NUR 5461/NUR5461 Module 4 V2 |
Neurological System Q&A with Rationale |
William Paterson University
1. A patient with a head injury presents with a blood pressure of 180/60, a heart rate of 45,
and irregular respirations. Which condition do these vital signs most likely indicate?
A. Hypovolemic shock
B. Cushing’s Triad
C. Septic shock
D. Normal recovery phase
Correct Answer: B
Expert Explanation: Cushing’s Triad is characterized by systolic hypertension with a
widening pulse pressure, bradycardia, and irregular respirations. These symptoms indicate
a significant increase in intracranial pressure and potential brainstem herniation. This is a
medical emergency that requires immediate intervention to prevent further neurological
damage.
2. When assessing a patient using the Glasgow Coma Scale (GCS), the nurse notes the patient
opens eyes to pain, makes incomprehensible sounds, and withdraws from pain. What is the
total GCS score?
A. 6
,B. 12
C. 10
D. 8
Correct Answer: D
Expert Explanation: The GCS score is calculated based on eye opening (2 for pain), verbal
response (2 for incomprehensible sounds), and motor response (4 for withdrawal from
pain). A score of 8 or less is generally used to define a coma or severe brain injury.
Monitoring the GCS score over time is critical for detecting subtle changes in neurological
status.
3. A patient with a suspected spinal cord injury at T6 reports a severe pounding headache and
is found to have a BP of 200/110. What is the priority nursing action?
A. Administer PRN pain medication
B. Increase the IV fluid rate
C. Check for bladder distension or a blocked catheter
D. Place the patient in a supine position
Correct Answer: C
Expert Explanation: Autonomic dysreflexia is a life-threatening condition occurring in
patients with spinal cord injuries at or above T6, often triggered by noxious stimuli like
bladder distension. The nurse must immediately identify and remove the trigger, such as
, checking for a full bladder or impacted bowel. Failure to treat this condition quickly can
lead to stroke, seizures, or myocardial infarction.
4. Which medication is the drug of choice for a patient in status epilepticus?
A. Phenytoin
B. Valproic acid
C. Lorazepam
D. Levetiracetam
Correct Answer: C
Expert Explanation: Lorazepam is the preferred benzodiazepine for stopping active
seizure activity due to its rapid onset and duration of action. While phenytoin is used for
long-term seizure control, it does not act fast enough to stop status epilepticus. Nurses
must monitor the airway and vital signs closely during the administration of IV
benzodiazepines.
5. A patient with Parkinson’s disease is prescribed Levodopa-Carbidopa. What is the primary
purpose of combining these two drugs?
A. To prevent the breakdown of dopamine in the brain
B. To cure the underlying neurodegeneration
C. To reduce the risk of hypertension
D. To increase the amount of levodopa that reaches the brain
Neurological System Q&A with Rationale |
William Paterson University
1. A patient with a head injury presents with a blood pressure of 180/60, a heart rate of 45,
and irregular respirations. Which condition do these vital signs most likely indicate?
A. Hypovolemic shock
B. Cushing’s Triad
C. Septic shock
D. Normal recovery phase
Correct Answer: B
Expert Explanation: Cushing’s Triad is characterized by systolic hypertension with a
widening pulse pressure, bradycardia, and irregular respirations. These symptoms indicate
a significant increase in intracranial pressure and potential brainstem herniation. This is a
medical emergency that requires immediate intervention to prevent further neurological
damage.
2. When assessing a patient using the Glasgow Coma Scale (GCS), the nurse notes the patient
opens eyes to pain, makes incomprehensible sounds, and withdraws from pain. What is the
total GCS score?
A. 6
,B. 12
C. 10
D. 8
Correct Answer: D
Expert Explanation: The GCS score is calculated based on eye opening (2 for pain), verbal
response (2 for incomprehensible sounds), and motor response (4 for withdrawal from
pain). A score of 8 or less is generally used to define a coma or severe brain injury.
Monitoring the GCS score over time is critical for detecting subtle changes in neurological
status.
3. A patient with a suspected spinal cord injury at T6 reports a severe pounding headache and
is found to have a BP of 200/110. What is the priority nursing action?
A. Administer PRN pain medication
B. Increase the IV fluid rate
C. Check for bladder distension or a blocked catheter
D. Place the patient in a supine position
Correct Answer: C
Expert Explanation: Autonomic dysreflexia is a life-threatening condition occurring in
patients with spinal cord injuries at or above T6, often triggered by noxious stimuli like
bladder distension. The nurse must immediately identify and remove the trigger, such as
, checking for a full bladder or impacted bowel. Failure to treat this condition quickly can
lead to stroke, seizures, or myocardial infarction.
4. Which medication is the drug of choice for a patient in status epilepticus?
A. Phenytoin
B. Valproic acid
C. Lorazepam
D. Levetiracetam
Correct Answer: C
Expert Explanation: Lorazepam is the preferred benzodiazepine for stopping active
seizure activity due to its rapid onset and duration of action. While phenytoin is used for
long-term seizure control, it does not act fast enough to stop status epilepticus. Nurses
must monitor the airway and vital signs closely during the administration of IV
benzodiazepines.
5. A patient with Parkinson’s disease is prescribed Levodopa-Carbidopa. What is the primary
purpose of combining these two drugs?
A. To prevent the breakdown of dopamine in the brain
B. To cure the underlying neurodegeneration
C. To reduce the risk of hypertension
D. To increase the amount of levodopa that reaches the brain
