Neurology NCLEX Questions and

Neurology NCLEX Questions and Answers Rated A

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?

• "This type of monitoring system is complex, and it is managed by skilled staff."
• "The monitoring system helps show whether blood flow to the brain is adequate."
• "The ventriculostomy monitoring system helps check for changes in cerebral perfusion

pressure."

• "This monitoring system has many benefits, including the ability to drain cerebrospinal

fluid." ✔✔B) short, simple, and accurate explanations should be given initially to patients and family members; A & D do not answer the family's question; C uses terminology that is too complex for initial explanations

Admission vitals for a patient who has a brain injury are BP 128/68, HR 110 bpm, and respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

• BP 154/68, HR 56, respirations 12 breaths/min
• BP 134/72, HR, 90, respirations 32 breaths/min

• BP 148/78, HR 112, respirations 28 breaths/min
• BP 110/70, HR 120, respirations 30 breaths/min ✔✔A)

systolic hypertension with widening pulse pressure, bradycardia, and abnormal respiratory rate are indicative of Cushing's triad. Indicates ICP has increased and brain herniation is imminent unless immediate action is taken; other VS indicate treatment is needed but are not as emergent as A

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and

flexion of the arms, the nurse reports the response as:

• flexion withdrawal
• localization of pain
• decorticate posturing
• decerebrate posturing ✔✔C)

internal rotation, adduction and flexion of the arms is documented as decorticate posturing; decerebrate posturing is extension of the arms and legs; generalized flexion does not indicate localization of pain or flexion withdrawal

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

• Blood pressure

• Oxygen saturation
• Intracranial pressure
• Hemoglobin and hematocrit ✔✔C)

mannitol is an osmotic diuretic and will reduce cerebral edema and ICP; A & D are not the best parameters for measuring effectiveness; oxygen saturation will not directly improve due to mannitol administration

An unconscious patient is admitted to the ED with a head injury. The patient's spouse and children stay at the bedside and ask many questions about the patient's treatments. What action is best for the nurse to take?

• Call the family's pastor to take them to the chapel
• Ask the family to remain in the waiting room until the assessment is completed
• Allow the family to stay with the patient and briefly explain all procedures to them
• Refer the family to the hospital's counseling services to help them deal with their anxiety

✔✔C)

the nurse should allow family to observe care and explain procedures unless they interfere with emergent care needs

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

• cough and deep breathe
• position patient with knees and hips flexed
• Keep head of the bed elevated to 30 degrees
• Cluster nursing interventions to provide rest periods ✔✔C)

patients with increased ICP should be maintained in the head-up position to help reduce ICP; flexion of the hips and knees increases abdominal pressure, which further increases ICP; coughing increases ICP; stimuli from nursing interventions elevates ICP, so clustering them would progressively worsen ICP

A 20 year-old male patient is admitted with a head injury from a collision while playing football.After noting the patient has developed clear nasal drainage, which action should the nurse take?

• have the patient gently blow his nose
• check the drainage for glucose content
• teach the patient that rhinorrhea is expected after a head injury
• obtain a specimen of the fluid to send for culture and sensitivity testing ✔✔B)

clear nasal drainage in a patient with a head injury suggests a dural tear and CSF leakage - CSF will test positive for glucose; blowing the nose is avoided to prevent CSF leakage; C&S testing is unnecessary because the drainage will have normal nasal flora present