lol
Q1: Which of the following is the priority nursing intervention after a lumbar puncture?
A. Encourage fluids and keep the patient flat for several hours.
B. Ambulate the patient immediately to prevent stiffness.
C. Apply heat to the puncture site.
D. Restrict fluids for 24 hours.
✅ Answer: A
Rationale: Lying flat helps prevent post–lumbar puncture headache caused by CSF leakage, and fluids help restore CSF volume. Ambulation and fluid restriction increase risk of headache and complications.
Q6: Which assessment finding indicates early increased ICP?
A. Cushing’s triad
B. Decreased level of consciousness
C. Fixed and dilated pupils
D. Irregular respirations
✅ Answer: B
Rationale: LOC changes are the earliest sign of rising ICP. Cushing’s triad (widened pulse pressure, bradycardia, irregular respirations) occurs later.
Q11: What is the time window for IV tPA administration in ischemic stroke?
A. Within 1 hour
B. Within 3–4.5 hours of symptom onset
C. Within 8 hours
D. Within 24 hours
✅ Answer: B
Rationale: IV tPA must be given within 3–4.5 hours of onset if no contraindications exist. Earlier administration improves outcomes.
Q16: Which condition involves difficulty articulating words due to muscle weakness?
A. Apraxia
B. Dysarthria
C. Dysphagia
D. Aphasia
✅ Answer: B
Rationale: Dysarthria = slurred speech from impaired motor control. Apraxia = inability to perform purposeful movements; Dysphagia = difficulty swallowing.
When documenting decorticate posturing, the nurse should describe:
A. Extension of arms and legs, pronated forearms.
B. Flexion of arms toward the chest and internal rotation of legs.
C. Arms extended and legs flexed.
D. Flaccid extremities with no movement.
✅ Answer: B
Rationale: Decorticate = arms flexed toward the “core.” It indicates damage above the brainstem (cerebral hemispheres).
Q2: A patient exhibits rigid extension of arms and legs, pronated forearms, and plantar flexed feet in response to pain. What does this indicate?
A. Damage to the cerebral cortex
B. Damage to the brainstem
C. Spinal cord injury
D. Normal withdrawal response
✅ Answer: B
Rationale: Decerebrate posturing reflects damage to the brainstem at or below the level of the red nucleus. It is more serious than decorticate posturing.
Q7: A patient has a GCS score of 8. What does this indicate?
A. Mild head injury
B. Moderate brain injury
C. Severe brain injury and possible coma
D. Brain death
✅ Answer: C
Rationale: GCS ranges 3–15. ≤8 = severe injury/coma, 9–12 = moderate, 13–15 = mild.
Q12: What is the purpose of the NIH Stroke Scale?
A. To diagnose stroke subtype
B. To quantify stroke severity and monitor changes
C. To determine ICP levels
D. To assess swallowing function
✅ Answer: B
Rationale: The NIHSS provides a standardized assessment of stroke severity (0–42 scale) to guide treatment and monitor recovery.
Q17: Which of the following is a modifiable risk factor for stroke?
A. Age
B. Family history
C. Hypertension
D. Gender
✅ Answer: C
Rationale: Hypertension is the most significant modifiable risk factor. Non-modifiable: age, gender, genetics.
Which post-seizure nursing action is most appropriate?
A. Insert an oral airway immediately.
B. Document seizure length and characteristics.
C. Apply restraints to prevent injury.
D. Begin oral feeding once the patient awakens.
✅ Answer: B
Rationale: After a seizure, documenting duration, movements, and recovery is crucial for medical management. Airway devices or feeding should wait until the gag reflex returns.
Q3: A patient’s upper extremities flex toward the chest while lower extremities extend. What does this indicate?
A. Brainstem injury
B. Corticospinal tract damage
C. Cerebellar injury
D. Midbrain intactness
✅ Answer: B
Rationale: Decorticate posturing suggests damage to the corticospinal tract or cerebral hemispheres, with preserved brainstem function.
Q8: Which medication helps reduce intracranial pressure by promoting osmotic diuresis?
A. Mannitol
B. Furosemide
C. Dexamethasone
D. Morphine
✅ Answer: A
Rationale: Mannitol (osmotic diuretic) draws water from brain tissue into circulation, lowering ICP. Furosemide and corticosteroids have different mechanisms
Q13: What is the most serious potential complication of Guillain–Barré syndrome?
A. Skin breakdown
B. Respiratory failure
C. Hypertension
D. Constipation
✅ Answer: B
Rationale: Paralysis can ascend to involve the diaphragm, causing respiratory failure. Monitoring vital capacity and airway management are critical.
Q18: What does the “B” in BEFAST stand for?
A. Breathing
B. Balance
C. Blood pressure
D. Brain
✅ Answer: B
Rationale: BEFAST = Balance, Eyes, Face, Arm, Speech, Time.
It helps identify stroke warning signs early. “Time” reminds to call 911 immediately.
Which level of consciousness describes a patient who opens eyes to painful stimuli but does not speak or follow commands?
A. Obtunded
B. Stuporous
C. Comatose
D. Delirious
✅ Answer: B
Rationale: Stuporous = only responds to vigorous or painful stimuli. “Comatose” = no response at all.
Q4: During a tonic–clonic seizure, what is the nurse’s priority action?
A. Insert a tongue depressor.
B. Place the patient in a side-lying position.
C. Restrain the patient to prevent injury.
D. Obtain vital signs immediately.
✅ Answer: B
Rationale: Turning the patient to the side prevents aspiration. Nothing should be placed in the mouth, and restraints increase risk of injury. Vital signs are checked after the seizure.
Q9: What happens when cerebral autoregulation fails after a head injury?
A. Blood flow to the brain remains constant.
B. Cerebral perfusion becomes dependent on systemic BP.
C. ICP decreases spontaneously.
D. Brain metabolism slows down permanently.
✅ Answer: B
Rationale: Loss of autoregulation means cerebral blood flow becomes pressure dependent, risking ischemia or hemorrhage with BP changes.
Q14: The nurse suspects a myasthenic crisis when the patient develops:
A. Bradycardia and excessive salivation
B. Muscle weakness and respiratory distress
C. Muscle twitching and diarrhea
D. Drooling and pinpoint pupils
✅ Answer: B
Rationale: Myasthenic crisis = sudden severe muscle weakness, including respiratory muscles, due to under-medication. Cholinergic crisis = over-medication (salivation, bradycardia, miosis).
During a lumbar puncture, the patient suddenly complains of sharp pain radiating down the right leg. What should the nurse do?
A. Continue to encourage the patient to remain still.
B. Notify the provider immediately.
C. Stop the procedure and reposition the patient.
D. Document this as an expected finding.
✅ Answer: A
Rationale: Brief pain or tingling during LP can occur if the needle touches a nerve root — it’s common and transient. The nurse should reassure and remind the patient to stay still unless pain is severe or persistent.
A patient with increased ICP is receiving mannitol. Which finding indicates the medication is effective?
A. BP increases
B. Urine output increases
C. ICP monitor reading rises
D. Serum sodium decreases
✅ Answer: B
Rationale: Mannitol promotes osmotic diuresis, drawing fluid out of the brain. Increased urine output indicates it’s working.
Q5: Which description best defines an obtunded patient?
A. Fully oriented but anxious
B. Responds slowly to stimulation and needs repeated prompts
C. Sleepy but easily aroused
D. Unresponsive except to painful stimuli
✅ Answer: B
Rationale: “Obtunded” means the patient responds slowly and needs repeated stimulation to maintain attention. “Somnolent” = sleepy but easily aroused; “stuporous” = arouses only to pain; “delirious” = disoriented/confused.
Q10: Which intervention is contraindicated for a hemorrhagic stroke?
A. Strict blood pressure control
B. Administration of tPA (alteplase)
C. Elevating the head of the bed 30°
D. Monitoring for increased ICP
✅ Answer: B
Rationale: tPA is contraindicated because it increases bleeding risk. Supportive management focuses on BP control and ICP management.
Q15: A patient has impulsivity, poor judgment, and neglect of the left side of the body. What is the likely lesion site?
A. Left cerebral hemisphere
B. Right cerebral hemisphere
C. Cerebellum
D. Brainstem
✅ Answer: B
Rationale: Right-sided damage causes left-side weakness/neglect, impulsivity, and poor spatial awareness. Left-sided damage causes aphasia and cautious behavior.
Which nursing observation most accurately reflects worsening brain function in a head-injury patient?
A. Change from decorticate to decerebrate posturing
B. Flexion withdrawal to pain
C. Movement of all extremities spontaneously
D. Localization of pain
✅ Answer: A
Rationale: Decerebrate posturing indicates a more severe deterioration of brain function compared to decorticate, reflecting progression of brainstem damage.
Which position best promotes venous drainage in a patient with increased ICP?
A. Supine with head flat
B. Trendelenburg position
C. Head of bed elevated 30°
D. Side-lying with neck flexed
✅ Answer: C
Rationale: 30° elevation promotes cerebral venous return without reducing cerebral perfusion. Trendelenburg and neck flexion increase ICP.