NSG 4100 Exam 4 Final –
Neurological & Critical Care Nursing
ACTUAL 2026!!
Question 1
A nurse is caring for a client with head trauma. The client’s urinary output is 300 mL over 2
hours. Which action should the nurse take first?
A. Document the output as normal
B. Notify the provider immediately
C. Decrease IV fluids
D. Check specific gravity
ANSWER: D – Check specific gravity
Rationale:
A – 300 mL over 2 hours is 150 mL/hr, which is above normal (30–80 mL/hr). Post-head injury,
this may indicate diabetes insipidus, so it is not normal and requires further assessment.
B – The provider should be notified, but only after completing an initial assessment to gather
more data (such as specific gravity).
C – Decreasing IV fluids without knowing the cause could lead to hypotension and worsen
cerebral perfusion.
D – Correct. A low specific gravity (<1.005) suggests diabetes insipidus due to posterior pituitary
injury. This is the best first action to confirm the cause of polyuria.
Question 2
,A client with traumatic brain injury (TBI) had a peak ICP reading 12 hours ago. Now at 36 hours
post-injury, the client becomes unconscious for 1 minute. What should the nurse do first?
A. Reorient the client
B. Notify provider of increased pupil size from 7 to 10 mm
C. Administer oxygen at 2 L/min
D. Check blood glucose
ANSWER: B – Notify provider of increased pupil size from 7 to 10 mm
Rationale:
A – The client is unconscious, so reorientation is not possible.
B – Correct. Pupil dilation from 7 mm to 10 mm indicates worsening brainstem compression and
imminent herniation. This requires immediate notification.
C – Oxygen administration may help with cerebral oxygenation but is not the priority over
reporting a herniation sign.
D – Hypoglycemia can cause unconsciousness, but the pupil change is more specific to
increased ICP.
Question 3
A client with closed head injury is on mechanical ventilation. Which intervention reduces risk of
increased ICP?
A. Flat head of bed
B. Elevate HOB 30–45 degrees
C. Turn client every 4 hours
D. Suction every hour
ANSWER: B – Elevate HOB 30–45 degrees
Rationale:
A – Flat positioning increases cerebral venous pressure and raises ICP.
B – Correct. Elevating the head of bed promotes venous drainage from the brain, reducing ICP.
,C – Turning every 4 hours is too infrequent; turning every 2 hours with logrolling is
recommended, but positioning changes must be done slowly to avoid ICP spikes.
D – Suctioning increases ICP transiently and should only be done when clinically indicated, not
on a fixed schedule.
Question 4
A client with a spinal cord injury wearing a halo vest has family report of “he can only move 2
fingers now, he used to move all.” What is the nurse’s priority?
A. Document as expected
B. Tighten halo pins
C. Notify provider of possible spinal cord compromise
D. Perform range of motion
ANSWER: C – Notify provider of possible spinal cord compromise
Rationale:
A – Loss of motor function is not expected; it suggests worsening cord edema or injury.
B – Tightening halo pins is not within nursing scope and does not address neurological decline.
C – Correct. New weakness after spinal cord injury requires immediate evaluation for cord
compression or re-injury.
D – Range of motion will not reverse neurological loss and could worsen injury if instability is
present.
Question 5
A client with cerebral hemorrhage becomes increasingly agitated. Which assessment finding
indicates worsening ICP?
A. Systolic BP 110
B. Pupils equal and reactive
C. Restlessness followed by decreased responsiveness
D. Respiratory rate 18
ANSWER: C – Restlessness followed by decreased responsiveness
, Rationale:
A – Systolic BP 110 is normal or low; increased ICP typically causes hypertension.
B – Equal and reactive pupils are reassuring but do not rule out early increased ICP.
C – Correct. Restlessness is an early sign of increased ICP; decreased responsiveness
(lethargy, stupor, coma) indicates worsening cerebral compression.
D – Respiratory rate 18 is normal; irregular breathing (Cheyne-Stokes, apneustic) is a late sign
of increased ICP.
Question 6
A client with Guillain-Barré syndrome (GBS) intermittently coughs up moderate secretions. What
is the nurse’s best action?
A. Suction immediately
B. Document as normal finding
C. Prepare for tracheostomy
D. Increase oral fluids
ANSWER: B – Document as normal finding
Rationale:
A – Suctioning is invasive and can cause vagal bradycardia; it is not needed if the cough is
effective.
B – Correct. In early GBS, the cough reflex may still be intact. Intermittent coughing with
moderate secretions is expected.
C – Tracheostomy is indicated only if respiratory failure develops (vital capacity <15 mL/kg,
declining FVC).
D – Increasing oral fluids may cause aspiration if dysphagia is present (common in GBS).
Question 7
A client with ALS requests that resuscitation be withheld if breathing stops. What should the
nurse do?
A. Respect the request and document
Neurological & Critical Care Nursing
ACTUAL 2026!!
Question 1
A nurse is caring for a client with head trauma. The client’s urinary output is 300 mL over 2
hours. Which action should the nurse take first?
A. Document the output as normal
B. Notify the provider immediately
C. Decrease IV fluids
D. Check specific gravity
ANSWER: D – Check specific gravity
Rationale:
A – 300 mL over 2 hours is 150 mL/hr, which is above normal (30–80 mL/hr). Post-head injury,
this may indicate diabetes insipidus, so it is not normal and requires further assessment.
B – The provider should be notified, but only after completing an initial assessment to gather
more data (such as specific gravity).
C – Decreasing IV fluids without knowing the cause could lead to hypotension and worsen
cerebral perfusion.
D – Correct. A low specific gravity (<1.005) suggests diabetes insipidus due to posterior pituitary
injury. This is the best first action to confirm the cause of polyuria.
Question 2
,A client with traumatic brain injury (TBI) had a peak ICP reading 12 hours ago. Now at 36 hours
post-injury, the client becomes unconscious for 1 minute. What should the nurse do first?
A. Reorient the client
B. Notify provider of increased pupil size from 7 to 10 mm
C. Administer oxygen at 2 L/min
D. Check blood glucose
ANSWER: B – Notify provider of increased pupil size from 7 to 10 mm
Rationale:
A – The client is unconscious, so reorientation is not possible.
B – Correct. Pupil dilation from 7 mm to 10 mm indicates worsening brainstem compression and
imminent herniation. This requires immediate notification.
C – Oxygen administration may help with cerebral oxygenation but is not the priority over
reporting a herniation sign.
D – Hypoglycemia can cause unconsciousness, but the pupil change is more specific to
increased ICP.
Question 3
A client with closed head injury is on mechanical ventilation. Which intervention reduces risk of
increased ICP?
A. Flat head of bed
B. Elevate HOB 30–45 degrees
C. Turn client every 4 hours
D. Suction every hour
ANSWER: B – Elevate HOB 30–45 degrees
Rationale:
A – Flat positioning increases cerebral venous pressure and raises ICP.
B – Correct. Elevating the head of bed promotes venous drainage from the brain, reducing ICP.
,C – Turning every 4 hours is too infrequent; turning every 2 hours with logrolling is
recommended, but positioning changes must be done slowly to avoid ICP spikes.
D – Suctioning increases ICP transiently and should only be done when clinically indicated, not
on a fixed schedule.
Question 4
A client with a spinal cord injury wearing a halo vest has family report of “he can only move 2
fingers now, he used to move all.” What is the nurse’s priority?
A. Document as expected
B. Tighten halo pins
C. Notify provider of possible spinal cord compromise
D. Perform range of motion
ANSWER: C – Notify provider of possible spinal cord compromise
Rationale:
A – Loss of motor function is not expected; it suggests worsening cord edema or injury.
B – Tightening halo pins is not within nursing scope and does not address neurological decline.
C – Correct. New weakness after spinal cord injury requires immediate evaluation for cord
compression or re-injury.
D – Range of motion will not reverse neurological loss and could worsen injury if instability is
present.
Question 5
A client with cerebral hemorrhage becomes increasingly agitated. Which assessment finding
indicates worsening ICP?
A. Systolic BP 110
B. Pupils equal and reactive
C. Restlessness followed by decreased responsiveness
D. Respiratory rate 18
ANSWER: C – Restlessness followed by decreased responsiveness
, Rationale:
A – Systolic BP 110 is normal or low; increased ICP typically causes hypertension.
B – Equal and reactive pupils are reassuring but do not rule out early increased ICP.
C – Correct. Restlessness is an early sign of increased ICP; decreased responsiveness
(lethargy, stupor, coma) indicates worsening cerebral compression.
D – Respiratory rate 18 is normal; irregular breathing (Cheyne-Stokes, apneustic) is a late sign
of increased ICP.
Question 6
A client with Guillain-Barré syndrome (GBS) intermittently coughs up moderate secretions. What
is the nurse’s best action?
A. Suction immediately
B. Document as normal finding
C. Prepare for tracheostomy
D. Increase oral fluids
ANSWER: B – Document as normal finding
Rationale:
A – Suctioning is invasive and can cause vagal bradycardia; it is not needed if the cough is
effective.
B – Correct. In early GBS, the cough reflex may still be intact. Intermittent coughing with
moderate secretions is expected.
C – Tracheostomy is indicated only if respiratory failure develops (vital capacity <15 mL/kg,
declining FVC).
D – Increasing oral fluids may cause aspiration if dysphagia is present (common in GBS).
Question 7
A client with ALS requests that resuscitation be withheld if breathing stops. What should the
nurse do?
A. Respect the request and document
