AMSN Neurological Nursing Care 1 — Questions and Answers
Question 1: A patient with suspected increased intracranial pressure (ICP) is admitted to the medical-surgical unit. Which nursing intervention is the priority?
- Elevate the head of bed to 30–45 degrees (Correct answer)
- Apply a heating pad to the neck
- Encourage vigorous coughing to clear secretions
- Place the patient in Trendelenburg position
Correct answer: Elevate the head of bed to 30–45 degrees
Elevating the head of bed to 30–45 degrees promotes venous drainage and helps reduce intracranial pressure.
Question 2: Which assessment finding in a post-stroke patient indicates a deteriorating neurological status requiring immediate notification of the provider?
- Blood pressure of 148/90 mmHg
- New onset confusion and unequal pupils (Correct answer)
- Mild headache rated 3/10
- Muscle weakness on the affected side
Correct answer: New onset confusion and unequal pupils
New onset confusion combined with unequal pupils (anisocoria) signals herniation or expanding hemorrhage and is a neurological emergency.
Question 3: A nurse is caring for a patient with a seizure disorder. Which action is MOST important during an active tonic-clonic seizure?
- Insert an oral airway to prevent tongue biting
- Restrain the patient's extremities to prevent injury
- Turn the patient to the side and protect the head (Correct answer)
- Administer oral diazepam immediately
Correct answer: Turn the patient to the side and protect the head
Positioning the patient on their side prevents aspiration of secretions and protecting the head reduces injury during a tonic-clonic seizure.
Question 4: Which Glasgow Coma Scale (GCS) score indicates a severe traumatic brain injury?
- 13–15
- 9–12
- 3–8 (Correct answer)
- 1–2
Correct answer: 3–8
A GCS score of 3–8 is classified as severe traumatic brain injury, indicating significant neurological compromise.
Question 5: A patient is receiving IV phenytoin for seizure management. The nurse should monitor for which priority adverse effect?
- Hyperglycemia
- Cardiac dysrhythmias (Correct answer)
- Constipation
- Hypokalemia
Correct answer: Cardiac dysrhythmias
IV phenytoin administered too rapidly can cause severe cardiac dysrhythmias, including bradycardia and heart block.
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:
- Proprioception
- Stereognosis (Correct answer)
- Two-point discrimination
- Graphesthesia
Correct answer: Stereognosis
Stereognosis is the ability to identify objects by touch alone, testing sensory cortex and parietal lobe integration.
AMSN Neurological Nursing Care 1
A patient with suspected increased intracranial pressure (ICP) is admitted to the medical-surgical unit.
Which nursing intervention is the priority?