Title WORKBOOK - NEURO (KEY) ✅

COMPREHENSIVE PHASE WORKBOOK NEUROLOGIC NURSING NOVEMBER 2025 Philippine Nurse Licensure Examination Review SITUATION: A 32 year old bus driver was rushed to the ER after sustaining severe head injury following a head-on collision with a ten wheeler truck. Nurse Lea is utilizing the Glasgow Coma Scale in assessing the neurologic status of the driver. 1. Nurse Lea is assessing the motor function of the driver. She would plan to use which of the following to test the driver’s peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Nail bed pressure D. Squeezing the sternocleidomastoid muscle 2. In assessing eye opening, the nurse observed that the driver opens his eyes only when peripheral pain is inflicted. What score will the nurse give? A. 1 B. 2 C. 3 D. 4 3. What GCS Score would the nurse give if Juan’s eyes open in response to pain, has no verbal response, and has decerebrate posturing? A. 4 B. 5 C. 6 D. 7 4. Nurse Lea has poor understanding about the Glasgow Coma Scale scoring when she states which of the following, EXCEPT? I. GCS is not a tool for assessing a client’s response to stimuli II. GCS scores range from 3 (normal) to 15 (deep coma) III. The smaller the GCS score, the deeper the coma IV. GCS assesses 3 areas (eye opening, motor response, verbal response) A. I and II B. II and III C. II, III and IV D. III and IV Situation 2 – A 14 year old teenager was admitted due to photophobia, throbbing headache and nuchal rigidity. A history of pneumonia was elicited. Diagnosis: Bacterial Meningitis. 5. To help support the diagnosis of bacterial meningitis, the nurse looks for Brudzinski’s sign. She knows that it is present if she sees: A. Hyperextension of the neck with passive shoulder flexion B. Flexion of the legs with rebound tenderness C. Flexion of the hip and knees with passive flexion of the neck D. Hyperflexion of the neck with rebound flexion of the legs 6. 8 hours after admission, the teenager suddenly had a tonic-clonic seizure and was unconscious after. What should the nurse do FIRST? A. Check the pulse B. Administer Valium C. Place the client in a side-lying position D. Place a tongue blade in the mouth 7. A 16 year old high school student was rushed to the ER due to a head injury following a car accident. The nurse notes a clear drainage from the left ear. The nurse would suspect: A. Concussion B. Subdural hematoma C. Basilar skull fracture D. Epidural hematoma SITUATION: A farmer is being assessed in the emergency room after sustaining a fall from a coconut tree. Admission assessment reveals that he hit his head on the grounD. 8. While assessing the farmer, which of the following neurological signs is of most concern? A. Reduced sensory responses B. Flaccid paralysis C. Pupils fixed and dilated D. Diminished spinal reflexes 9. We would be able to determine that the intracranial pressure (ICP) is rising if which of the following pulse rate result in the VITAL SIGNS is noted during the course of the work shift? I. Increased temperature II. Decreased pulse III. Increased respirations IV. Decreased BP V. Decreased temperature VI. Increased pulse VII. Decreased respirations VIII. Increased BP A. 2, 4 and 6 B. 2 C. 1, 2, 7 and 8 D. 3, 4, 5 and 6 10. The farmer is drowsy and complains of chest pain. Which of the following doctor’s orders shouldn’t the nurse question? I. Elevate the head 30° II. Nitroglycerin III. Apply antibiotics ointment to abrasions IV. Codeine for pain A. 1, 2 and 3 B. 2 and 4 only C. 3 and 4 only D. 4 only 11. On the 6th hospital day, the client developed cerebral edema and is given mannitol intravenously. The nurse knows that the drug is effective with which renal result: I. Urinary output increases II. Respirations drop to 12 and become regular III. Client’s level of consciousness improves IV. Client has no seizures A. 1 and 3 B. 1 only C. 1, 2 and 3 D. All are correct 12. The physician orders hyperventilation of the mechanical ventilator in a patient with head injury suffering from increased intracranial pressure. The nurse recognizes that hyperventilation is used to: TOP RANK REVIEW ACADEMY, INC. Page 1 | 7