NR 340 Week 3 Evolve Questions & Answers
Question 1
What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment
on increased intracranial pressure (ICP)?
A. Reduces ICP by improving venous drainage
B. Increases cerebral blood flow
C. Decreases cerebral perfusion pressure
D. Enhances cerebrospinal fluid production
Correct Answer: A. Reduces ICP by improving venous drainage
Explanation: Elevating the head of the bed (30–45°) and maintaining neutral head and neck
alignment promote venous drainage from the brain, reducing intracranial pressure by decreasing
venous congestion.
Question 2
Under normal circumstances, the cerebral vasculature exhibits pressure and chemical
autoregulation. What happens when autoregulation is lost?
A. Cerebral blood flow becomes dependent on systemic blood pressure
B. Cerebral blood flow increases uncontrollably
C. Intracranial pressure decreases significantly
D. Blood-brain barrier becomes impermeable
Correct Answer: A. Cerebral blood flow becomes dependent on systemic blood pressure
Explanation: Loss of autoregulation impairs the brain’s ability to maintain constant blood
flow despite changes in systemic blood pressure, making cerebral blood flow directly dependent
on systemic pressure, risking ischemia or edema.
Question 3
The nurse is monitoring a patient’s intracranial pressure (ICP). While providing hygiene
measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority
nursing action?
,A. Notify the physician immediately
B. Continue hygiene measures and reassess
C. Administer mannitol as per standing orders
D. Lower the head of the bed
Correct Answer: A. Notify the physician immediately
Explanation: A sustained ICP of 18 mm Hg is elevated (normal is 5–15 mm Hg), indicating a
potential risk of brain injury. Notifying the physician is the priority to initiate interventions to
prevent further increase.
Question 4
Herniation syndromes can be life-threatening situations. Which syndrome causes the
supratentorial contents to shift downward and compress vital centers of the brainstem?
A. Uncal herniation
B. Central (transtentorial) herniation
C. Cerebellar tonsillar herniation
D. Subfalcine herniation
Correct Answer: B. Central (transtentorial) herniation
Explanation: Central herniation involves downward displacement of supratentorial contents
through the tentorial notch, compressing the brainstem and vital centers, leading to life-
threatening symptoms like respiratory failure.
Question 5
In a patient with increased intracranial pressure (ICP), which of the following cranial nerves is
most commonly assessed to evaluate pupil response and eye movement?
A. Oculomotor nerve (III)
B. Optic nerve (II)
C. Trigeminal nerve (V)
D. Facial nerve (VII)
Correct Answer: A. Oculomotor nerve (III)
, Explanation: The oculomotor nerve (III) controls pupil constriction and most eye movements.
Assessing pupil response and eye movement is critical in ICP patients, as compression can
impair this nerve, causing fixed pupils or abnormal eye movements.
Question 6
The nurse is managing the blood pressure of a patient with a traumatic brain injury. Which
statement best represents appropriate blood pressure management?
A. Maintain cerebral perfusion pressure (CPP) between 60–70 mm Hg
B. Keep systolic BP below 90 mm Hg
C. Allow BP to fluctuate to promote autoregulation
D. Administer vasopressors to maintain ICP above 20 mm Hg
Correct Answer: A. Maintain cerebral perfusion pressure (CPP) between 60–70 mm Hg
Explanation: In traumatic brain injury, maintaining CPP (mean arterial pressure minus ICP)
between 60–70 mm Hg ensures adequate brain perfusion without exacerbating ICP.
Question 7
The nurse is caring for a patient with a ruptured cerebral aneurysm and observes a Glasgow
Coma Scale score of 7. What is the best interpretation of this finding by the nurse?
A. Moderate brain injury requiring close monitoring
B. Severe brain injury with poor prognosis
C. Mild brain injury with expected recovery
D. No neurological impairment
Correct Answer: B. Severe brain injury with poor prognosis
Explanation: A Glasgow Coma Scale (GCS) score of 7 indicates a severe brain injury (GCS
3–8), suggesting significant neurological impairment and a poor prognosis, requiring urgent
intervention.
Question 8
The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse
notes a complete loss of motor and sensory function below the patient’s nipple line. What is the
best understanding of this assessment finding by the nurse?
Question 1
What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment
on increased intracranial pressure (ICP)?
A. Reduces ICP by improving venous drainage
B. Increases cerebral blood flow
C. Decreases cerebral perfusion pressure
D. Enhances cerebrospinal fluid production
Correct Answer: A. Reduces ICP by improving venous drainage
Explanation: Elevating the head of the bed (30–45°) and maintaining neutral head and neck
alignment promote venous drainage from the brain, reducing intracranial pressure by decreasing
venous congestion.
Question 2
Under normal circumstances, the cerebral vasculature exhibits pressure and chemical
autoregulation. What happens when autoregulation is lost?
A. Cerebral blood flow becomes dependent on systemic blood pressure
B. Cerebral blood flow increases uncontrollably
C. Intracranial pressure decreases significantly
D. Blood-brain barrier becomes impermeable
Correct Answer: A. Cerebral blood flow becomes dependent on systemic blood pressure
Explanation: Loss of autoregulation impairs the brain’s ability to maintain constant blood
flow despite changes in systemic blood pressure, making cerebral blood flow directly dependent
on systemic pressure, risking ischemia or edema.
Question 3
The nurse is monitoring a patient’s intracranial pressure (ICP). While providing hygiene
measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority
nursing action?
,A. Notify the physician immediately
B. Continue hygiene measures and reassess
C. Administer mannitol as per standing orders
D. Lower the head of the bed
Correct Answer: A. Notify the physician immediately
Explanation: A sustained ICP of 18 mm Hg is elevated (normal is 5–15 mm Hg), indicating a
potential risk of brain injury. Notifying the physician is the priority to initiate interventions to
prevent further increase.
Question 4
Herniation syndromes can be life-threatening situations. Which syndrome causes the
supratentorial contents to shift downward and compress vital centers of the brainstem?
A. Uncal herniation
B. Central (transtentorial) herniation
C. Cerebellar tonsillar herniation
D. Subfalcine herniation
Correct Answer: B. Central (transtentorial) herniation
Explanation: Central herniation involves downward displacement of supratentorial contents
through the tentorial notch, compressing the brainstem and vital centers, leading to life-
threatening symptoms like respiratory failure.
Question 5
In a patient with increased intracranial pressure (ICP), which of the following cranial nerves is
most commonly assessed to evaluate pupil response and eye movement?
A. Oculomotor nerve (III)
B. Optic nerve (II)
C. Trigeminal nerve (V)
D. Facial nerve (VII)
Correct Answer: A. Oculomotor nerve (III)
, Explanation: The oculomotor nerve (III) controls pupil constriction and most eye movements.
Assessing pupil response and eye movement is critical in ICP patients, as compression can
impair this nerve, causing fixed pupils or abnormal eye movements.
Question 6
The nurse is managing the blood pressure of a patient with a traumatic brain injury. Which
statement best represents appropriate blood pressure management?
A. Maintain cerebral perfusion pressure (CPP) between 60–70 mm Hg
B. Keep systolic BP below 90 mm Hg
C. Allow BP to fluctuate to promote autoregulation
D. Administer vasopressors to maintain ICP above 20 mm Hg
Correct Answer: A. Maintain cerebral perfusion pressure (CPP) between 60–70 mm Hg
Explanation: In traumatic brain injury, maintaining CPP (mean arterial pressure minus ICP)
between 60–70 mm Hg ensures adequate brain perfusion without exacerbating ICP.
Question 7
The nurse is caring for a patient with a ruptured cerebral aneurysm and observes a Glasgow
Coma Scale score of 7. What is the best interpretation of this finding by the nurse?
A. Moderate brain injury requiring close monitoring
B. Severe brain injury with poor prognosis
C. Mild brain injury with expected recovery
D. No neurological impairment
Correct Answer: B. Severe brain injury with poor prognosis
Explanation: A Glasgow Coma Scale (GCS) score of 7 indicates a severe brain injury (GCS
3–8), suggesting significant neurological impairment and a poor prognosis, requiring urgent
intervention.
Question 8
The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse
notes a complete loss of motor and sensory function below the patient’s nipple line. What is the
best understanding of this assessment finding by the nurse?
