NUR 265 Exam 3: -GALEN
COLLEGE Neurologic
Emergencies & Traumatic
Brain Injury
Section 1: Increased Intracranial Pressure (ICP) & Cerebral Perfusion Pressure (CPP)
1. A nurse is caring for a client with a traumatic brain injury (TBI). Which assessment
finding is the earliest and most sensitive indicator of a change in neurologic status?
a) Pupillary dilation
b) Decorticate posturing
c) Change in level of consciousness (LOC)
d) Cheyne-Stokes respirations
Correct Answer: c) Change in level of consciousness (LOC)
Rationale: LOC is the most sensitive and earliest indicator of neurologic deterioration.
Changes in LOC (e.g., restlessness, confusion, lethargy) precede changes in vital signs
(Cushing’s triad) and pupillary responses. Options a, b, and d are late signs of herniation.
2. The nurse calculates a client’s cerebral perfusion pressure (CPP) as 52 mm Hg. What is
the priority nursing action?
a) Document the finding as normal.
b) Position the client in Trendelenburg.
c) Notify the healthcare provider immediately.
d) Administer a prescribed stool softener.
Correct Answer: c) Notify the healthcare provider immediately.
Rationale: Normal CPP is 60-100 mm Hg. A CPP < 60 mm Hg indicates inadequate cerebral
blood flow and cerebral ischemia, leading to irreversible neurologic damage. The provider
must be notified immediately to intervene (e.g., manage ICP or increase MAP).
Trendelenburg (option b) would increase ICP and is contraindicated.
3. A client has an ICP of 22 mm Hg and a mean arterial pressure (MAP) of 80 mm Hg. What
is the CPP, and what does this indicate?
a) CPP 102 mm Hg; adequate perfusion
b) CPP 58 mm Hg; inadequate perfusion
c) CPP 62 mm Hg; borderline perfusion
d) CPP 80 mm Hg; normal perfusion
,Correct Answer: b) CPP 58 mm Hg; inadequate perfusion
Rationale: CPP = MAP – ICP. 80 – 22 = 58 mm Hg. A CPP of 58 mm Hg is below the threshold
of 60 mm Hg, indicating inadequate cerebral perfusion.
4. The nurse is caring for a client with an external ventricular drain (EVD). Which finding
requires immediate intervention?
a) CSF drainage of 5 mL in the last hour
b) A sterile dressing at the insertion site
c) The transducer is level with the client’s ear
d) A sudden increase in drainage of 15 mL with bright red blood
Correct Answer: d) A sudden increase in drainage of 15 mL with bright red blood
Rationale: A sudden increase in drainage, especially with bright red blood, suggests a new
hemorrhage or rupture. The nurse must clamp the drain immediately and notify the
provider. The transducer should be leveled at the tragus of the ear (foramen of Monro) to
ensure accuracy.
5. The nurse is monitoring a client for Cushing’s triad. Which vital sign changes are
consistent with this finding?
a) Hypotension, bradycardia, tachypnea
b) Hypertension, bradycardia, bradypnea
c) Hypotension, tachycardia, tachypnea
d) Hypertension, tachycardia, bradypnea
Correct Answer: b) Hypertension, bradycardia, bradypnea
Rationale: Cushing’s triad is a late sign of increased ICP. It consists of systolic hypertension
(widening pulse pressure), bradycardia, and irregular respirations (often bradypnea). This is a
compensatory response to maintain cerebral blood flow.
6. Which nursing intervention is most effective in preventing secondary brain injury in a
client with increased ICP?
a) Cluster all nursing activities to provide rest.
b) Maintain the head of the bed flat.
c) Administer hypotonic IV fluids.
d) Maintain normothermia and treat fever promptly.
Correct Answer: d) Maintain normothermia and treat fever promptly.
Rationale: Fever increases cerebral metabolic demand, oxygen consumption, and ICP,
contributing to secondary brain injury. Maintaining normothermia is crucial. Clustering
activities (option a) increases ICP; HOB should be 30-45 degrees (option b) to promote
venous drainage; isotonic fluids (e.g., normal saline) are used, not hypotonic (option c),
which can increase cerebral edema.
,7. A client is exhibiting decerebrate posturing. What does this indicate?
a) Damage to the cerebral cortex
b) A favorable neurologic outcome
c) Severe dysfunction in the brainstem
d) A psychogenic response to pain
Correct Answer: c) Severe dysfunction in the brainstem
Rationale: Decerebrate posturing (arms extended, internally rotated, legs extended)
indicates severe damage in the brainstem (midbrain, pons). It is a more ominous sign than
decorticate posturing (damage to the cerebral cortex).
8. The nurse is administering mannitol (Osmitrol) to a client with increased ICP. Which
assessment finding indicates the medication is effective?
a) Urine output decreases to 20 mL/hr
b) ICP decreases from 24 to 14 mm Hg
c) Serum osmolality decreases to 280 mOsm/kg
d) Blood pressure drops to 90/60 mm Hg
Correct Answer: b) ICP decreases from 24 to 14 mm Hg
Rationale: Mannitol is an osmotic diuretic that reduces cerebral edema by drawing fluid
from brain tissue into the vascular space. The desired outcome is a decrease in ICP. Urine
output should increase. Serum osmolality should be monitored to avoid hyperosmolality; a
decrease is not the goal.
9. Which position is appropriate for a client with increased ICP?
a) Supine with head turned to the side
b) Trendelenburg position
c) Head of bed (HOB) elevated 30-45 degrees with head in neutral alignment
d) Reverse Trendelenburg with hips flexed
Correct Answer: c) Head of bed (HOB) elevated 30-45 degrees with head in neutral
alignment
Rationale: Elevating HOB 30-45 degrees promotes venous drainage from the brain, reducing
ICP. The head should remain in neutral alignment (not turned or flexed) to prevent jugular
vein compression. Trendelenburg (option b) increases ICP.
10. A nurse is caring for a client with a ventriculostomy. Which finding indicates an
infection related to this device?
a) Clear CSF drainage
b) CSF glucose of 65 mg/dL
c) Cloudy CSF with a positive Gram stain
d) A dry dressing with a small serous stain
, Correct Answer: c) Cloudy CSF with a positive Gram stain
Rationale: Cloudy CSF and a positive Gram stain are indicative of ventriculitis or meningitis, a
serious complication of a ventriculostomy. Normal CSF is clear and colorless.
Section 2: Traumatic Brain Injury (TBI) & Skull Fractures
11. A client arrives in the ED following a motor vehicle crash. The client has clear fluid
draining from the nose. How should the nurse confirm this fluid is cerebrospinal fluid
(CSF)?
a) Suction the nares to obtain a sample.
b) Test the fluid for glucose using a test strip.
c) Place the fluid on a white gauze and assess for a halo/target sign.
d) Have the client blow their nose to increase drainage.
Correct Answer: c) Place the fluid on a white gauze and assess for a halo/target sign.
Rationale: The halo or target sign (blood surrounded by a clear ring) indicates CSF leakage.
Testing for glucose (option b) is not definitive because nasal secretions also contain glucose.
The client should never blow their nose (option d) as it can introduce bacteria and lead to
meningitis.
12. A client with a basilar skull fracture is at high risk for which complication?
a) Subdural hematoma
b) Meningitis
c) Epidural hematoma
d) Cerebral contusion
Correct Answer: b) Meningitis
Rationale: A basilar skull fracture often tears the dura, creating a communication between
the brain and the environment (e.g., via the sinuses, nose, or ears). This places the client at
significant risk for meningitis. Signs include raccoon eyes, Battle’s sign, and CSF
rhinorrhea/otorrhea.
13. A client with a head injury has a Glasgow Coma Scale (GCS) score of 6. The nurse
interprets this as:
a) Minor head injury
b) Moderate head injury
c) Severe head injury
d) A normal score
Correct Answer: c) Severe head injury
Rationale: GCS scores range from 3-15. A score of 8 or less indicates severe head injury and
often requires intubation for airway protection. 9-12 is moderate, and 13-15 is mild.
COLLEGE Neurologic
Emergencies & Traumatic
Brain Injury
Section 1: Increased Intracranial Pressure (ICP) & Cerebral Perfusion Pressure (CPP)
1. A nurse is caring for a client with a traumatic brain injury (TBI). Which assessment
finding is the earliest and most sensitive indicator of a change in neurologic status?
a) Pupillary dilation
b) Decorticate posturing
c) Change in level of consciousness (LOC)
d) Cheyne-Stokes respirations
Correct Answer: c) Change in level of consciousness (LOC)
Rationale: LOC is the most sensitive and earliest indicator of neurologic deterioration.
Changes in LOC (e.g., restlessness, confusion, lethargy) precede changes in vital signs
(Cushing’s triad) and pupillary responses. Options a, b, and d are late signs of herniation.
2. The nurse calculates a client’s cerebral perfusion pressure (CPP) as 52 mm Hg. What is
the priority nursing action?
a) Document the finding as normal.
b) Position the client in Trendelenburg.
c) Notify the healthcare provider immediately.
d) Administer a prescribed stool softener.
Correct Answer: c) Notify the healthcare provider immediately.
Rationale: Normal CPP is 60-100 mm Hg. A CPP < 60 mm Hg indicates inadequate cerebral
blood flow and cerebral ischemia, leading to irreversible neurologic damage. The provider
must be notified immediately to intervene (e.g., manage ICP or increase MAP).
Trendelenburg (option b) would increase ICP and is contraindicated.
3. A client has an ICP of 22 mm Hg and a mean arterial pressure (MAP) of 80 mm Hg. What
is the CPP, and what does this indicate?
a) CPP 102 mm Hg; adequate perfusion
b) CPP 58 mm Hg; inadequate perfusion
c) CPP 62 mm Hg; borderline perfusion
d) CPP 80 mm Hg; normal perfusion
,Correct Answer: b) CPP 58 mm Hg; inadequate perfusion
Rationale: CPP = MAP – ICP. 80 – 22 = 58 mm Hg. A CPP of 58 mm Hg is below the threshold
of 60 mm Hg, indicating inadequate cerebral perfusion.
4. The nurse is caring for a client with an external ventricular drain (EVD). Which finding
requires immediate intervention?
a) CSF drainage of 5 mL in the last hour
b) A sterile dressing at the insertion site
c) The transducer is level with the client’s ear
d) A sudden increase in drainage of 15 mL with bright red blood
Correct Answer: d) A sudden increase in drainage of 15 mL with bright red blood
Rationale: A sudden increase in drainage, especially with bright red blood, suggests a new
hemorrhage or rupture. The nurse must clamp the drain immediately and notify the
provider. The transducer should be leveled at the tragus of the ear (foramen of Monro) to
ensure accuracy.
5. The nurse is monitoring a client for Cushing’s triad. Which vital sign changes are
consistent with this finding?
a) Hypotension, bradycardia, tachypnea
b) Hypertension, bradycardia, bradypnea
c) Hypotension, tachycardia, tachypnea
d) Hypertension, tachycardia, bradypnea
Correct Answer: b) Hypertension, bradycardia, bradypnea
Rationale: Cushing’s triad is a late sign of increased ICP. It consists of systolic hypertension
(widening pulse pressure), bradycardia, and irregular respirations (often bradypnea). This is a
compensatory response to maintain cerebral blood flow.
6. Which nursing intervention is most effective in preventing secondary brain injury in a
client with increased ICP?
a) Cluster all nursing activities to provide rest.
b) Maintain the head of the bed flat.
c) Administer hypotonic IV fluids.
d) Maintain normothermia and treat fever promptly.
Correct Answer: d) Maintain normothermia and treat fever promptly.
Rationale: Fever increases cerebral metabolic demand, oxygen consumption, and ICP,
contributing to secondary brain injury. Maintaining normothermia is crucial. Clustering
activities (option a) increases ICP; HOB should be 30-45 degrees (option b) to promote
venous drainage; isotonic fluids (e.g., normal saline) are used, not hypotonic (option c),
which can increase cerebral edema.
,7. A client is exhibiting decerebrate posturing. What does this indicate?
a) Damage to the cerebral cortex
b) A favorable neurologic outcome
c) Severe dysfunction in the brainstem
d) A psychogenic response to pain
Correct Answer: c) Severe dysfunction in the brainstem
Rationale: Decerebrate posturing (arms extended, internally rotated, legs extended)
indicates severe damage in the brainstem (midbrain, pons). It is a more ominous sign than
decorticate posturing (damage to the cerebral cortex).
8. The nurse is administering mannitol (Osmitrol) to a client with increased ICP. Which
assessment finding indicates the medication is effective?
a) Urine output decreases to 20 mL/hr
b) ICP decreases from 24 to 14 mm Hg
c) Serum osmolality decreases to 280 mOsm/kg
d) Blood pressure drops to 90/60 mm Hg
Correct Answer: b) ICP decreases from 24 to 14 mm Hg
Rationale: Mannitol is an osmotic diuretic that reduces cerebral edema by drawing fluid
from brain tissue into the vascular space. The desired outcome is a decrease in ICP. Urine
output should increase. Serum osmolality should be monitored to avoid hyperosmolality; a
decrease is not the goal.
9. Which position is appropriate for a client with increased ICP?
a) Supine with head turned to the side
b) Trendelenburg position
c) Head of bed (HOB) elevated 30-45 degrees with head in neutral alignment
d) Reverse Trendelenburg with hips flexed
Correct Answer: c) Head of bed (HOB) elevated 30-45 degrees with head in neutral
alignment
Rationale: Elevating HOB 30-45 degrees promotes venous drainage from the brain, reducing
ICP. The head should remain in neutral alignment (not turned or flexed) to prevent jugular
vein compression. Trendelenburg (option b) increases ICP.
10. A nurse is caring for a client with a ventriculostomy. Which finding indicates an
infection related to this device?
a) Clear CSF drainage
b) CSF glucose of 65 mg/dL
c) Cloudy CSF with a positive Gram stain
d) A dry dressing with a small serous stain
, Correct Answer: c) Cloudy CSF with a positive Gram stain
Rationale: Cloudy CSF and a positive Gram stain are indicative of ventriculitis or meningitis, a
serious complication of a ventriculostomy. Normal CSF is clear and colorless.
Section 2: Traumatic Brain Injury (TBI) & Skull Fractures
11. A client arrives in the ED following a motor vehicle crash. The client has clear fluid
draining from the nose. How should the nurse confirm this fluid is cerebrospinal fluid
(CSF)?
a) Suction the nares to obtain a sample.
b) Test the fluid for glucose using a test strip.
c) Place the fluid on a white gauze and assess for a halo/target sign.
d) Have the client blow their nose to increase drainage.
Correct Answer: c) Place the fluid on a white gauze and assess for a halo/target sign.
Rationale: The halo or target sign (blood surrounded by a clear ring) indicates CSF leakage.
Testing for glucose (option b) is not definitive because nasal secretions also contain glucose.
The client should never blow their nose (option d) as it can introduce bacteria and lead to
meningitis.
12. A client with a basilar skull fracture is at high risk for which complication?
a) Subdural hematoma
b) Meningitis
c) Epidural hematoma
d) Cerebral contusion
Correct Answer: b) Meningitis
Rationale: A basilar skull fracture often tears the dura, creating a communication between
the brain and the environment (e.g., via the sinuses, nose, or ears). This places the client at
significant risk for meningitis. Signs include raccoon eyes, Battle’s sign, and CSF
rhinorrhea/otorrhea.
13. A client with a head injury has a Glasgow Coma Scale (GCS) score of 6. The nurse
interprets this as:
a) Minor head injury
b) Moderate head injury
c) Severe head injury
d) A normal score
Correct Answer: c) Severe head injury
Rationale: GCS scores range from 3-15. A score of 8 or less indicates severe head injury and
often requires intubation for airway protection. 9-12 is moderate, and 13-15 is mild.
