Critical Neurological Dysfunction Assessment Exam
Questions And Answers
A nurse is caring for a client who has increased intracranial pressure. Which of the
following actions should the nurse take? Select all that apply - answer Maintain systolic
blood pressure 90
Keep the head med line to the body
Monitor for seizures
Anurse is caring for a 78-year-old dient who has a traumatic brain injury (TB). Which of the
following should the nurse understand places this client at high risk for falls?
Select all that apply. - answer Balance impairment
Eyesight changes
Arcinypertensives
Diabetes mellitus
A nurse is teaching a group of newly licensed nurses about a client's genetic risk factors
for subarachnoid hemorrhages (SAH). Which of the following genetic risk factors should
the nurse lnclude in the teaching? - answer Ehlers-Danlos syndrome
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 18/min. The repeats
the vital signs 1 hr later. Which of the following repeat vital signs are most concerning
during reassessment? - answer Blood pressure 130/54 mm Hg, pulse 60/min, respirations
28/min
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 rhinorrhea. Which of the following actions should the nurse perform? - answer
Check the fluid for beta-2 transferrin.
A nurse is planning care for a client who has increased intracranial pressure, Which of the
following factors should the nurse ünderstand will cause a loss of muscle and malnutrition
if enteral feedings are not started early? - answer An imbalance of oral intake and the
