NRSG 357 Exam 3 - Neuro (SCI, TBI, Delirium, Seizure,
Stroke): Questions And Accurate Answers
What does SCI stand for?
A. Susceptible Cord Infection
B. Super Comfy Injection
C. Superior Cord Infarct
D. Spinal Cord Injury Right Ans - D. Spinal Cord Injury
True or False: Primary SCI is the initial disruption of axons; Secondary SCI is
the ongoing, progressive damage due to ischemia, hypoxia, micro-
hemorrhage, and edema. Right Ans - True
A client is admitted to the emergency department with SCI at the level of T2.
Which finding is of MOST concern to the nurse?
A. Loss of motor and sensory function in arms and legs
B. BP of 92/60 mm Hg
C. Heart rate of 42 bpm
D. SpO2 of 92% Right Ans - C. Heart rate of 42 bpm
What causes an initial incomplete SCI to result in complete cord damage?
A. Mechanical transection of the cord by sharp vertebral bone fragments after
the initial injury
B. Edematous compression of the cord above the level of the injury
C. Continued trauma to the cord resulting from damage to stabilizing
ligaments
D. Infarction and necrosis of the cord caused by edema, hemorrhage, and
metabolites Right Ans - D. Infarction and necrosis of the cord caused by
edema, hemorrhage, and metabolites
The nurse knows that a client suffering from complete paralysis from the
waist down would have the condition of which of the following?
A. Hemiparesis
B. Paraparesis
C. Paraplegia
D. Hemiplegia Right Ans - C. Paraplegia
,Use of Glasgow Coma Scale (GCS) provides a relatively objective assessment of
Level of Consciousness (LOC). What are the Three functions assessed?
A. Verbal response, eye opening, motor response
B. Eye opening, motor response, sensation
C. Verbal response, pupil reaction, motor response
D. Pupil reaction, orientation, sensation Right Ans - A. Verbal response, eye
opening, motor response
When the nurse applies painful stimulus to the nailbeds of and unconscious
patient, the patient responds with internal rotation, adduction and flexion of
the arms. The nurse documents this finding as:
A. Flexion withdrawal
B. Decorticate posturing
C. Decerebrate posturing
D. Localization of pain Right Ans - B. Decorticate posturing
What is the normal value range of Intracranial Pressure (ICP)?
A. 5-15 mm Hg
B. 15-25 mm Hg
C. >25 mm Hg
D. <5 mm Hg Right Ans - A. 5-15 mm Hg
What type of brain injury occurs due to swelling or impaired blood flow to the
area of the injury (i.e. Increased Intracranial pressure, infection, ischemia,
hypoxia)
A. Primary Injury
B. Secondary Injury
C. Focal Injury
D. Diffuse Axonal Injury Right Ans - B. Secondary Injury
Complication which results from bleeding between the skull and dura mater
Right Ans - Epidural Hematoma
Complication which results from bleeding between the dura mater and
arachnoid layer Right Ans - Subdural Hematoma
Complication which results from bleeding within the brain tissue Right Ans
- Intracerebral Hematoma
, The patient with a spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse would AVOID which of the following measures to
minimize the risk of recurrence?
A. Strict adherence to a bowel retraining program
B. Keeping the linen wrinkle-free under the patient
C. Preventing unnecessary pressure of the lower limbs
D. Limiting bladder catheterization to once every 12 hours Right Ans - D.
Limiting bladder catheterization to once every 12 hours
A patient has an incomplete left spinal cord lesion at the level of T7, resulting
in Brown-Sequard syndrome. Which nursing action should be included in the
plan of care?
A. Assessment of the patient fro right arm weakness
B. Assessment of the patient for increased right leg pain
C. Positioning the patient's left leg, when turning the patient
D. Teaching the patient to look at the right leg to verify its position Right
Ans - C. Positioning the patient's left leg when turning the patient
- Rare neurological condition
- characterized by weakness or paralysis on one side of body and a loss of
sensation on the opposite side
- Incomplete spinal cord injury syndrome
- May be caused by spinal cord tumor, trauma, ischemia, or infectious
INFO NOT ON EXAM
The nurse will explain to the patient who has a T2 spinal cord transection
injury that
A. Function of both arms should be retained
B. Total loss of respiratory function may occur
C. Use of the shoulders will be limited
D. Tachycardia is common with this type of injury Right Ans - A. Function
of both arms should be retained
- Should not reach C4 level, so won't effect diaphragm or breathing
- Bradycardia is common, not tachycardia
Stroke): Questions And Accurate Answers
What does SCI stand for?
A. Susceptible Cord Infection
B. Super Comfy Injection
C. Superior Cord Infarct
D. Spinal Cord Injury Right Ans - D. Spinal Cord Injury
True or False: Primary SCI is the initial disruption of axons; Secondary SCI is
the ongoing, progressive damage due to ischemia, hypoxia, micro-
hemorrhage, and edema. Right Ans - True
A client is admitted to the emergency department with SCI at the level of T2.
Which finding is of MOST concern to the nurse?
A. Loss of motor and sensory function in arms and legs
B. BP of 92/60 mm Hg
C. Heart rate of 42 bpm
D. SpO2 of 92% Right Ans - C. Heart rate of 42 bpm
What causes an initial incomplete SCI to result in complete cord damage?
A. Mechanical transection of the cord by sharp vertebral bone fragments after
the initial injury
B. Edematous compression of the cord above the level of the injury
C. Continued trauma to the cord resulting from damage to stabilizing
ligaments
D. Infarction and necrosis of the cord caused by edema, hemorrhage, and
metabolites Right Ans - D. Infarction and necrosis of the cord caused by
edema, hemorrhage, and metabolites
The nurse knows that a client suffering from complete paralysis from the
waist down would have the condition of which of the following?
A. Hemiparesis
B. Paraparesis
C. Paraplegia
D. Hemiplegia Right Ans - C. Paraplegia
,Use of Glasgow Coma Scale (GCS) provides a relatively objective assessment of
Level of Consciousness (LOC). What are the Three functions assessed?
A. Verbal response, eye opening, motor response
B. Eye opening, motor response, sensation
C. Verbal response, pupil reaction, motor response
D. Pupil reaction, orientation, sensation Right Ans - A. Verbal response, eye
opening, motor response
When the nurse applies painful stimulus to the nailbeds of and unconscious
patient, the patient responds with internal rotation, adduction and flexion of
the arms. The nurse documents this finding as:
A. Flexion withdrawal
B. Decorticate posturing
C. Decerebrate posturing
D. Localization of pain Right Ans - B. Decorticate posturing
What is the normal value range of Intracranial Pressure (ICP)?
A. 5-15 mm Hg
B. 15-25 mm Hg
C. >25 mm Hg
D. <5 mm Hg Right Ans - A. 5-15 mm Hg
What type of brain injury occurs due to swelling or impaired blood flow to the
area of the injury (i.e. Increased Intracranial pressure, infection, ischemia,
hypoxia)
A. Primary Injury
B. Secondary Injury
C. Focal Injury
D. Diffuse Axonal Injury Right Ans - B. Secondary Injury
Complication which results from bleeding between the skull and dura mater
Right Ans - Epidural Hematoma
Complication which results from bleeding between the dura mater and
arachnoid layer Right Ans - Subdural Hematoma
Complication which results from bleeding within the brain tissue Right Ans
- Intracerebral Hematoma
, The patient with a spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse would AVOID which of the following measures to
minimize the risk of recurrence?
A. Strict adherence to a bowel retraining program
B. Keeping the linen wrinkle-free under the patient
C. Preventing unnecessary pressure of the lower limbs
D. Limiting bladder catheterization to once every 12 hours Right Ans - D.
Limiting bladder catheterization to once every 12 hours
A patient has an incomplete left spinal cord lesion at the level of T7, resulting
in Brown-Sequard syndrome. Which nursing action should be included in the
plan of care?
A. Assessment of the patient fro right arm weakness
B. Assessment of the patient for increased right leg pain
C. Positioning the patient's left leg, when turning the patient
D. Teaching the patient to look at the right leg to verify its position Right
Ans - C. Positioning the patient's left leg when turning the patient
- Rare neurological condition
- characterized by weakness or paralysis on one side of body and a loss of
sensation on the opposite side
- Incomplete spinal cord injury syndrome
- May be caused by spinal cord tumor, trauma, ischemia, or infectious
INFO NOT ON EXAM
The nurse will explain to the patient who has a T2 spinal cord transection
injury that
A. Function of both arms should be retained
B. Total loss of respiratory function may occur
C. Use of the shoulders will be limited
D. Tachycardia is common with this type of injury Right Ans - A. Function
of both arms should be retained
- Should not reach C4 level, so won't effect diaphragm or breathing
- Bradycardia is common, not tachycardia
