NR 341 EDAPT Week 6 (2026) PDF | Neurological Alterations | Complex Adult
Health
1. Which of the following is considered a normal range for Intracranial Pressure
(ICP) in a healthy adult?
A. 0 to 5 mmHg
B. 30 to 40 mmHg
C. 20 to 25 mmHg
D. 5 to 15 mmHg
Answer: D
Rationale: Normal ICP ranges from 5 to 15 mmHg. A sustained pressure greater than 20
mmHg is considered abnormal and requires treatment.
2. A patient has a Mean Arterial Pressure (MAP) of 90 mmHg and an ICP of 20
mmHg. What is the Cerebral Perfusion Pressure (CPP)?
A. 110 mmHg
B. 4.5 mmHg
C. 1800 mmHg
D. 70 mmHg
Answer: D
Rationale: CPP is calculated as MAP minus ICP (90 - 20 = 70 mmHg). Normal CPP is 60 to
100 mmHg.
,3. Which assessment finding is known as Cushing’s Triad, indicating late-stage
increased ICP?
A. Tachycardia, hypotension, and tachypnea
B. Hypotension, bradycardia, and Cheyne-Stokes respirations
C. Bradycardia, hypertension with widening pulse pressure, and irregular respirations
D. Hypertension, tachycardia, and Kussmaul respirations
Answer: C
Rationale: Cushing’s Triad consists of systolic hypertension with a widening pulse
pressure, bradycardia with a full and bounding pulse, and irregular or slowed respirations.
4. A patient with a traumatic brain injury (TBI) exhibits an extension of all four
extremities and internal rotation of the shoulders. How should the nurse
document this?
A. Decorticate posturing
B. Flaccid paralysis
C. Hemiparesis
D. Decerebrate posturing
Answer: D
Rationale: Decerebrate posturing (extension) indicates more serious damage to the
midbrain or brainstem compared to decorticate (flexion).
5. What is the gold standard for monitoring intracranial pressure?
A. Subarachnoid screw
B. Epidural sensor
C. Ventriculostomy (External Ventricular Drain)
D. Lumbar puncture
Answer: C
Rationale: Ventriculostomy is the gold standard because it allows for both accurate
pressure monitoring and the drainage of CSF to control ICP.
, 6. A nurse is caring for a patient with a GCS of 7. Which action is the priority?
A. Monitoring urine output
B. Assessing pupillary reaction
C. Preparing for intubation and mechanical ventilation
D. Checking the patient’s temperature
Answer: C
Rationale: A GCS score of 8 or less generally indicates a coma, and the priority is to secure
the airway (intubate) because the patient cannot protect it.
7. Which medication is an osmotic diuretic commonly used to reduce cerebral
edema in patients with increased ICP?
A. Mannitol
B. Furosemide
C. Hydrochlorothiazide
D. Spironolactone
Answer: A
Rationale: Mannitol acts as an osmotic diuretic, drawing fluid from the brain tissue into
the vascular space to reduce ICP.
8. When suctioning a patient with increased ICP, which nursing action is most
important?
A. Suctioning for at least 20 seconds to ensure a clear airway
B. Suctioning every hour regardless of breath sounds
C. Limiting suctioning to two passes and no more than 10 seconds each
D. Maintaining the patient in a supine position during suctioning
Answer: C
Rationale: Suctioning can increase ICP. It should be limited to necessary instances, lasting
no more than 10 seconds per pass, with pre-oxygenation.
Health
1. Which of the following is considered a normal range for Intracranial Pressure
(ICP) in a healthy adult?
A. 0 to 5 mmHg
B. 30 to 40 mmHg
C. 20 to 25 mmHg
D. 5 to 15 mmHg
Answer: D
Rationale: Normal ICP ranges from 5 to 15 mmHg. A sustained pressure greater than 20
mmHg is considered abnormal and requires treatment.
2. A patient has a Mean Arterial Pressure (MAP) of 90 mmHg and an ICP of 20
mmHg. What is the Cerebral Perfusion Pressure (CPP)?
A. 110 mmHg
B. 4.5 mmHg
C. 1800 mmHg
D. 70 mmHg
Answer: D
Rationale: CPP is calculated as MAP minus ICP (90 - 20 = 70 mmHg). Normal CPP is 60 to
100 mmHg.
,3. Which assessment finding is known as Cushing’s Triad, indicating late-stage
increased ICP?
A. Tachycardia, hypotension, and tachypnea
B. Hypotension, bradycardia, and Cheyne-Stokes respirations
C. Bradycardia, hypertension with widening pulse pressure, and irregular respirations
D. Hypertension, tachycardia, and Kussmaul respirations
Answer: C
Rationale: Cushing’s Triad consists of systolic hypertension with a widening pulse
pressure, bradycardia with a full and bounding pulse, and irregular or slowed respirations.
4. A patient with a traumatic brain injury (TBI) exhibits an extension of all four
extremities and internal rotation of the shoulders. How should the nurse
document this?
A. Decorticate posturing
B. Flaccid paralysis
C. Hemiparesis
D. Decerebrate posturing
Answer: D
Rationale: Decerebrate posturing (extension) indicates more serious damage to the
midbrain or brainstem compared to decorticate (flexion).
5. What is the gold standard for monitoring intracranial pressure?
A. Subarachnoid screw
B. Epidural sensor
C. Ventriculostomy (External Ventricular Drain)
D. Lumbar puncture
Answer: C
Rationale: Ventriculostomy is the gold standard because it allows for both accurate
pressure monitoring and the drainage of CSF to control ICP.
, 6. A nurse is caring for a patient with a GCS of 7. Which action is the priority?
A. Monitoring urine output
B. Assessing pupillary reaction
C. Preparing for intubation and mechanical ventilation
D. Checking the patient’s temperature
Answer: C
Rationale: A GCS score of 8 or less generally indicates a coma, and the priority is to secure
the airway (intubate) because the patient cannot protect it.
7. Which medication is an osmotic diuretic commonly used to reduce cerebral
edema in patients with increased ICP?
A. Mannitol
B. Furosemide
C. Hydrochlorothiazide
D. Spironolactone
Answer: A
Rationale: Mannitol acts as an osmotic diuretic, drawing fluid from the brain tissue into
the vascular space to reduce ICP.
8. When suctioning a patient with increased ICP, which nursing action is most
important?
A. Suctioning for at least 20 seconds to ensure a clear airway
B. Suctioning every hour regardless of breath sounds
C. Limiting suctioning to two passes and no more than 10 seconds each
D. Maintaining the patient in a supine position during suctioning
Answer: C
Rationale: Suctioning can increase ICP. It should be limited to necessary instances, lasting
no more than 10 seconds per pass, with pre-oxygenation.
