NSG 223 Neuro Review Practice Exam | Questions
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Terms in this set (58)
The emergency room (ER) nurse is ANS: A, C Rationale: Fractures of the base of the
caring for a client who has been skull tend to traverse the paranasal sinus of the
brought in by frontal bone or the middle ear located in the
ambulance after sustaining a fall at temporal bone. Therefore, they frequently produce
home. What physical assessment hemorrhage from the nose (epistaxis), pharynx, or
finding(s) are ears, and blood may appear under the conjunctiva.
suggestive of a basilar skull fracture? An area of ecchymosis (bruising) may be seen over
Select all that apply the mastoid (Battle sign). Pain is usually localized to
A. Epistaxis the area of injury and swelling of the tongue and
B. Swelling of the tongue and lips lips may have been the result of direct impact of
C. Bruising over the mastoid the face due to the fall or an anaphylactic reaction
D. Unilateral facial numbness of some type. Numbness on one side of the face is
E. Severe back pain not a typical finding in basilar skull fractures.
,A client is brought to the trauma ANS: B Rationale: If endotracheal intubation is
center by ambulance after sustaining necessary, extreme care is taken to avoid flexing or
a high cervical extending the client's neck, which can result in
spinal cord injury 11/2 hours ago. extension of a cervical injury. Intubation does not
Endotracheal intubation has been directly cause autonomic dysreflexia and the threat
deemed necessary to skin integrity is not a primary concern. Intubation
and the nurse is preparing to assist. does not carry the potential to cause suffocation.
What nursing diagnosis should the
nurse associate
with this procedure?
A. Risk for impaired skin integrity
B. Risk for injury
C. Risk for autonomic dysreflexia
D. Risk for suffocation
A nurse is caring for a critically ill ANS: B Rationale: Autonomic dysreflexia is
client with autonomic dysreflexia. characterized by a pounding headache, profuse
What clinical sweating, nasal congestion, piloerection (goose
manifestations would the nurse bumps), bradycardia, and hypertension. It occurs in
expect in this client? cord lesions above T6 after spinal shock has
A. Respiratory distress and projectile resolved; it does not result in vomiting, tachycardia,
vomiting or third-spacing.
B. Bradycardia and hypertension
C. Tachycardia and agitation
D. Third-spacing and hyperthermia
,The nurse is caring for a client with ANS: A Rationale: Signs of increasing ICP include
increased intracranial pressure (ICP) slowing of the heart rate (bradycardia), increasing
caused by a systolic BP, and widening pulse pressure. As brain
traumatic brain injury. Which of the compression increases, respirations become rapid,
following clinical manifestations BP may decrease, and the pulse slows further. A
would suggest that rapid rise in body temperature is regarded as
the client may be experiencing unfavorable. Hyperthermia increases the metabolic
increased brain compression causing demands of the brain and may indicate brain stem
brain stem damage? damage.
A. Hyperthermia
B. Tachycardia
C. Hypertension
D. Bradypnea
A client is brought to the ED by ANS: C Rationale: An epidural hematoma is
family after falling off the roof. The considered an extreme emergency. Marked
care team suspects neurological deficit or respiratory arrest can occur
an epidural hematoma, prompting within minutes. Treatment consists of making an
the nurse to anticipate for which opening through the skull to decrease ICP
priority emergently, remove the clot, and control the
intervention? bleeding. Antihypertensive medications would not
A. Insertion of an intracranial be a priority. Anticoagulant therapy should not be
monitoring device prescribed for a client who has a cranial bleed. This
B. Treatment with antihypertensives could further increase bleeding activity. Insertion
C. Making openings in the skull of an intracranial monitoring device may be done
D. Administration of anticoagulant during the surgery, but is not priority for this client.
therapy
, The staff educator is precepting a The staff educator is precepting a nurse new to the
nurse new to the critical care unit critical care unit when a client with a T2 spinal cord
when a client with injury is admitted. The client is soon exhibiting
a T2 spinal cord injury is admitted. manifestations of neurogenic shock. In addition to
The client is soon exhibiting monitoring the client closely, what would be the
manifestations of nurse's most appropriate action? A. Prepare to
neurogenic shock. In addition to transfuse packed red blood cells. B. Prepare for
monitoring the client closely, what interventions to increase the client's BP. C. Place
would be the nurse's the client in the Trendelenburg position. D. Prepare
most appropriate action? an ice bath to lower core body temperature.
A. Prepare to transfuse packed red
blood cells.
B. Prepare for interventions to
increase the client's BP.
C. Place the client in the
Trendelenburg position.
D. Prepare an ice bath to lower core
body temperature.
An ED nurse has just received a call ANS: D Rationale: The most common causes of
from EMS that they are transporting SCIs are motor vehicle crashes, falls, violence, and
a 17-year-old sports.
client who has just sustained a spinal
cord injury (SCI). The nurse
recognizes that the
most common cause of this type of
injury is what event?
A. Syncope (fainting)
B. Suicide attempts
C. Workplace injuries
D. Motor vehicle accidents
with 100% Correct Answers | Verified | Latest
Update 2026
Save
Terms in this set (58)
The emergency room (ER) nurse is ANS: A, C Rationale: Fractures of the base of the
caring for a client who has been skull tend to traverse the paranasal sinus of the
brought in by frontal bone or the middle ear located in the
ambulance after sustaining a fall at temporal bone. Therefore, they frequently produce
home. What physical assessment hemorrhage from the nose (epistaxis), pharynx, or
finding(s) are ears, and blood may appear under the conjunctiva.
suggestive of a basilar skull fracture? An area of ecchymosis (bruising) may be seen over
Select all that apply the mastoid (Battle sign). Pain is usually localized to
A. Epistaxis the area of injury and swelling of the tongue and
B. Swelling of the tongue and lips lips may have been the result of direct impact of
C. Bruising over the mastoid the face due to the fall or an anaphylactic reaction
D. Unilateral facial numbness of some type. Numbness on one side of the face is
E. Severe back pain not a typical finding in basilar skull fractures.
,A client is brought to the trauma ANS: B Rationale: If endotracheal intubation is
center by ambulance after sustaining necessary, extreme care is taken to avoid flexing or
a high cervical extending the client's neck, which can result in
spinal cord injury 11/2 hours ago. extension of a cervical injury. Intubation does not
Endotracheal intubation has been directly cause autonomic dysreflexia and the threat
deemed necessary to skin integrity is not a primary concern. Intubation
and the nurse is preparing to assist. does not carry the potential to cause suffocation.
What nursing diagnosis should the
nurse associate
with this procedure?
A. Risk for impaired skin integrity
B. Risk for injury
C. Risk for autonomic dysreflexia
D. Risk for suffocation
A nurse is caring for a critically ill ANS: B Rationale: Autonomic dysreflexia is
client with autonomic dysreflexia. characterized by a pounding headache, profuse
What clinical sweating, nasal congestion, piloerection (goose
manifestations would the nurse bumps), bradycardia, and hypertension. It occurs in
expect in this client? cord lesions above T6 after spinal shock has
A. Respiratory distress and projectile resolved; it does not result in vomiting, tachycardia,
vomiting or third-spacing.
B. Bradycardia and hypertension
C. Tachycardia and agitation
D. Third-spacing and hyperthermia
,The nurse is caring for a client with ANS: A Rationale: Signs of increasing ICP include
increased intracranial pressure (ICP) slowing of the heart rate (bradycardia), increasing
caused by a systolic BP, and widening pulse pressure. As brain
traumatic brain injury. Which of the compression increases, respirations become rapid,
following clinical manifestations BP may decrease, and the pulse slows further. A
would suggest that rapid rise in body temperature is regarded as
the client may be experiencing unfavorable. Hyperthermia increases the metabolic
increased brain compression causing demands of the brain and may indicate brain stem
brain stem damage? damage.
A. Hyperthermia
B. Tachycardia
C. Hypertension
D. Bradypnea
A client is brought to the ED by ANS: C Rationale: An epidural hematoma is
family after falling off the roof. The considered an extreme emergency. Marked
care team suspects neurological deficit or respiratory arrest can occur
an epidural hematoma, prompting within minutes. Treatment consists of making an
the nurse to anticipate for which opening through the skull to decrease ICP
priority emergently, remove the clot, and control the
intervention? bleeding. Antihypertensive medications would not
A. Insertion of an intracranial be a priority. Anticoagulant therapy should not be
monitoring device prescribed for a client who has a cranial bleed. This
B. Treatment with antihypertensives could further increase bleeding activity. Insertion
C. Making openings in the skull of an intracranial monitoring device may be done
D. Administration of anticoagulant during the surgery, but is not priority for this client.
therapy
, The staff educator is precepting a The staff educator is precepting a nurse new to the
nurse new to the critical care unit critical care unit when a client with a T2 spinal cord
when a client with injury is admitted. The client is soon exhibiting
a T2 spinal cord injury is admitted. manifestations of neurogenic shock. In addition to
The client is soon exhibiting monitoring the client closely, what would be the
manifestations of nurse's most appropriate action? A. Prepare to
neurogenic shock. In addition to transfuse packed red blood cells. B. Prepare for
monitoring the client closely, what interventions to increase the client's BP. C. Place
would be the nurse's the client in the Trendelenburg position. D. Prepare
most appropriate action? an ice bath to lower core body temperature.
A. Prepare to transfuse packed red
blood cells.
B. Prepare for interventions to
increase the client's BP.
C. Place the client in the
Trendelenburg position.
D. Prepare an ice bath to lower core
body temperature.
An ED nurse has just received a call ANS: D Rationale: The most common causes of
from EMS that they are transporting SCIs are motor vehicle crashes, falls, violence, and
a 17-year-old sports.
client who has just sustained a spinal
cord injury (SCI). The nurse
recognizes that the
most common cause of this type of
injury is what event?
A. Syncope (fainting)
B. Suicide attempts
C. Workplace injuries
D. Motor vehicle accidents
