Cranial Nerves
This cranial nerve is responsible for pupil constriction, most extraocular movements, and is commonly affected in increased ICP, causing a fixed dilated pupil.
What is Cranial Nerve III (Oculomotor nerve).
This invasive device is considered the gold standard for measuring ICP and allows for CSF drainage.
What is a ventriculostomy.
Why is determining “last known well” time critical in suspected ischemic stroke?
It determines eligibility for thrombolytic therapy.
A nurse is caring for a patient with traumatic brain injury. Which action would increase ICP?
A. Maintaining neutral neck alignment
B. Clustering nursing care
C. Elevating HOB 30 degrees
D. Providing stool softeners
B. Clustering nursing care
Loss of all motor and sensory function below the level of injury describes:
A. Complete injury
B. Partial lesion
C. Incomplete injury
D. Central cord syndrome
A. Complete injury
A patient who cannot smile symmetrically or puff out their cheeks likely has damage to this cranial nerve.
What is Cranial Nerve VII (Facial nerve).
This is the most sensitive and reliable indicator of increased ICP.
What is a change in level of consciousness.
An ischemic stroke patient has a BP of 168/92 mmHg, is not a candidate for tPA, and is neurologically stable. Which action is most appropriate?
A. Administer IV antihypertensive to lower systolic <140
B. Maintain BP
C. Initiate nitroprusside infusion
D. Administer loop diuretic
What is B — maintain BP to support cerebral perfusion.
A patient arrives with right-sided weakness and expressive aphasia. Which brain region is most likely affected?
A. Right temporal lobe
B. Left frontal lobe
C. Right parietal lobe
D. Brainstem
B. Left frontal lobe
(Left hemisphere = language; Broca’s area = frontal lobe.)
Which finding is most consistent with spinal shock?
A. Severe hypertension and headache
B. Hypotension and bradycardia
C. Flaccid paralysis and absent reflexes
D. Peripheral vasoconstriction
C. Flaccid paralysis and absent reflexes
If the tongue deviates to the right when protruded, dysfunction of this cranial nerve on the right side is suspected.
What is Cranial Nerve XII (Hypoglossal nerve).
This type of posturing involves rigid extension of all four extremities and indicates brainstem involvement.
What is decerebrate posturing?
A patient receives alteplase for an ischemic stroke. Thirty minutes later, the patient reports a sudden severe headache and becomes increasingly drowsy. What is the nurse’s priority action?
A. Lower the head of the bed
B. Administer IV antihypertensive
C. Stop the alteplase infusion immediately
D. Perform a swallow evaluation
C. Stop the alteplase infusion immediately
*Sudden headache and decreased LOC during tPA infusion suggest intracranial hemorrhage. The infusion must be stopped immediately and the provider notified.
A patient with a severe head injury becomes restless, has a worsening headache, and vomits. What is the nurse’s priority action?
Elevate the head of the bed to 30 degrees and assess neurologic status.
(Resting position helps decrease ICP; vomiting + headache = rising ICP.)
This complication occurs when the parasympathetic nervous system cannot counteract a massive sympathetic response below the level of injury.
What is autonomic dysreflexia?
A patient cannot move the right eye laterally past midline. Damage to this cranial nerve is suspected.
What is Cranial Nerve VI (Abducens nerve).
When increased ICP is suspected, this diagnostic procedure is generally contraindicated because it may cause herniation.
What is lumbar puncture.
Which laboratory results must be assessed prior to initiating thrombolytic therapy? (Select all that apply.)
A. Platelet count
B. PT/INR
C. aPTT
D. Serum creatinine
E. Blood glucose
F. Hemoglobin A1C
A. Platelets (must be ≥100,000)
B. INR (typically ≤1.7)
C. aPTT (not elevated if on heparin)
E. Blood glucose (hypoglycemia can mimic stroke)
A client with a T6 injury reports a severe headache and blurred vision. BP is 200/104. Which actions should the nurse take? (Select all that apply.)
☐ Lay patient flat
☐ Sit patient upright
☐ Assess bladder
☐ Loosen restrictive clothing
☐ Administer stool softener immediately
✔ Sit upright
✔ Assess bladder
✔ Loosen restrictive clothing
A client with a T4 injury reports a severe headache and flushing. BP is 210/110. What is the nurse’s FIRST action?
A. Check temperature
B. Sit the patient upright
C. Lay the patient flat
D. Administer pain medication
B. Sit the patient upright
These two cranial nerves are tested when assessing the gag reflex and evaluating swallowing function.
What are Cranial Nerves IX (Glossopharyngeal) and X (Vagus).
Describe Cushing’s triad.
Bradycardia, hypertension with widening pulse pressure, and irregular respirations (indicates brainstem compression).
A patient with a large ischemic stroke begins to show increasing drowsiness and unequal pupils. BP is 196/104 mmHg, HR 52 bpm, RR irregular. What is the nurse’s priority action?
A. Administer IV labetalol
B. Prepare for possible intubation and notify provider immediately
C. Lower the head of the bed
D. Encourage deep breathing
B. Prepare for possible intubation and notify provider immediately
*The patient is exhibiting signs of increased ICP and possible brainstem compression (Cushing response). Airway protection and rapid intervention take priority over BP management at this point.
A patient 12 hours post-SCI has flaccid paralysis and absent reflexes but stable blood pressure. What condition is most likely occurring?
Spinal shock
(Neurologic shutdown without hemodynamic instability.)
A client with SCI develops urinary retention and high bladder pressure. The nurse recognizes this as:
A. Acute renal failure
B. Neurogenic bladder
C. SIADH
D. Diabetes insipidus
B. Neurogenic bladder