CLMS CERTIFICATION EXAM 2 2026 ACTUAL
SCRIPT COMPLETE QUESTIONS AND
ANSWERS 100% CORRECT
◉ What is the cardinal neurologic sign of a temporal lobe traumatic
brain injury? Answer: Amnesia or disorientation.
◉ Upon discharge, which s/s would you teach the patient to return
to the emergency department if they begin experiencing? Answer: -
decreased LOC.
- worsening headache.
- Dizziness.
- Seizures.
- Abnormal pupil response.
- vomiting.
- irritability.
- slurred speech.
- weakness or numbness of the extremities.
◉ What are the three cardinal signs of brain death? Answer: 1. coma.
2. absence of reflexes.
3. apnea.
,◉ What GCS score indicates a severe traumatic brain injury?
Answer: A score of 3-8.
◉ What are the three signs of the Cushing's Triad and what do they
indicate? Answer: 1. Bradycardia (decreased heart rate).
2. Widening pulse pressure (SBP is rising).
3. Irregular respirations.
- Cushing's Triad indicates increased intracranial pressure.
◉ What is a common electrolyte imbalance in patients who
experience a TBI? Answer: Hyponatremia (low sodium).
Normal sodium levels are 135-145 mEq/L.
◉ What are some nursing interventions for a TBI? Answer: -
Maintain a patent airway.
- monitor neurologic function (neuro checks).
- monitor vitals (look for Cushing's triad).
- POSITION HOB AT 30 DEGREES WITH THE NECK IN A NEUTRAL
POSITION TO PROTECT C-SPINE.
- assess motor function.
,- monitor for fluid and electrolyte imbalances, especially sodium.
- promote adequate nutrition.
- maintain thermoregulation.
- maintain skin integrity.
- early administration of anticonvulsants.
- maintain cerebral perfusion pressure.
◉ What can hyponatremia cause? What precautions do we need to
place our patient on because of this? Answer: Seizures!
Seizure precautions.
◉ What should cerebral perfusion pressure be maintained at?
Answer: Above 50 mmHg.
◉ What are three common symptoms for a patient coming out of a
coma? Answer: 1. agitation.
2. restlessness.
3. incontinence.
May also experience lethargy and stupor.
, ◉ What do unilaterally dilated and poorly responding pupils
indicate? Answer: The development of a hematoma, with
subsequent pressure on the third cranial nerve due to shifting of the
brain.
◉ What is the medication Phenytoin (Dilantin) used for? Answer:
Used to control seizures!
◉ What is an important patient teaching point for a young woman
who is taking Phenytoin? Answer: Oral contraceptives are less
effective when taking this medication. Therefore, you should use
other forms of contraception in addition to oral contraceptives if you
choose to be sexually active.
◉ What are the side effects of Phenytoin and what are some patient
teaching points? Answer: S/E: nausea, vomiting, drowsiness,
lethargy, and ataxia.
Pt teaching: maintain good oral hygiene to prevent gum disease!
Also, use contraception, oral contraceptives are less effective when
taking Phenytoin.
◉ What is Propofol and what is it used for? Answer: It is an IV
anesthetic (sedative/hypnotic).
SCRIPT COMPLETE QUESTIONS AND
ANSWERS 100% CORRECT
◉ What is the cardinal neurologic sign of a temporal lobe traumatic
brain injury? Answer: Amnesia or disorientation.
◉ Upon discharge, which s/s would you teach the patient to return
to the emergency department if they begin experiencing? Answer: -
decreased LOC.
- worsening headache.
- Dizziness.
- Seizures.
- Abnormal pupil response.
- vomiting.
- irritability.
- slurred speech.
- weakness or numbness of the extremities.
◉ What are the three cardinal signs of brain death? Answer: 1. coma.
2. absence of reflexes.
3. apnea.
,◉ What GCS score indicates a severe traumatic brain injury?
Answer: A score of 3-8.
◉ What are the three signs of the Cushing's Triad and what do they
indicate? Answer: 1. Bradycardia (decreased heart rate).
2. Widening pulse pressure (SBP is rising).
3. Irregular respirations.
- Cushing's Triad indicates increased intracranial pressure.
◉ What is a common electrolyte imbalance in patients who
experience a TBI? Answer: Hyponatremia (low sodium).
Normal sodium levels are 135-145 mEq/L.
◉ What are some nursing interventions for a TBI? Answer: -
Maintain a patent airway.
- monitor neurologic function (neuro checks).
- monitor vitals (look for Cushing's triad).
- POSITION HOB AT 30 DEGREES WITH THE NECK IN A NEUTRAL
POSITION TO PROTECT C-SPINE.
- assess motor function.
,- monitor for fluid and electrolyte imbalances, especially sodium.
- promote adequate nutrition.
- maintain thermoregulation.
- maintain skin integrity.
- early administration of anticonvulsants.
- maintain cerebral perfusion pressure.
◉ What can hyponatremia cause? What precautions do we need to
place our patient on because of this? Answer: Seizures!
Seizure precautions.
◉ What should cerebral perfusion pressure be maintained at?
Answer: Above 50 mmHg.
◉ What are three common symptoms for a patient coming out of a
coma? Answer: 1. agitation.
2. restlessness.
3. incontinence.
May also experience lethargy and stupor.
, ◉ What do unilaterally dilated and poorly responding pupils
indicate? Answer: The development of a hematoma, with
subsequent pressure on the third cranial nerve due to shifting of the
brain.
◉ What is the medication Phenytoin (Dilantin) used for? Answer:
Used to control seizures!
◉ What is an important patient teaching point for a young woman
who is taking Phenytoin? Answer: Oral contraceptives are less
effective when taking this medication. Therefore, you should use
other forms of contraception in addition to oral contraceptives if you
choose to be sexually active.
◉ What are the side effects of Phenytoin and what are some patient
teaching points? Answer: S/E: nausea, vomiting, drowsiness,
lethargy, and ataxia.
Pt teaching: maintain good oral hygiene to prevent gum disease!
Also, use contraception, oral contraceptives are less effective when
taking Phenytoin.
◉ What is Propofol and what is it used for? Answer: It is an IV
anesthetic (sedative/hypnotic).
