Neuro Emergencies
A nurse enters a patient's room after hearing a loud noise and finds the patient lying on the floor experiencing rhythmic jerking movements. Which action should the nurse perform first?
A. Place a padded tongue blade in the patient's mouth
B. Roll the patient onto one side
C. Restrain the patient's arms
D. Attempt to stop the movements
B. Roll the patient onto one side
A patient suddenly reports, "This is the worst headache of my life."
What should the nurse suspect?
A. Migraine
B. Sinus infection
C. Possible intracranial bleeding
D. Tension headache
C. Possible intracranial bleeding
A medication that removes excess fluid from brain tissue by creating an osmotic gradient is called __________.
Answer: Mannitol
A patient with weakness is able to lift both arms but cannot maintain elevation for 20 seconds.
This assessment best evaluates:
A. Cranial nerves
B. Motor strength
C. Orientation
D. Vision
B. Motor strength
Which patient should the nurse assess first?
A. Stable patient requesting pain medication
B. Patient with new slurred speech
C. Patient waiting for discharge paperwork
D. Patient asking for a blanket
B. Patient with new slurred speech
Which task is appropriate to delegate to the UAP?
A. Perform a swallowing assessment
B. Assist with ambulation after the nurse evaluates the patient
C. Teach stroke prevention
D. Interpret neurologic findings
B. Assist with ambulation after the nurse evaluates the patient
Which findings require immediate follow-up?
□ Unequal pupils
□ Sudden confusion
□ Mild fatigue
□ New unilateral weakness
□ Resting quietly after lunch
Answers
Unequal pupils
Sudden confusion
New unilateral weakness
A patient with increased intracranial pressure begins vomiting without nausea.
This finding is most concerning because it suggests:
A. GI bleeding
B. Increased pressure on the brain
C. Food poisoning
D. Anxiety
B. Increased pressure on the brain
Which findings suggest impaired cerebellar function?
□ Wide-based gait
□ Smooth coordinated movements
□ Poor balance
□ Difficulty performing finger-to-nose testing
□ Equal pupils
Answers
Wide-based gait
Poor balance
Difficulty performing finger-to-nose testing
Which medication should the nurse question for a patient who has difficulty swallowing tablets?
A. Liquid acetaminophen
B. Enteric-coated tablet crushed into applesauce
C. Oral suspension antibiotic
D. Dissolvable medication
B. Enteric-coated tablet crushed into applesauce
The nurse elevates the head of the bed to ______ degrees for a patient with suspected increased intracranial pressure unless contraindicated.
Answer: 30
A patient suddenly becomes difficult to awaken.
Which action is priority?
A. Notify dietary
B. Repeat assessment tomorrow
C. Assess airway and neurologic status
D. Encourage fluids
C. Assess airway and neurologic status
Which task should the RN perform?
A. Empty urinary drainage bag
B. Assess new numbness in a patient's arm
C. Obtain daily weight
D. Assist with feeding
B. Assess new numbness in a patient's arm
Which assessment finding most strongly indicates deterioration?
A. HR 82
B. BP 128/76
C. New inability to follow commands
D. Temperature 99°F
C. New inability to follow commands
Which actions help reduce intracranial pressure?
□ Limit coughing when possible
□ Maintain head midline
□ Cluster all nursing care
□ Avoid hip flexion
□ Encourage Valsalva maneuver
Answers
Maintain head midline
Avoid hip flexion
A patient follows commands but cannot identify a familiar object placed in the hand.
This finding most likely represents:
A. Normal aging
B. Cortical sensory deficit
C. Hearing loss
D. Aphasia
B. Cortical sensory deficit
A nurse administers an antiepileptic medication. Which laboratory value should be monitored with many medications in this class?
A. Liver function
B. Cholesterol
C. Calcium
D. Hemoglobin A1C
A. Liver function
A patient receiving osmotic therapy has urine output increase significantly.
This indicates:
A. Medication is having the intended effect
B. Kidney failure
C. Fluid overload
D. Drug toxicity
A. Medication is having the intended effect
Which patient requires immediate intervention?
A. Reports mild nausea
B. New unequal pupils
C. Requests water
D. Wants to walk
B. New unequal pupils
Which tasks may be delegated?
□ Obtain vital signs
□ Reinforce teaching
□ Report intake/output
□ Evaluate swallowing
□ Assist with hygiene
Answers
Obtain vital signs
Report intake/output
Assist with hygiene
The nurse uses the acronym ______ to rapidly identify signs of stroke.
Answer: BE FAST OR FAST
A nurse is caring for four patients on a neurological unit. Which patient should the nurse assess first?
A. A patient with a history of seizures who reports feeling tired after physical therapy.
B. A patient recovering from a concussion who has a headache rated 4/10 despite acetaminophen.
C. A patient who suddenly becomes restless, repeatedly attempts to climb out of bed, and cannot state where they are.
D. A patient with Bell's palsy requesting assistance with eating.
C. A patient who suddenly becomes restless, repeatedly attempts to climb out of bed, and cannot state where they are.
The nurse is assessing a patient after a neurological injury. Which findings suggest possible worsening neurologic status?
□ Increasing drowsiness
□ New confusion
□ Equal hand grips
□ Slowed responses to questions
□ Sudden urinary incontinence
□ Pupils equal and reactive
Answers:
Increasing drowsiness
New confusion
Slowed responses
Sudden urinary incontinence
A patient receives a medication that commonly causes dizziness and sedation. Which nursing intervention is the priority?
A. Encourage unlimited activity.
B. Instruct the patient to request assistance before ambulating.
C. Restrict oral fluids.
D. Keep the patient NPO.
B. Instruct the patient to request assistance before ambulating.
The nurse notes the following assessment findings in a patient admitted for neurological monitoring.
Which finding requires immediate follow-up?
A. Mild nausea
B. Oxygen saturation 90%
C. Request for pain medication
D. Family concern
B. Oxygen saturation 90%
The nurse receives report on four patients. Which patient is the highest priority?
A. A patient waiting for discharge instructions.
B. A patient with chronic numbness unchanged for several months.
C. A patient whose speech has become noticeably slurred within the last 10 minutes.
D. A patient requesting assistance to the bathroom.
C. A patient whose speech has become noticeably slurred within the last 10 minutes.
The RN is caring for a stable patient with weakness. Which task is appropriate to delegate to the UAP?
A. Evaluate motor strength after ambulation.
B. Assist the patient with transferring from bed to chair using a gait belt.
C. Perform the neurological assessment.
D. Teach the patient fall-prevention strategies.
B. Assist the patient with transferring from bed to chair using a gait belt.
Which findings should cause the nurse to suspect a patient is at high risk for aspiration?
□ Wet or gurgling voice after drinking
□ Strong cough after swallowing
□ Drooling from one side of the mouth
□ Difficulty managing oral secretions
□ Eats meals without difficulty
□ Frequent throat clearing during meals
Answers:
Wet or gurgling voice
Drooling
Difficulty managing oral secretions
Frequent throat clearing
A patient who experienced a neurological injury earlier in the day now develops increasing lethargy. The patient's blood pressure is rising, heart rate is decreasing, and respirations are becoming irregular.
Which action should the nurse take first?
A. Document the findings and reassess in 30 minutes.
B. Activate the rapid response team and notify the provider immediately.
C. Administer the prescribed pain medication.
D. Encourage the patient to cough and deep breathe.
B. Activate the rapid response team and notify the provider immediately.
When performing a neurological assessment, the nurse compares strength between the patient's right and left extremities to evaluate for ____________.
Answer: Symmetry (or bilateral motor function)
The nurse is teaching a patient about medication safety. Which statements indicate the patient understands the teaching?
□ "I'll take my medication exactly as prescribed."
□ "I'll stop taking it once I feel better."
□ "I'll notify my provider if I develop a rash."
□ "I'll avoid driving until I know how the medication affects me."
□ "I'll double my next dose if I miss one."
Answers:
Take exactly as prescribed
Notify provider about rash
Avoid driving until effects are known
A patient suddenly reports numbness in one arm, difficulty speaking, and blurred vision. Which provider prescription should the nurse anticipate first?
A. Routine laboratory work next week
B. Immediate diagnostic imaging
C. High-fiber diet
D. Physical therapy consultation
B. Immediate diagnostic imaging
Which patient should the nurse evaluate first?
A. Reports constipation for two days.
B. Reports a pain level of 7/10.
C. Develops sudden confusion after previously being alert and oriented.
D. Requests a sleeping pill.
C. Develops sudden confusion after previously being alert and oriented.
Which activities are appropriate for the UAP caring for a patient with fall precautions?
□ Keep the call light within reach.
□ Stay with the patient during toileting.
□ Evaluate the patient's gait.
□ Place nonskid footwear on the patient.
□ Reinforce discharge teaching.
□ Report changes in mobility to the nurse.
Answers:
Keep call light within reach
Stay during toileting
Place nonskid footwear
Report changes in mobility
The nurse enters a room and finds a patient sitting in bed with food in the mouth, coughing repeatedly, and unable to speak clearly.
What is the priority action?
A. Offer water.
B. Encourage another bite.
C. Assess for airway obstruction and intervene immediately.
D. Document the episode.
C. Assess for airway obstruction and intervene immediately.
A 58-year-old patient was admitted after a fall at home. On admission, the patient was alert and oriented ×4 with equal pupils and full strength in all extremities. Four hours later, the nurse notes the following:
What is the nurse's priority action?
A. Administer the prescribed opioid for the patient's headache.
B. Activate the rapid response team and notify the provider immediately.
C. Reassess the patient in 30 minutes to determine if symptoms improve.
D. Lower the head of the bed to improve cerebral perfusion.
B. Activate the rapid response team and notify the provider immediately.
A nurse is performing neurological assessments every hour. Which findings indicate the patient's neurological status has worsened?
□ The patient requires repeated stimulation to awaken.
□ Speech changes from clear to slurred.
□ Hand grips remain equal bilaterally.
□ The patient becomes increasingly restless.
□ Pupils remain equal and reactive.
□ The patient cannot recall today's date after previously being oriented.
Answers
Requires repeated stimulation
Slurred speech
Increasing restlessness
New disorientation
A patient receiving a medication that can cause excessive drowsiness asks to walk independently to the bathroom because "I'm feeling much better."
What is the nurse's best response?
A. "As long as you move slowly, you should be safe."
B. "Please use your call light because your medication may increase your fall risk."
C. "You may walk independently after dinner."
D. "I'll discontinue your fall precautions."
B. "Please use your call light because your medication may increase your fall risk."
The nurse receives bedside report on four patients.
Which patient requires assessment first?
A. A patient requesting an antiemetic for nausea.
B. A patient whose family states, "He doesn't seem like himself today."
C. A patient requesting assistance with lunch.
D. A patient waiting for discharge prescriptions.
B. A patient whose family states, "He doesn't seem like himself today."
The nurse identifies these findings during assessment.
Place the nursing actions in the correct order.
Correct Order
3 → 2 → 1 → 4
The RN is caring for several patients. Which task is appropriate to delegate to an experienced UAP?
A. Assess a patient reporting sudden numbness.
B. Reinforce teaching regarding medication side effects.
C. Obtain orthostatic vital signs on a stable patient.
D. Evaluate the effectiveness of pain medication.
C. Obtain orthostatic vital signs on a stable patient.
The nurse is caring for a patient at high risk for aspiration.
Which interventions should be included in the plan of care?
□ Keep suction equipment available.
□ Place the patient flat during meals.
□ Encourage small bites and slow eating.
□ Verify swallowing ability before oral intake.
□ Offer thin liquids first.
□ Keep the head of the bed elevated during meals.
Answers
Suction available
Small bites
Assess swallowing
HOB elevated