ATI NURSING EXAMS: ENGAGE ADULT MEDICAL SURGICAL- RN
CRITICAL NEUROLOGIC DYSFUNCTION ASSESSMENT I REAL
QUESTIONS AND ANSWERS
1.
2. A nurse is planning care for a client who has increased intracranial pressure (ICP). Which
Of the following should the nurse understand is a cause of increased ICP?
A. Cephalosporin
B. Decreased cerebral blood flow
C. Haemorrhage
D. Decreased cerebrospinal fluid production
Answer: C. Haemorrhage
3. A nurse is performing the Glasgow Coma Scale (GCS) on a client who has increased
intracranial pressure. Which of the following does the scale assess?
A. Level of consciousness
B. Level of sensory function
C. Level Of spinal cord injury
D. Level of pain
Answer: A. Level of consciousness
4. A nurse is caring for a client who has a traumatic brain injury. Which Of the following
should the nurse understand is a manifestation of brain herniation?
A. Muscular rigidity
B. Diabetes mellitus
C. Loss of cough and gag reflex
D. upper extremity weakness
Answer: C. Loss of cough and gag reflex
5. A nurse is caring for a client who has a neurologic injury following a 10 foot fall. Which of
the following actions would be the highest priority?
A. Maintaining the airway
B. Managing pain levels
C. Monitoring neurologic status
D. Establishing a bowel routine
Answer: A. Maintaining the airway
6. A nurse is caring for a 78-year-old client who has a traumatic brain injury (TBI). Which of
the following should the nurse understand places this client at high risk for falls?
A. Balance impairment
B. Eyesight changes
C. Constipation
D. Antihypertensives
E. Diabetes mellitus
Answer: A. Balance impairment
B. Eyesight changes
D. Antihypertensives
E. Diabetes mellitus
7. A nurse is caring for a client with a traumatic brain injury and records the following vital
signs: blood pressure 126/76 mm Hg, pulse 105/min, and respirations 181min. The nurse
repeats the vital signs 1 hr later. Which of the following repeat vital signs are most
concerning during reassessment?
A. Blood pressure 126/56 mm Hg, pulse 70/min, respirations 14/min
B. Blood pressure 130/54 mm Hg, pulse 60/min, respirations 28/min
C. Blood pressure 126/54 mm Hg, pulse 88/min, respirations 16/min
D. Blood pressure 120/54 mm Hg, pulse 97/min, respirations 22/min
Answer: B. Blood pressure 130/54 mm Hg, pulse 60/min, respirations 28/min
8. A nurse is teaching the family of a client who sustained a traumatic brain injury. Which of
the following should the nurse include in the teaching?
A. use multiple teaching sources and provide frequent teaching sessions.
B. Only provide handouts to the family so they can read them at home when ready.
C. Provide only face-to-face teaching sessions.
D. Refer the client to videos on traumatic brain injuries.
Answer: A. use multiple teaching sources and provide frequent teaching sessions.
9. A nurse is caring for a client who sustained severe manifestations from a subarachnoid
haemorrhage. Which Of the following mechanisms explains why the effects are devastating?
A. The blood brain barrier creates transient ischemia in the body
B. The injury is not limited to the site of the haemorrhage.
C. Cerebral perfusion pressure (CPP) is increased rapidly.
D. Cerebral vasospasm leads to dilation of blood vessels.
Answer: B. The injury is not limited to the site of the haemorrhage.
10. A nurse is caring for a client who presents to the neurology clinic reporting difficulty with
their memory and mood. Which of the following client history details should the nurse
understand indicates the client may be experiencing chronic traumatic encephalopathy
(CTE)?
A. The client drinks three to five beers after work each day.
B. The client worked as a carpenter and rooferfor4 years.
C. The client played a lot of basketball while in college.
D. The client served two tours in Afghanistan while in the army.
Answer: D. The client served two tours in Afghanistan while in the army.
11. A nurse is planning care for a client who has increased intracranial pressure. Which Of the
following factors should the nurse understand will cause a loss of muscle and malnutrition if
enteral feedings are not started early?
A. dysfunction and increased immune response
B. The effects of creatine and exercise
C. Decreased metabolic demands and increased physical activity
D. An imbalance of oral intake and the effects of catabolism
Answer: D. An imbalance of oral intake and the effects of catabolism
12. A nurse is teaching the family Of a client who has a neurologic injury. The family
member asks why increased intracranial pressure causes so many problems. Which of the
following should the nurse include in the teaching?
A. Increased intracranial pressure causes the skull to expand to accommodate cerebral edema.
B. Increased intracranial pressure causes a shift of brain tissue, cerebrospinal fluid, or blood.
C. Increased intracranial pressure causes cerebral blood vessels to dilate to decrease blood
flow.
D. Increased intracranial pressure causes an increase in cerebral perfusion pressure.
Answer: B. Increased intracranial pressure causes a shift of brain tissue, cerebrospinal fluid,
or blood.
13. A nurse is explaining to a client's family about the Monro-Kellie doctrine and how the
components within the cranium change in relation to intracranial pressure (ICP) along with
cerebral perfusion. Which of the following processes of cerebral autoregulation maintains a
client's cerebral perfusion?
A. Dilation of peripheral blood vessels to increase cerebral perfusion pressure
B. Constriction of cerebral blood vessels when mean arterial pressure is high
C. Maintenance of mean arterial pressure near or equal to ICP
D. Reduction of cerebrospinal fluid production within the brainstem
Answer: B. Constriction of cerebral blood vessels when mean arterial pressure is high
14. A nurse is caring for a client who has a subarachnoid haemorrhage involving a ruptured
aneurysm, Which of the following options should the nurse understand are evidence-based
guidelines to treat subarachnoid haemorrhage and reduce the 1 -year mortality rate? Select all
that apply.
A. Administration of antihypertensive
B. Administration of nimodipine
C. Administration of morphine
D. Colling or clipping of ruptured aneurysm
E. Insert an indwelling urinary catheter
Answer: A. Administration of antihypertensive
B. Administration of nimodipine
D. Colling or clipping of ruptured aneurysm
15. A nurse is caring for a client who has sustained a traumatic brain injury and recognizes
that both a primary and secondary injury may occur. Which of the following causes a
secondary injury to occur?
A. A blunt impact causing double vision and headaches
B. A concussion causing increased confusion and loss of consciousness
C. A contusion causing compromised blood supply and ischemia
D. A skull fracture presenting with a Glasgow Coma Scale (GCS) score of 14 and hypoxia
Answer: C. A contusion causing compromised blood supply and ischemia
16. A nurse is teaching a client who has a traumatic brain injury (TBI) about comorbidities
that can contribute to a functional impairment following the injury. Which of the following
should the nurse include in the teaching?
A. Arthritis
B. Diabetes mellitus
C. Hypotension
D. Psychiatric conditions
Answer: D. Psychiatric conditions
17. A nurse is caring for a client who has a subarachnoid haemorrhage. Which Of the
following should the nurse use to predict vasospasm in this client?
A. Hunt and Hess scale
B. World Federation of Neurological Surgeons (WENS) scale
C. Fisher scale
D Glasgow Coma Scale (GCS)
Answer: C. Fisher scale
18. A nurse is teaching a group Of newly licensed nurses about a client's genetic risk factors
for subarachnoid haemorrhages (SAH). Which Of the following genetic risk factors should
the nurse include in the teaching?
A. Apert syndrome
B. Cystic fibrosis
C. Ehlers-Danlos syndrome
D. Ankylosing spondylitis
Answer: C. Ehlers-Danlos syndrome
19. A nurse is caring for a client who presents to the emergency department after falling and
hitting their head. The nurse finds clear drainage from the client's ear and is concerned about
rhinorrhoea. Which of the following actions should the nurse perform?
A. Check the fluid for beta-2 transferrin.
B. Have the client lay fiat in bed.
C. Pack the affected ear with gauze.
D. Monitor for Battle's sign every hour,
Answer: A. Check the fluid for beta-2 transferrin.
20. A nurse is caring for a client who has a suspected brain herniation. Which of the
following should the nurse identify as manifestations of brain herniation? Select all that
apply.
A. Symmetric pupils
B. Diabetes insipidus
C. Loss of corneal reflex
D. Poor judgement
E. Decorticate posturing
Answer: B. Diabetes insipidus
C. Loss of corneal reflex
D. Poor judgement
E. Decorticate posturing
21. A nurse is caring for a client in the emergency department who presents with a gunshot
wound to the head. Which of the following are clients with penetrating wounds at risk for?
A. Decreased risk of falls
B. Increased risk of infection
C. Decreased risk of anxiety
D. Increased risk of diabetes
Answer: B. Increased risk of infection
22. A nurse is teaching a client who has had a subarachnoid haemorrhage about changes to
mobility, sensory perception, perfusion, and cognition. Which of the following information
should the nurse include in the teaching?
A. The client may have improved language abilities.
B. The client may develop tau accumulation and loss of proprioception.
C. The client may have aggressive behaviors with labile mood.
D. The client may have hemiparesis and difficulty with speech.
Answer: D. The client may have hemiparesis and difficulty with speech.
23. A nurse is caring for a client who has increased intracranial pressure (ICP). Which Of the
following psychosocial alterations should the nurse anticipate the client may develop
following increased ICP?
A. Improved relationships with family and friends
B. Prohibitor control resulting in good moods
C. Increased desire to pursue hobbies
D. Difficulty with interpretation of social cues
Answer: D. Difficulty with interpretation of social cues
24. A nurse is caring for a client who has a subarachnoid haemorrhage (SAH). Which Of the
following manifestations should the nurse monitor the client for?
A. Changes in vision
B. Leg pain
C. Chest pain
D. Rhinorrhoea
Answer: A. Changes in vision
25. A nurse is caring for a client who has a traumatic brain injury. Which of the following
should the nurse understand the client is at high risk for? Select all that apply.
A. Cognitive deficits
B. Thrombocytopenic purpura
C. Falls
D. Drowsiness
E. Hemiparesis
Answer: A. Cognitive deficits
C. Falls
D. Drowsiness
E. Hemiparesis
26. A nurse is caring for a client who has increased intracranial pressure from a traumatic
brain injury and a Glasgow Coma Score Of 10 on admission. Which of the following
manifestations indicate to the nurse a worsening neurological injury is occurring?
A. Glasgow Coma Score of 14
B. Improving confusion and orientation
C. Breathing patterns become irregular
D. Pupils equal and reactive to light
Answer: C. Breathing patterns become irregular
27. A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the
following mechanisms should the nurse understand may cause a TBI? Select all that apply.
A. Hypertension
B. Motor vehicle crash
C. Interpersonal violence
D. Blast Injury
E. Firearms
Answer: B. Motor vehicle crash
C. Interpersonal violence
D. Blast Injury
E. Firearms
Hypertension is incorrect. Hypertension can lead to a higher functional impairment after a
TBI. However, hypertension is nota risk factor for TBI.
Motor vehicle crash is correct. Firearms, motor vehicle injuries related to sports or
interpersonal violence, and blast injuries are alt mechanisms associated with TBIs.
Interpersonal violence is correct. Firearms, motor vehicle injuries, injuries related to sports
or interpersonal violence, and blast injuries are all mechanisms associated with T81s.
Blast injury is correct. Firearms, motor vehicle injuries, injuries related to sports or
interpersonal violence, and blast injuries are all mechanisms associated with TBIs.
Firearms is correct. Firearms, motor vehicle injuries, injuries related to sports or
interpersonal violence, and blast injuries are all mechanisms associated with Tats.
28. A nurse is caring for a client who has a subarachnoid haemorrhage (SAH). Which of the
following should the nurse understand are risk factors for SAH? Select all that apply.
A. Male Sex
B. Hypertension
C. Obesity
D. Smoking
E. Alcohol use disorder
Answer: B. Hypertension
D. Smoking
E. Alcohol use disorder
Male sex is incorrect. Females are often more affected by SAH than males.
Hypertension is correct. Hypertension is a risk factor for SAH along with smoking alcohol
use disorder, and cocaine use.
Obesity is incorrect. Obesity is nota risk factor for SAH.
Smoking is correct. Smoking and alcohol use disorder are risk factors for SAH.
Alcohol use disorder is correct. Smoking and alcohol use disorder are risk factors for SAH.
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