ATI MED SURG: ICP NCLEX Test Exam Review Questions
with all Answers verified for accuracy Updated 2025/2026
The patient comes to the emergency department (ED) with cortical blindness and visual
field defects. Which type of
head injury does the nurse suspect?
a. Cerebral contusion c. Posterior fossa fracture
b. Orbital skull fracture d. Frontal lobe skull fracture - correct Answer c. The posterior
fossa fracture causes occipital bruising
resulting in cortical blindness or visual field defects.
A cerebral contusion is bruising of brain tissue within
a focal area. An orbital skull fracture would cause
periorbital ecchymosis (raccoon eyes) and possible
optic nerve injury. A frontal lobe skull fracture would
expose the brain to contaminants through the frontal
air sinus and the patient would have CSF rhinorrhea or
pneumocranium.
The patient has a depressed skull fracture and scalp lacerations with communication to
the intracranial cavity. Which
type of injury should the nurse record?
a. Linear skull fracture c. Compound skull fracture
b. Depressed skull fracture d. Comminuted skull fracture - correct Answer c. The
compound skull fracture is a depressed skull fracture
and scalp lacerations with communicating pathway(s) to the
intracranial cavity. A linear skull fracture is a straight break
in the bone without alteration in the fragments. A depressed
skull fracture is an inward indentation of the skull that may
cause pressure on the brain. A comminuted skull fracture
has multiple linear fractures with bone fragmented into
,many pieces.
A patient with a head injury has bloody drainage from the ear. What should the nurse do
to determine if CSF is
present in the drainage?
a. Examine the tympanic membrane for a tear.
b. Test the fluid for a halo sign on a white dressing.
c. Test the fluid with a glucose-identifying strip or stick.
d. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis. - correct
Answer b. Testing clear drainage for CSF in nasal or ear drainage
may be done with a Dextrostik or Tes-Tape strip but if
blood is present, the glucose in the blood will produce an
unreliable result. To test bloody drainage, the nurse should
test the fluid for a "halo" or "ring" that occurs when a
yellowish ring encircles blood dripped onto a white pad or
towel within a few minutes.
The nurse suspects the presence of an arterial epidural hematoma in the patient who
experiences
a. failure to regain consciousness following a head injury.
b. a rapid deterioration of neurologic function within 24 to 48 hours following a head
injury.
c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or
months.
d. unconsciousness at the time of a head injury with a brief period of consciousness
followed by a decrease in LOC. - correct Answer d. An arterial epidural hematoma is
the most acute
neurologic emergency and typical symptoms include
unconsciousness at the scene with a brief lucid interval
followed by a decrease in LOC. An acute subdural
hematoma manifests signs within 48 hours of an injury. A
,chronic subdural hematoma develops over weeks or months.
Skull x-rays and a computed tomography (CT) scan provide evidence of a depressed
parietal fracture with a subdural
hematoma in a patient admitted to the ED following an automobile accident. In planning
care for the patient, what
should the nurse anticipate?
a. The patient will receive life support measures until the condition stabilizes.
b. Immediate burr holes will be made to rapidly decompress the intracranial cavity.
c. The patient will be treated conservatively with close monitoring for changes in
neurologic status.
d. The patient will be taken to surgery for a craniotomy for evacuation of blood and
decompression of the cranium. - correct Answer d. When there is a depressed fracture
or a fracture with
loose fragments, a craniotomy is indicated to elevate the
depressed bone and remove free fragments. A craniotomy
is also indicated in cases of acute subdural and epidural
hematomas to remove the blood and control the bleeding.
Burr holes may be used in an extreme emergency for rapid
decompression or to aid in removing a bone flap but with
a depressed fracture, surgery would be the treatment of
choice.
Priority Decision: When a patient is admitted to the ED following a head injury, what
should be the nurse's first
priority in management of the patient once a patent airway is confirmed?
a. Maintain cervical spine precautions. c. Determine the presence of increased ICP.
b. Monitor for changes in neurologic status. d. Establish IV access with a large-bore
catheter - correct Answer a. In addition to monitoring for a patent airway during
emergency care of the patient with a head injury, the nurse
must always assume that a patient with a head injury may
, have a cervical spine injury. Maintaining cervical spine
precautions in all assessment and treatment activities with
the patient is essential to prevent additional neurologic
damage.
A 54-year-old man is recovering from a skull fracture with a subacute subdural
hematoma that caused unconsciousness.
He has return of motor control and orientation but appears apathetic and has reduced
awareness of his environment. When
planning discharge of the patient, what should the nurse explain to the patient and the
family?
a. The patient is likely to have long-term emotional and mental changes that may
require professional help.
b. Continuous improvement in the patient's condition should occur until he has returned
to pretrauma status.
c. The patient's complete recovery may take years and the family should plan for his
long-term dependent care.
d. Role changes in family members will be necessary because the patient will be
dependent on his family for care
and support. - correct Answer a. Residual mental and emotional changes of brain
trauma
with personality changes are often the most incapacitating
problems following head injury and are common in patients
who have been comatose for longer than 6 hours. Families
must be prepared for changes in the patient's behavior
to avoid family-patient friction and maintain family
functioning and professional assistance may be required.
There is no indication the patient will be dependent on
others for care but he likely will not return to pretrauma
status.
with all Answers verified for accuracy Updated 2025/2026
The patient comes to the emergency department (ED) with cortical blindness and visual
field defects. Which type of
head injury does the nurse suspect?
a. Cerebral contusion c. Posterior fossa fracture
b. Orbital skull fracture d. Frontal lobe skull fracture - correct Answer c. The posterior
fossa fracture causes occipital bruising
resulting in cortical blindness or visual field defects.
A cerebral contusion is bruising of brain tissue within
a focal area. An orbital skull fracture would cause
periorbital ecchymosis (raccoon eyes) and possible
optic nerve injury. A frontal lobe skull fracture would
expose the brain to contaminants through the frontal
air sinus and the patient would have CSF rhinorrhea or
pneumocranium.
The patient has a depressed skull fracture and scalp lacerations with communication to
the intracranial cavity. Which
type of injury should the nurse record?
a. Linear skull fracture c. Compound skull fracture
b. Depressed skull fracture d. Comminuted skull fracture - correct Answer c. The
compound skull fracture is a depressed skull fracture
and scalp lacerations with communicating pathway(s) to the
intracranial cavity. A linear skull fracture is a straight break
in the bone without alteration in the fragments. A depressed
skull fracture is an inward indentation of the skull that may
cause pressure on the brain. A comminuted skull fracture
has multiple linear fractures with bone fragmented into
,many pieces.
A patient with a head injury has bloody drainage from the ear. What should the nurse do
to determine if CSF is
present in the drainage?
a. Examine the tympanic membrane for a tear.
b. Test the fluid for a halo sign on a white dressing.
c. Test the fluid with a glucose-identifying strip or stick.
d. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis. - correct
Answer b. Testing clear drainage for CSF in nasal or ear drainage
may be done with a Dextrostik or Tes-Tape strip but if
blood is present, the glucose in the blood will produce an
unreliable result. To test bloody drainage, the nurse should
test the fluid for a "halo" or "ring" that occurs when a
yellowish ring encircles blood dripped onto a white pad or
towel within a few minutes.
The nurse suspects the presence of an arterial epidural hematoma in the patient who
experiences
a. failure to regain consciousness following a head injury.
b. a rapid deterioration of neurologic function within 24 to 48 hours following a head
injury.
c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or
months.
d. unconsciousness at the time of a head injury with a brief period of consciousness
followed by a decrease in LOC. - correct Answer d. An arterial epidural hematoma is
the most acute
neurologic emergency and typical symptoms include
unconsciousness at the scene with a brief lucid interval
followed by a decrease in LOC. An acute subdural
hematoma manifests signs within 48 hours of an injury. A
,chronic subdural hematoma develops over weeks or months.
Skull x-rays and a computed tomography (CT) scan provide evidence of a depressed
parietal fracture with a subdural
hematoma in a patient admitted to the ED following an automobile accident. In planning
care for the patient, what
should the nurse anticipate?
a. The patient will receive life support measures until the condition stabilizes.
b. Immediate burr holes will be made to rapidly decompress the intracranial cavity.
c. The patient will be treated conservatively with close monitoring for changes in
neurologic status.
d. The patient will be taken to surgery for a craniotomy for evacuation of blood and
decompression of the cranium. - correct Answer d. When there is a depressed fracture
or a fracture with
loose fragments, a craniotomy is indicated to elevate the
depressed bone and remove free fragments. A craniotomy
is also indicated in cases of acute subdural and epidural
hematomas to remove the blood and control the bleeding.
Burr holes may be used in an extreme emergency for rapid
decompression or to aid in removing a bone flap but with
a depressed fracture, surgery would be the treatment of
choice.
Priority Decision: When a patient is admitted to the ED following a head injury, what
should be the nurse's first
priority in management of the patient once a patent airway is confirmed?
a. Maintain cervical spine precautions. c. Determine the presence of increased ICP.
b. Monitor for changes in neurologic status. d. Establish IV access with a large-bore
catheter - correct Answer a. In addition to monitoring for a patent airway during
emergency care of the patient with a head injury, the nurse
must always assume that a patient with a head injury may
, have a cervical spine injury. Maintaining cervical spine
precautions in all assessment and treatment activities with
the patient is essential to prevent additional neurologic
damage.
A 54-year-old man is recovering from a skull fracture with a subacute subdural
hematoma that caused unconsciousness.
He has return of motor control and orientation but appears apathetic and has reduced
awareness of his environment. When
planning discharge of the patient, what should the nurse explain to the patient and the
family?
a. The patient is likely to have long-term emotional and mental changes that may
require professional help.
b. Continuous improvement in the patient's condition should occur until he has returned
to pretrauma status.
c. The patient's complete recovery may take years and the family should plan for his
long-term dependent care.
d. Role changes in family members will be necessary because the patient will be
dependent on his family for care
and support. - correct Answer a. Residual mental and emotional changes of brain
trauma
with personality changes are often the most incapacitating
problems following head injury and are common in patients
who have been comatose for longer than 6 hours. Families
must be prepared for changes in the patient's behavior
to avoid family-patient friction and maintain family
functioning and professional assistance may be required.
There is no indication the patient will be dependent on
others for care but he likely will not return to pretrauma
status.
