Substance Use
A nurse is caring for a patient with a history of substance use who frequently misses follow-up appointments. The patient states, “The nurses always look at me like I’m a junkie.” Which nursing statement best demonstrates an understanding of the impact of inadequate or stigmatizing care?
A. “If you really want help, you’ll have to keep your appointments.”
B. “I can understand why you feel that way—let’s talk about how we can make your care feel more supportive.”
C. “You shouldn’t let other people’s opinions stop you from seeking care.”
D. “It’s important to focus on your recovery, not how others treat you.”
Correct Answer: B
Rationale: Stigma and judgment discourage patients from seeking or continuing care, worsening outcomes. Acknowledging the patient’s feelings and promoting a supportive environment fosters trust and engagement.
A nurse is assessing a patient who was admitted after a motor vehicle accident. The patient opens eyes to verbal command, mumbles incoherently, and withdraws from painful stimuli. What is the patient’s Glasgow Coma Scale (GCS) score?
A. 10
B. 9
C. 8
D. 7
Correct Answer: B
Rationale: Eye opening (3), verbal (2), and motor (4) = total score of 9. A GCS ≤ 8 indicates coma; this score reflects a moderate brain injury requiring close monitoring for deterioration.
A patient arrives to the ED with a Glasgow Coma Scale (GCS) score of 7 following a motorcycle accident. How would the nurse categorize this injury?
A. Mild traumatic brain injury
B. Moderate traumatic brain injury
C. Severe traumatic brain injury
D. Catastrophic brain injury
Correct Answer: C
Rationale: A GCS ≤8 indicates a severe TBI, associated with loss of protective reflexes, airway compromise, and high mortality risk.
Which nursing action best prevents secondary brain injury in a patient with a severe TBI?
A. Elevating the HOB to 90°
B. Maintaining oxygen saturation above 92% and systolic BP above 90 mmHg
C. Limiting IV fluids to avoid edema
D. Withholding sedation to better monitor neuro status
Correct Answer: B
Rationale: Hypoxia and hypotension worsen secondary brain injury by reducing cerebral perfusion. Maintaining adequate oxygenation and perfusion is essential for survival.
A patient in the ICU is becoming increasingly restless, disoriented, and pulling at IV lines. The nurse notes bright overhead lighting, multiple alarms, and frequent interruptions for care. Which nursing action is most appropriate to reduce sensory overload?
A. Increase room lighting to maintain orientation
B. Allow uninterrupted rest periods and dim the lights at night
C. Turn off all alarms to promote sleep
D. Provide frequent physical stimulation to maintain alertness
Correct Answer: B
Rationale: Clustered care, quiet environments, and maintaining day–night cycles reduce sensory overload and delirium risk in critically ill patients.
A patient presenting with frequent injuries and mood swings denies alcohol or drug use. The nurse suspects substance use but hesitates to screen because the emergency department is busy. What barrier to screening does this represent?
A. Patient-related barrier
B. Provider-related barrier
C. System-related barrier
D. Legal barrier
Correct Answer: C
Rationale: Limited resources, time constraints, and poor workflow are system-level barriers that delay screening and referral, contributing to missed opportunities for early intervention.
Which finding in a patient with a traumatic brain injury requires immediate provider notification?
A. Pupils equal and reactive to light
B. Slight weakness in right hand grip
C. GCS change from 14 to 10 over two hours
D. Periods of drowsiness after medication administration
Correct Answer: C
Rationale: A drop in GCS ≥ 2 points indicates a significant decline in neurologic function, possibly due to increasing ICP or cerebral edema, and warrants urgent intervention.
A patient struck their forehead on the steering wheel and now has occipital bruising on imaging. The nurse identifies this as what type of injury mechanism?
A. Linear fracture
B. Coup–contrecoup injury
C. Diffuse axonal injury
D. Rotational injury
Correct Answer: B
Rationale: Coup–contrecoup injuries occur when the brain impacts the skull at the site of impact (coup) and the opposite side (contrecoup) due to rapid acceleration-deceleration.
A patient with an external ventricular drain (EVD) suddenly develops a fever and cloudy CSF drainage. What is the priority nursing action?
A. Flush the EVD tubing to remove the blockage
B. Clamp the EVD and document findings
C. Notify the provider and obtain cultures
D. Increase the drainage level to reduce pressure
Correct Answer: C
Rationale: Cloudy CSF and fever suggest infection (ventriculitis or meningitis). The nurse should notify the provider and collect CSF for culture immediately.
A nurse is assessing a 70-year-old postoperative patient who is suddenly confused, disoriented to time, and easily distracted. The patient was alert the previous day. Which condition does this presentation indicate?
A. Dementia
B. Delirium
C. Depression
D. Mild cognitive impairment
Correct Answer: B
Rationale: Delirium develops acutely (hours to days) with fluctuating awareness and inattention, often due to reversible causes such as infection, hypoxia, or medications.
A nurse notes that a patient admitted for pneumonia is diaphoretic, anxious, and tremulous, stating, “I need a drink.” The nurse suspects alcohol withdrawal. Which symptom would require immediate intervention?
A. Tremors of the hands and tongue
B. Nausea and vomiting
C. Seizures or hallucinations
D. Diaphoresis and anxiety
Correct Answer: C
Rationale: Alcohol withdrawal can progress to delirium tremens (DTs), which include seizures and hallucinations—life-threatening complications requiring rapid intervention and benzodiazepine administration.
A patient’s mean arterial pressure (MAP) is 80 mmHg and intracranial pressure (ICP) is 25 mmHg. What is the patient’s cerebral perfusion pressure (CPP), and how should the nurse interpret this value?
A. 65 mmHg; adequate
B. 55 mmHg; inadequate
C. 75 mmHg; ideal
D. 45 mmHg; hyperperfused
Correct Answer: B
Rationale: CPP = MAP – ICP = 80 – 25 = 55 mmHg. Normal CPP is 60–100 mmHg. A value below 60 compromises cerebral blood flow and oxygenation, risking ischemia.
A patient with a head injury has clear drainage from the nose and bruising behind the ears (Battle’s sign). What should the nurse suspect?
A. Linear skull fracture
B. Depressed skull fracture
C. Basilar skull fracture
D. Temporal contusion
Correct Answer: C
Rationale: Basilar fractures often present with CSF rhinorrhea/otorrhea, periorbital ecchymosis (“raccoon eyes”), and Battle’s sign. Risk for meningitis is high—no nasal suctioning or NG tubes.
A patient recovering from TBI has urine output of 400–600 mL/hr, serum sodium of 155 mEq/L, and low urine specific gravity. Which condition does the nurse suspect?
A. SIADH
B. Diabetes insipidus
C. Cerebral salt wasting
D. Hyponatremia due to dehydration
Correct Answer: B
Rationale: Diabetes insipidus (DI) results from decreased ADH secretion leading to polyuria, hypernatremia, and dilute urine. Management includes fluids and desmopressin.
The nurse is caring for a mechanically ventilated patient who is sedated with propofol. Which nursing action is a priority to ensure safe and effective sedation management?
A. Discontinue sedation if the patient becomes restless
B. Perform daily sedation interruptions and assess readiness to wean
C. Increase infusion rate if the patient’s blood pressure rises
D. Withhold analgesics to avoid oversedation
Correct Answer: B
Rationale: Daily sedation vacations and spontaneous breathing trials (SBTs) promote faster weaning, prevent oversedation, and reduce complications such as delirium and ventilator-associated pneumonia.
Which statement best reflects the nurse’s role when providing care to a patient with a substance use disorder?
A. “I’ll ask the provider to handle substance-related discussions to avoid upsetting you.”
B. “It’s my role to assess your risk factors and connect you to recovery resources.”
C. “I’ll need to report your drug use to the authorities.”
D. “We’ll focus on your physical symptoms for now and discuss recovery later.”
Correct Answer: B
Rationale: Nurses are frontline advocates who assess, educate, and refer patients to appropriate treatment and recovery services. Their nonjudgmental communication and resource coordination are vital for holistic care.
During a neuro exam, a patient exhibits rigid extension of the arms and legs with hyperpronation when exposed to painful stimuli. Which condition does this response indicate?
A. Decorticate posturing – cerebral hemisphere damage
B. Decerebrate posturing – brainstem damage
C. Flaccid posturing – severe hypotonia
D. Localizing pain – intact motor function
Correct Answer: B
Rationale: Decerebrate posturing (extension, hyperpronation, plantar flexion) indicates brainstem dysfunction and a worse prognosis compared to decorticate posturing.
A patient develops a severe headache, vomiting, and right-sided weakness hours after a fall. The nurse recognizes these symptoms as most consistent with which condition?
A. Subdural hematoma
B. Intracerebral hemorrhage
C. Epidural hematoma
D. Subarachnoid hemorrhage
Correct Answer: B
Rationale: Intracerebral hemorrhage presents with a gradual onset of focal deficits and worsening LOC due to bleeding within brain parenchyma and increased ICP.
A patient has MAP = 70 mmHg and ICP = 25 mmHg. What is the CPP, and what does it indicate?
A. 55 mmHg – adequate perfusion
B. 45 mmHg – inadequate perfusion
C. 65 mmHg – normal perfusion
D. 80 mmHg – elevated perfusion
Correct Answer: B
Rationale: CPP = MAP – ICP = 70 – 25 = 45 mmHg. Normal CPP = 60–100 mmHg; 45 mmHg indicates impaired cerebral blood flow and risk for ischemia.
A patient with severe ARDS is receiving cisatracurium (Nimbex). The nurse notes the patient’s eyes are open and tearing. What is the most appropriate nursing intervention?
A. Increase the paralytic dose
B. Provide eye lubrication and ensure sedation and analgesia are continued
C. Turn off sedation to assess consciousness
D. Apply restraints to prevent injury
Correct Answer: B
Rationale: Patients receiving paralytics are awake but immobile—they must receive adequate sedation and eye care to prevent distress and corneal injury.
A patient recovering from opioid addiction asks, “Why do I need methadone if I’m trying to quit drugs?” Which nurse response demonstrates therapeutic education?
A. “Methadone replaces your opioid so you won’t feel cravings or withdrawal.”
B. “It’s just another medication to keep you dependent, but it’s safer.”
C. “It prevents withdrawal symptoms while helping your body stabilize for recovery.”
D. “It works best if you stop using it as soon as possible.”
Correct Answer: C
Rationale: Methadone is a long-acting opioid agonist that stabilizes the body and prevents withdrawal while reducing cravings, supporting long-term recovery when used under medical supervision.
The nurse notes that a patient with a recent head injury has irregular respirations, bradycardia, and widening pulse pressure. Which action should the nurse take first?
A. Notify the provider and prepare for possible intubation
B. Administer an antipyretic for elevated temperature
C. Increase IV fluids to improve cerebral perfusion
D. Lower the head of the bed to promote circulation
Correct Answer: A
Rationale: This combination of vital signs—Cushing’s triad—signals increased ICP and potential brain herniation. The nurse must notify the provider immediately and prepare for airway protection and ICP management.
Which assessment finding indicates increased intracranial pressure requiring immediate intervention?
A. Headache relieved by analgesics
B. Pupils equal and reactive
C. Cushing’s triad: bradycardia, irregular respirations, widening pulse pressure
D. Mild restlessness after awakening
Correct Answer: C
Rationale: Cushing’s triad is a late and life-threatening sign of increased ICP signaling possible herniation — a medical emergency.
A patient with a head injury becomes unresponsive with dilated, nonreactive pupils and decerebrate posturing. Which action should the nurse take first?
A. Increase IV fluids
B. Notify the provider and prepare for emergent intervention
C. Reassess in 15 minutes for changes
D. Administer analgesic for comfort
Correct Answer: B
Rationale: Fixed, dilated pupils and decerebrate posturing indicate impending brain herniation. This is a neurological emergency requiring immediate provider notification and ICP-lowering measures (EVD, mannitol, or surgery).
Which nursing intervention best aligns with the A–F Bundle for ICU patient care?
A. Maintaining deep continuous sedation for patient comfort
B. Performing pain assessments and spontaneous awakening/breathing trials
C. Restricting family visitation to minimize interruptions
D. Limiting mobility until sedation is discontinued
Correct Answer: B
Rationale: The A–F Bundle emphasizes evidence-based ICU care: Assess pain, perform awakening/breathing trials, choose appropriate sedation, manage delirium, promote early mobility, and engage families to improve recovery outcomes.