client with head trauma develops a urine output of
300 ml/hr, dry skin, and dry mucous membranes.
Which of the following nursing interventions is the
most appropriate to perform initially?
A. Evaluate urine specific gravity.
B. Anticipate treatment for renal failure.
C. Provide emollients to the skin to prevent
breakdown.
D. Slow down the IV fluids and notify the physician.
4. When evaluating an ABG from a client with a
subdural hematoma, the nurse notes the PaCO2 is 30
mm Hg. Which of the following responses best
describes this result?
A. Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP).
B. Emergent; the client is poorly oxygenated.
C. Normal
D. Significant; the client has alveolar hypoventilation.
5. A client who had a transsphenoidal
hypophysectomy should be watched carefully for
hemorrhage, which may be shown by which of the
following signs?
A. Bloody drainage from the ears
B. Frequent swallowing
C. Guaiac-positive stools
D. Hematuria
6. After a hypophysectomy, vasopressin is given IM
for which of the following reasons?
A. To treat growth failure.
B. To prevent syndrome of inappropriate antidiuretic
hormone (SIADH).
C. To reduce cerebral edema and lower intracranial
pressure.
D. To replace antidiuretic hormone (ADH)
normally secreted by the pituitary.
7. A client comes into the ER after hitting his head in
an MVA. He’s alert and oriented. Which of the
following nursing interventions should be done first?
A. Assess full ROM to determine extent of injuries.
B. Call for an immediate chest x-ray.
C. Immobilize the client’s head and neck.
D. Open the airway with the head-tilt-chin-lift
maneuver.
8. A client with a C6 spinal injury would most likely
have which of the following symptoms?
A. Aphasia
B. Hemiparesis
C. Paraplegia
D. Tetraplegia
9. A 30-year-old was admitted to the progressive care
unit with a C5 fracture from a motorcycle accident.
Which of the following assessments would take
priority?
A. Bladder distension
B. Neurological deficit
C. Pulse ox readings
D. The client’s feelings about the injury
10. While in the ER, a client with C8 tetraplegia
develops a blood pressure of 80/40, pulse 48, and RR
of 18. The nurse suspects which of the following
conditions?
A. Autonomic dysreflexia
B. Hemorrhagic shock
C. Neurogenic shock
D. Pulmonary embolism
11. A client is admitted with a spinal cord injury at the
level of T12. He has limited movement of his upper
extremities. Which of the following medications would
be used to control edema of the spinal cord?
A. acetazolamide (Diamox)
B. furosemide (Lasix)
C. methylprednisolone (Solu-Medrol)
D. sodium bicarbonate
12. A 22-year-old client with quadriplegia is
apprehensive and flushed, with a blood pressure of
210/100 and a heart rate of 50 bpm. Which of the
following nursing interventions should be done first?
A. Place the client flat in bed.
B. Assess patency of the indwelling urinary catheter.
C. Give one SL nitroglycerin tablet.
D. Raise the head of the bed immediately to 90
degrees.
13. A client with a cervical spine injury has Gardner-
Wells tongs inserted for which of the following
reasons?
A. To hasten wound healing.
B. To immobilize the cervical spine.
C. To prevent autonomic dysreflexia.
D. To hold bony fragments of the skull together.
14. Which of the following interventions describes an
appropriate bladder program for a client in
rehabilitation for spinal cord injury?
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A. Insert an indwelling urinary catheter to straight
drainage.
B. Schedule intermittent catheterization every 2
to 4 hours.
C. Perform a straight catheterization every 8 hours
while awake.
D. Perform Crede’s maneuver to the lower abdomen
before the client voids.
15. A client who is admitted to the ER for head trauma
is diagnosed with an epidural hematoma. The
underlying cause of epidural hematoma is usually
related to which of the following conditions?
A. Laceration of the middle meningeal artery.
B. Rupture of the carotid artery.
C. Thromboembolism from a carotid artery.
D. Venous bleeding from the arachnoid space.
16. A 23-year-old client has been hit on the head with
a baseball bat. The nurse notes clear fluid draining
from his ears and nose. Which of the following nursing
interventions should be done first?
A. Position the client flat in bed.
B. Check the fluid for dextrose with a dipstick.
C. Suction the nose to maintain airway patency.
D. Insert nasal and ear packing with sterile gauze.
17. When discharging a client from the ER after An
interval when the client’s speech is garbled. head
trauma, the nurse teaches the guardian to observe for
a lucid interval. Which of the following statements best
describes a lucid interval?
A. An interval when the client’s speech is garbled.
B. An interval when the client is alert but can’t recall
recent events.
C. An interval when the client is oriented but then
becomes somnolent.
D. An interval when the client has a “warning”
symptom, such as an odor or visual disturbance.
18. Which of the following clients on the rehab unit is
most likely to develop autonomic dysreflexia?
A. A client with a brain injury.
B. A client with a herniated nucleus pulposus.
C. A client with a high cervical spine injury.
D. A client with a stroke.
19. Which of the following conditions indicates that
spinal shock is resolving in a client with C7
quadriplegia?
A. Absence of pain sensation in chest
B. Spasticity
C. Spontaneous respirations
D. Urinary continence
20. A nurse assesses a client who has episodes of
autonomic dysreflexia. Which of the following
conditions can cause autonomic dysreflexia?
A. Headache
B. Lumbar spinal cord injury
C. Neurogenic shock
D. Noxious stimuli
21. During an episode of autonomic dysreflexia in
which the client becomes hypertensive, the nurse
should perform which of the following interventions?
A. Elevate the client’s legs.
B. Put the client flat in bed.
C. Put the client in Trendelenburg's position.
D. Put the client in the high-Fowler’s position.
22. A client with a T1 spinal cord injury arrives at the
emergency department with a BP of 82/40, pulse 34,
dry skin, and flaccid paralysis of the lower extremities.
Which of the following conditions would most likely be
suspected?
A. Autonomic dysreflexia
B. Hypervolemia
C. Neurogenic shock
D. Sepsis
23. A client has a cervical spine injury at the level of
C5. Which of the following conditions would the nurse
anticipate during the acute phase?A. Absent corneal
reflex.
A. Absent corneal reflex.
B. Decerebrate posturing.
C. Movement of only the right or left half of the body.
D. The need for mechanical ventilation.
24. A client with C7 quadriplegia is flushed and
anxious and complains of a pounding headache.
Which of the following symptoms would also be
anticipated?
A. Decreased urine output or oliguria
B. Hypertension and bradycardia
C. Respiratory depression
D. Symptoms of shock
25. A 40-year-old paraplegic must perform intermittent
catheterization of the bladder. Which of the following
instructions should be given?
A. “Clean the meatus from back to front.”
B. “Measure the quantity of urine.”
C. “Gently rotate the catheter during removal.”
D. “Clean the meatus with soap and water.”
26. An 18-year-old client was hit in the head with a
baseball during practice. When discharging him to the
care of his mother, the nurse gives which of the
following instructions?
A. “Watch him for a keyhole pupil the next 24 hours.”
B. “Expect profuse vomiting for 24 hours after the
injury.”
C. “Wake him every hour and assess his
orientation to person, time, and place.”
D. “Notify the physician immediately if he has a
headache.”
27. Which neurotransmitter is responsible for many of
the functions of the frontal lobe?
A. Dopamine
B. GABA
C. Histamine
D. Norepinephrine
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28. The nurse is discussing the purpose of an
electroencephalogram (EEG) with the family of a
client with massive cerebral hemorrhage and loss of
consciousness. It would be most accurate for the
nurse to tell family members that the test measures
which of the following conditions?
A. Extent of intracranial bleeding.
B. Sites of brain injury.
C. Activity of the brain.
D. Percent of functional brain tissue.
29. A client arrives at the ER after slipping on a patch
of ice and hitting her head. A CT scan of the head
shows a collection of blood between the skull and
dura mater. Which type of head injury does this
finding suggest?
A. Subdural hematoma
B. Subarachnoid hemorrhage
C. Epidural hematoma
D. Contusion
30. After falling 20’, a 36-year-old man sustains a C6
fracture with spinal cord transaction. Which other
findings should the nurse expect?
A. Quadriplegia with gross arm movement and
diaphragmatic breathing.
B. Quadriplegia and loss of respiratory function.
C. Paraplegia with intercostal muscle loss.
D. Loss of bowel and bladder control.
31. A 20-year-old client who fell approximately 30’ is
unresponsive and breathless. A cervical spine injury is
suspected. How should the first-responder open the
client’s airway for rescue breathing?
A. By inserting a nasopharyngeal airway.
B. By inserting an oropharyngeal airway.
C. By performing a jaw thrust maneuver.
D. By performing the head-tilt, chin-lift maneuver.
32. The nurse is caring for a client with a T5 complete
spinal cord injury. Upon assessment, the nurse notes
flushed skin, diaphoresis above the T5, and a blood
pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing
interventions would be appropriate for this client?
Select all that apply.
A. Elevate the HOB to 90 degrees.
B. Loosen constrictive clothing.
C. Use a fan to reduce diaphoresis.
D. Assess for bladder distention and bowel
impaction.
E. Administer antihypertensive medication.
F. Place the client in a supine position with legs
elevated.
33. The client with a head injury has been urinating
copious amounts of dilute urine through the Foley
catheter. The client’s urine output for the previous shift
was 3000 ml. The nurse implements a new physician
order to administer:
A. desmopressin (DDAVP, Stimate)
B. Dexamethasone (Decadron)
B. Dexamethasone (Decadron) C. ethacrynic acid
(Edecrin)
D. mannitol (Osmitrol)
34. The nurse is caring for the client in the ER
following a head injury. The client momentarily lost
consciousness at the time of the injury and then
regained it. The client now has lost consciousness
again. The nurse takes quick action, knowing this is
compatible with:
A. Skull fracture
B. Concussion
C. Subdural hematoma
D. Epidural hematoma
35. The nurse is caring for a client who suffered a
spinal cord injury 48 hours ago. The nurse monitors
for GI complications by assessing for:
A. A flattened abdomen.
B. Hematest positive nasogastric tube drainage.
C. Hyperactive bowel sounds.
D. A history of diarrhea.
36. A client with a spinal cord injury is prone to
experiencing autonomic dysreflexia. The nurse would
avoid which of the following measures to minimize the
risk of recurrence?
A. Strict adherence to a bowel retraining program.
B. Limiting bladder catheterization to once every
12 hours.
C. Keeping the linen wrinkle-free under the client.
D. Preventing unnecessary pressure on the lower
limbs.
37. The nurse is planning care for the client in spinal
shock. Which of the following actions would be least
helpful in minimizing the effects of vasodilation below
the level of the injury?
A. Monitoring vital signs before and during position
changes.
B. Using vasopressor medications as prescribed.
C. Moving the client quickly as one unit.
D. Applying Teds or compression stockings.
38. The nurse is caring for a client admitted with
spinal cord injury. The nurse minimizes the risk of
compounding the injury most effectively by:
A. Keeping the client on a stretcher.
B. Logrolling the client on a firm mattress.
C. Logrolling the client on a soft mattress.
D. Placing the client on a Stryker frame.
39. The nurse is evaluating neurological signs of the
male client in spinal shock following spinal cord injury.
Which of the following observations by the nurse
indicates that spinal shock persists?
A. Positive reflexes
B. Hyperreflexia
C. Inability to elicit a Babinski’s reflex.
D. Reflex emptying of the bladder.
40. A client is at risk for increased ICP. Which of the
following would be a priority for the nurse to monitor?
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A. Unequal pupil size
B. Decreasing systolic blood pressure
C. Tachycardia
D. Decreasing body temperature
41. Which of the following respiratory patterns indicate
increasing ICP in the brain stem?
A. Slow, irregular respirations
B. Rapid, shallow respirations
C. Asymmetric chest expansion
D. Nasal flaring
42. Which of the following nursing interventions is
appropriate for a client with an ICP of 20 mm Hg?
A. Give the client a warming blanket.
B. Administer low-dose barbiturate.
C. Encourage the client to hyperventilate.
D. Restrict fluids.
43. A client has signs of increased ICP. Which of the
following is an early indicator of deterioration in the
client’s condition?
A. Widening pulse pressure
B. Decrease in the pulse rate
C. Dilated, fixed pupil
D. Decrease in LOC
44. A client who is regaining consciousness after a
craniotomy becomes restless and attempts to pull out
her IV line. Which nursing intervention protects the
client without increasing her ICP?
A. Place her in a jacket restraint.
B. Wrap her hands in soft “mitten” restraints.
C. Tuck her arms and hands under the draw sheet.
D. Apply a wrist restraint to each arm.
45. Which of the following describes decerebrate
posturing?
A. Internal rotation and adduction of arms with flexion
of elbows, wrists, and fingers.
B. Back hunched over, rigid flexion of all four
extremities with supination of arms and plantar flexion
of the feet.
C. Supination of arms, dorsiflexion of feet.
D. Back arched; rigid extension of all four
extremities.
46. A client receiving vent-assisted mode ventilation
begins to experience cluster breathing after recent
intracranial occipital bleeding. Which action would be
most appropriate?
A. Count the rate to be sure the ventilations are deep
enough to be sufficient.
B. Call the physician while another nurse checks
the vital signs and ascertains the patient’s
Glasgow Coma score.
C. Call the physician to adjust the ventilator settings.
D. Check deep tendon reflexes to determine the best
motor response.
47. In planning the care for a client who has had a
posterior fossa (infratentorial) craniotomy, which of the
following is contraindicated when positioning the
client?
A. Keeping the client flat on one side or the other.
B. Elevating the head of the bed to 30 degrees.
C. Logrolling or turning as a unit when turning.
D. Keeping the head in a neutral position.
48. A client has been pronounced brain dead. Which
findings would the nurse assess? Select all that apply.
A. Decerebrate posturing
B. Dilated nonreactive pupils
C. Deep tendon reflexes
D. Absent corneal reflex
49. A 23-year-old patient with a recent history of
encephalitis is admitted to the medical unit with new
onset generalized tonic-clonic seizures. Which
nursing activities included in the patient’s care will be
best to delegate to an LPN/LVN whom you are
supervising?
A. Document the onset time, nature of seizure
activity, and postictal behaviors for all seizures.
B. Administer phenytoin (Dilantin) 200 mg PO
daily.
C. Teach the patient about the need for good oral
hygiene.
D. Develop a discharge plan, including physician
visits and referral to the Epilepsy Foundation.
1. To encourage adequate nutritional intake for a
female client with Alzheimer’s disease, the nurse
should:
A. Stay with the client and encourage him to eat.
B. Help the client fill out his menu.
C. Give the client privacy during meals.
D. Fill out the menu for the client.
2. The nurse is performing a mental status
examination on a male client diagnosed with a
subdural hematoma. This test assesses which of the
following?
A. Cerebellar function
B. Intellectual function
C. Cerebral function
D. Sensory function
3. Shortly after admission to an acute care facility, a
male client with a seizure disorder develops status
epilepticus. The physician orders diazepam (Valium)
10 mg I.V. stat. How soon can the nurse administer
the second dose of diazepam, if needed and
prescribed?
A. In 30 to 45 seconds
B. In 10 to 15 minutes
C. In 30 to 45 minutes
D. In 1 to 2 hours
4. A female client complains of periorbital aching,
tearing, blurred vision, and photophobia in her right
eye. Ophthalmologic examination reveals a small,
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Nurselabs Neurological Practice Exam with Answers (169 Solved Questions)

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