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

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?

Accepted Answer

New onset confusion and unequal pupils

Answer

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?

Accepted Answer

Turn the patient to the side and protect the head

Answer

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?

Accepted Answer

3–8

Answer

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?

Accepted Answer

Cardiac dysrhythmias

Answer

IV phenytoin administered too rapidly can cause severe cardiac dysrhythmias, including bradycardia and heart block.

AMSN - Academy of Medical-Surgical Nurses Practice Test