ATI MED SURG NEURO-SHOCK &
BURNS PRACTICE TEST LATEST
DETAILED ANSWER KEY
1. A nurse in the ED is assessing a client with sudden onset of right-
sided weakness, facial droop, and slurred speech. What is the priority
action?
A. Obtain a CT scan of the head
B. Start an IV of normal saline
C. Check blood glucose level
D. Administer aspirin 325 mg
Answer: A. Obtain a CT scan of the head
Rationale: For a suspected acute ischemic stroke, a non-contrast CT scan is
the priority to rule out hemorrhagic stroke before thrombolytics (tPA) can
be given. Time to CT is critical (within 25 minutes of arrival). Blood glucose
should be checked quickly, but CT is the priority.
2. Which finding in a client with a traumatic brain injury (TBI) is the
earliest sign of increasing intracranial pressure (ICP)?
A. Widening pulse pressure
B. Decorticate posturing
C. Change in level of consciousness (LOC)
D. Bradycardia
Answer: C. Change in level of consciousness
Rationale: Altered LOC (restlessness, confusion, lethargy) is the most
, sensitive and earliest indicator of rising ICP. Cushing’s triad (hypertension,
bradycardia, irregular respirations) and posturing occur later.
3. A nurse is caring for a client post-ictal after a generalized tonic-
clonic seizure. Which intervention is most important?
A. Insert an oral airway
B. Turn the client to the side
C. Restrain the client to prevent injury
D. Administer IV lorazepam
Answer: B. Turn the client to the side
Rationale: After a seizure, turn the client to a lateral position to maintain a
patent airway and allow secretions to drain, preventing aspiration. Never
insert anything into the mouth after the seizure has started. Restraint is
contraindicated.
4. A client with a subarachnoid hemorrhage from a ruptured aneurysm
reports a sudden severe headache. What medication should the nurse
anticipate to prevent rebleeding?
A. Heparin
B. Nimodipine
C. Mannitol
D. Phenytoin
Answer: B. Nimodipine
Rationale: Nimodipine is a calcium channel blocker given to prevent
vasospasm, a major complication after subarachnoid hemorrhage. It
reduces the risk of delayed cerebral ischemia and rebleeding indirectly.
5. A nurse is assessing a client with a spinal cord injury at T4. Which
finding indicates autonomic dysreflexia?
A. Hypotension and tachycardia
B. Hypertension and bradycardia
C. Cool, clammy skin below the injury
, D. Flaccid paralysis
Answer: B. Hypertension and bradycardia
Rationale: Autonomic dysreflexia (hyperreflexia) occurs in spinal cord
injuries above T6. A noxious stimulus (e.g., distended bladder) triggers
massive sympathetic discharge causing severe hypertension, pounding
headache, bradycardia, and sweating above the lesion.
6. Which Glasgow Coma Scale (GCS) score indicates severe traumatic
brain injury?
A. 15
B. 12
C. 6
D. 9
Answer: C. 6
Rationale: GCS scores: 13–15 mild, 9–12 moderate, 3–8 severe. A score of 6
indicates severe brain injury with poor prognosis.
7. A client with bacterial meningitis has petechial rash, fever, and
nuchal rigidity. Which precaution is most important?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Protective isolation
Answer: B. Droplet precautions
Rationale: Bacterial meningitis (especially Neisseria meningitidis) is spread
via respiratory droplets. Place client in a private room with mask within 3
feet. Droplet precautions continue for the first 24 hours of antibiotic
therapy.
8. The nurse is teaching a client with a new diagnosis of epilepsy about
phenytoin (Dilantin). Which statement indicates understanding?
, A. "I can stop the medication if I am seizure-free for 6 months."
B. "I will take the medication with milk to prevent stomach upset."
C. "I need to practice good oral hygiene and see my dentist regularly."
D. "I should take the medication only when I feel a seizure coming on."
Answer: C. "I need to practice good oral hygiene and see my dentist
regularly."
Rationale: Phenytoin causes gingival hyperplasia (gum overgrowth). Regular
brushing, flossing, and dental visits are essential. Never stop
anticonvulsants abruptly.
9. A client with an ischemic stroke has a BP of 190/100 mm Hg. Which
intervention is appropriate?
A. Administer IV labetalol immediately to lower BP to 120/80
B. Only treat BP if it is >220/120 or if the client is receiving tPA
C. Give sublingual nifedipine
D. Hold all antihypertensives for 48 hours
Answer: B. Only treat BP if it is >220/120 or if the client is receiving
tPA
Rationale: In acute ischemic stroke, hypertension is permissive to maintain
cerebral perfusion pressure. Do not lower BP unless >220/120 or if tPA is
planned (then target <185/110). Abrupt lowering can worsen ischemia.
10. Which diagnostic test confirms brain death?
A. EEG showing persistent electrical activity
B. Absent cerebral blood flow on cerebral angiography
C. Positive Babinski reflex
D. Pupils reactive to light
Answer: B. Absent cerebral blood flow on cerebral angiography
Rationale: Confirmatory tests for brain death include cerebral angiography
(no flow), transcranial Doppler, or radionuclide scan. EEG may show
absence of activity, but angiography is definitive. Clinical exam (no
brainstem reflexes, apnea) is primary.
BURNS PRACTICE TEST LATEST
DETAILED ANSWER KEY
1. A nurse in the ED is assessing a client with sudden onset of right-
sided weakness, facial droop, and slurred speech. What is the priority
action?
A. Obtain a CT scan of the head
B. Start an IV of normal saline
C. Check blood glucose level
D. Administer aspirin 325 mg
Answer: A. Obtain a CT scan of the head
Rationale: For a suspected acute ischemic stroke, a non-contrast CT scan is
the priority to rule out hemorrhagic stroke before thrombolytics (tPA) can
be given. Time to CT is critical (within 25 minutes of arrival). Blood glucose
should be checked quickly, but CT is the priority.
2. Which finding in a client with a traumatic brain injury (TBI) is the
earliest sign of increasing intracranial pressure (ICP)?
A. Widening pulse pressure
B. Decorticate posturing
C. Change in level of consciousness (LOC)
D. Bradycardia
Answer: C. Change in level of consciousness
Rationale: Altered LOC (restlessness, confusion, lethargy) is the most
, sensitive and earliest indicator of rising ICP. Cushing’s triad (hypertension,
bradycardia, irregular respirations) and posturing occur later.
3. A nurse is caring for a client post-ictal after a generalized tonic-
clonic seizure. Which intervention is most important?
A. Insert an oral airway
B. Turn the client to the side
C. Restrain the client to prevent injury
D. Administer IV lorazepam
Answer: B. Turn the client to the side
Rationale: After a seizure, turn the client to a lateral position to maintain a
patent airway and allow secretions to drain, preventing aspiration. Never
insert anything into the mouth after the seizure has started. Restraint is
contraindicated.
4. A client with a subarachnoid hemorrhage from a ruptured aneurysm
reports a sudden severe headache. What medication should the nurse
anticipate to prevent rebleeding?
A. Heparin
B. Nimodipine
C. Mannitol
D. Phenytoin
Answer: B. Nimodipine
Rationale: Nimodipine is a calcium channel blocker given to prevent
vasospasm, a major complication after subarachnoid hemorrhage. It
reduces the risk of delayed cerebral ischemia and rebleeding indirectly.
5. A nurse is assessing a client with a spinal cord injury at T4. Which
finding indicates autonomic dysreflexia?
A. Hypotension and tachycardia
B. Hypertension and bradycardia
C. Cool, clammy skin below the injury
, D. Flaccid paralysis
Answer: B. Hypertension and bradycardia
Rationale: Autonomic dysreflexia (hyperreflexia) occurs in spinal cord
injuries above T6. A noxious stimulus (e.g., distended bladder) triggers
massive sympathetic discharge causing severe hypertension, pounding
headache, bradycardia, and sweating above the lesion.
6. Which Glasgow Coma Scale (GCS) score indicates severe traumatic
brain injury?
A. 15
B. 12
C. 6
D. 9
Answer: C. 6
Rationale: GCS scores: 13–15 mild, 9–12 moderate, 3–8 severe. A score of 6
indicates severe brain injury with poor prognosis.
7. A client with bacterial meningitis has petechial rash, fever, and
nuchal rigidity. Which precaution is most important?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Protective isolation
Answer: B. Droplet precautions
Rationale: Bacterial meningitis (especially Neisseria meningitidis) is spread
via respiratory droplets. Place client in a private room with mask within 3
feet. Droplet precautions continue for the first 24 hours of antibiotic
therapy.
8. The nurse is teaching a client with a new diagnosis of epilepsy about
phenytoin (Dilantin). Which statement indicates understanding?
, A. "I can stop the medication if I am seizure-free for 6 months."
B. "I will take the medication with milk to prevent stomach upset."
C. "I need to practice good oral hygiene and see my dentist regularly."
D. "I should take the medication only when I feel a seizure coming on."
Answer: C. "I need to practice good oral hygiene and see my dentist
regularly."
Rationale: Phenytoin causes gingival hyperplasia (gum overgrowth). Regular
brushing, flossing, and dental visits are essential. Never stop
anticonvulsants abruptly.
9. A client with an ischemic stroke has a BP of 190/100 mm Hg. Which
intervention is appropriate?
A. Administer IV labetalol immediately to lower BP to 120/80
B. Only treat BP if it is >220/120 or if the client is receiving tPA
C. Give sublingual nifedipine
D. Hold all antihypertensives for 48 hours
Answer: B. Only treat BP if it is >220/120 or if the client is receiving
tPA
Rationale: In acute ischemic stroke, hypertension is permissive to maintain
cerebral perfusion pressure. Do not lower BP unless >220/120 or if tPA is
planned (then target <185/110). Abrupt lowering can worsen ischemia.
10. Which diagnostic test confirms brain death?
A. EEG showing persistent electrical activity
B. Absent cerebral blood flow on cerebral angiography
C. Positive Babinski reflex
D. Pupils reactive to light
Answer: B. Absent cerebral blood flow on cerebral angiography
Rationale: Confirmatory tests for brain death include cerebral angiography
(no flow), transcranial Doppler, or radionuclide scan. EEG may show
absence of activity, but angiography is definitive. Clinical exam (no
brainstem reflexes, apnea) is primary.
