AMSN Neurological Nursing Care

Question 1

A patient with suspected increased intracranial pressure (ICP) is admitted to the medical-surgical unit. Which nursing intervention is the priority?

Accepted Answer

Elevate the head of bed to 30–45 degrees

Answer

Apply a heating pad to the neck

Answer

Encourage vigorous coughing to clear secretions

Answer

Place the patient in Trendelenburg position

Question 2

Which assessment finding in a post-stroke patient indicates a deteriorating neurological status requiring immediate notification of the provider?

Accepted Answer

New onset confusion and unequal pupils

Answer

Blood pressure of 148/90 mmHg

Answer

Mild headache rated 3/10

Answer

Muscle weakness on the affected side

Question 3

A nurse is caring for a patient with a seizure disorder. Which action is MOST important during an active tonic-clonic seizure?

Accepted Answer

Turn the patient to the side and protect the head

Answer

Insert an oral airway to prevent tongue biting

Answer

Restrain the patient's extremities to prevent injury

Answer

Administer oral diazepam immediately

Question 4

Which Glasgow Coma Scale (GCS) score indicates a severe traumatic brain injury?

Accepted Answer

3–8

Answer

13–15

Answer

9–12

Answer

1–2

Question 5

A patient is receiving IV phenytoin for seizure management. The nurse should monitor for which priority adverse effect?

Accepted Answer

Cardiac dysrhythmias

Answer

Hyperglycemia

Answer

Constipation

Answer

Hypokalemia

Question 6

When performing a neurological assessment, the nurse asks the patient to identify a familiar object placed in their hand without looking. This test evaluates:

Accepted Answer

Stereognosis

Answer

Proprioception

Answer

Two-point discrimination

Answer

Graphesthesia