CNRN Neurological Assessment and Monitoring 3

Question 1

A nurse notes Cushing's triad in a neuroscience patient. Which set of findings is characteristic?

Accepted Answer

Hypertension, bradycardia, irregular respirations

Answer

Cushing's triad consists of hypertension (widening pulse pressure), bradycardia, and irregular respirations, signaling impending brainstem herniation.

Question 2

Which type of brain herniation results in ipsilateral CN III palsy and contralateral hemiplegia?

Accepted Answer

Uncal herniation

Answer

Uncal herniation compresses the ipsilateral oculomotor nerve (CN III) and contralateral corticospinal tract, producing these classic deficits.

Question 3

When using the FOUR (Full Outline of UnResponsiveness) scale, which domain is assessed that the GCS does NOT include?

Accepted Answer

Brainstem reflexes

Answer

The FOUR scale includes brainstem reflexes (corneal, cough, pupillary) as a distinct domain, which the Glasgow Coma Scale does not assess.

Question 4

A patient with a subarachnoid hemorrhage develops a sudden severe headache described as 'the worst headache of my life.' The nurse recognizes this as:

Accepted Answer

Sentinel headache or thunderclap headache

Answer

A sudden, severe 'thunderclap' headache reaching maximum intensity in seconds is the classic presentation of subarachnoid hemorrhage.

Question 5

Which scale is commonly used by CNRN nurses to grade subarachnoid hemorrhage severity based on clinical presentation?

Accepted Answer

Hunt and Hess Scale

Answer

The Hunt and Hess Scale grades subarachnoid hemorrhage severity from I (mild headache) to V (deep coma), guiding surgical timing.

CNRN Test Practice Test

CNRN Test Practice Test

CNRN Neurological Assessment and Monitoring 3