NLE Neurosensory Nursing Reviewer 2026

Answer: C. 15

Step 1: Recall that the GCS tests three components. Step 2: Eye opening (E) is scored 1–4, Verbal response (V) is scored 1–5, and Best motor response (M) is scored 1–6. Step 3: Add the maximum scores: 4 + 5 + 6 = 15. Step 4: A fully alert, oriented person scores E4 V5 M6 = 15. Step 5: The minimum score is 3 (1+1+1), representing the deepest coma. Options A, B, and D are incorrect because they do not represent the actual sum of the three subscale maximums.

Answer: B. Prepare for airway protection or intubation

Step 1: A GCS score of 8 or below indicates severe neurologic impairment (coma). Step 2: Using Maslow's hierarchy, airway/breathing is the highest physiologic priority. Step 3: At GCS ≤ 8, the patient cannot protect their own airway due to loss of protective reflexes (gag, swallowing). Step 4: The clinical standard is to prepare for intubation at GCS ≤ 8 to prevent aspiration and hypoxia. Step 5: The other options (diuretics, positioning, LP) may be relevant later but are NOT the immediate first priority when the airway is at risk.

Answer: C. Level of consciousness (LOC)

Step 1: The reticular activating system (RAS) in the brainstem governs wakefulness and alertness. Step 2: Even small disruptions in cerebral perfusion or rising ICP first affect the RAS, causing changes in LOC before other signs appear. Step 3: Vital signs (Cushing's triad) are LATE signs of increased ICP — they appear after LOC has already declined. Step 4: Pupillary changes also occur later, typically when herniation is already occurring. Step 5: Therefore, any decline in LOC — becoming harder to arouse, confused, or agitated — must be reported immediately as it signals deterioration.

Answer: C. Uncal herniation compressing cranial nerve III on the right side

Step 1: Cranial nerve III (oculomotor) controls pupil constriction and eyelid elevation. Step 2: A unilateral fixed, dilated ('blown') pupil indicates that CN III is being compressed on that same side. Step 3: This compression is caused by uncal (transtentorial) herniation — brain tissue shifting downward due to rising ICP. Step 4: This is a neurologic emergency requiring IMMEDIATE intervention. Step 5: Opioid toxicity causes bilateral PINPOINT pupils. Pontine hemorrhage also causes bilateral pinpoint pupils. A fixed, dilated pupil is never a normal variant.

Answer: B. Rising systolic BP with widening pulse pressure, bradycardia, and irregular respirations

Step 1: Cushing's Triad is a reflex response of the body to dangerously high ICP. Step 2: As ICP rises, the brainstem is compressed, causing the body to increase systolic blood pressure to maintain cerebral perfusion. Step 3: This hypertension triggers a baroreceptor reflex causing bradycardia (slow heart rate). Step 4: Compression of the respiratory centers in the brainstem causes irregular, abnormal breathing (e.g., Cheyne-Stokes). Step 5: This triad signals imminent brainstem herniation and requires emergency intervention. The other options describe shock, infection/sepsis, or incorrect combinations.

Answer: C. Lateral recumbent (fetal position) with knees drawn to the chest

Step 1: A lumbar puncture accesses the subarachnoid space between L3–L4 or L4–L5. Step 2: The goal is to widen the spaces between the vertebrae to allow safe needle insertion. Step 3: The lateral recumbent (side-lying) fetal position — with the back curved outward, knees pulled to the chest, and chin tucked — maximally widens the intervertebral spaces. Step 4: This position also prevents patient movement during the procedure, reducing the risk of nerve injury. Step 5: The other positions do not adequately open the intervertebral spaces and are not used for LP.

Answer: B. Lie flat for several hours and increase fluid intake

Step 1: Post-LP headache (spinal headache) is caused by leakage of CSF through the puncture site, reducing CSF pressure. Step 2: Lying flat reduces the pressure gradient, preventing further CSF leakage. Step 3: Increasing fluid intake (oral or IV) helps replenish CSF volume, raising the pressure back to normal. Step 4: Early ambulation worsens the headache by increasing CSF leakage due to the effect of gravity on the upright position. Step 5: Fluid restriction would worsen CSF depletion, making the headache worse — this is the opposite of correct care.

Answer: B. CT scan of the head without contrast

Step 1: The clinical picture (sudden severe headache + hemiplegia) raises concern for acute stroke, either ischemic or hemorrhagic. Step 2: It is critical to distinguish hemorrhagic from ischemic stroke BEFORE giving thrombolytics, because thrombolytics given in a hemorrhagic stroke are fatal. Step 3: CT scan is FAST (minutes) and excels at detecting acute hemorrhage, which appears bright (hyperdense/white) on non-contrast CT. Step 4: MRI is superior for soft-tissue detail but takes much longer and is not the first-line choice in acute emergencies. Step 5: EEG is for seizure activity. LP is contraindicated if ICP is elevated, and in acute stroke workup, CT comes first.

Answer: B. 70 mmHg

Step 1: The formula is CPP = MAP − ICP. Step 2: Substitute the values: CPP = 90 − 20 = 70 mmHg. Step 3: Normal CPP is 60–100 mmHg, so 70 mmHg is within the acceptable range, though the ICP of 20 mmHg is above normal (normal is 5–15 mmHg). Step 4: If CPP falls below 50 mmHg, cerebral ischemia occurs. Below 30 mmHg is incompatible with viable brain tissue. Step 5: The nurse must monitor both MAP and ICP to ensure adequate brain perfusion — lowering ICP or maintaining MAP protects the brain.

Answer: C. A positive Babinski reflex indicating an upper motor neuron lesion

Step 1: The Babinski reflex (plantar reflex) is elicited by stroking the lateral sole of the foot from heel to ball. Step 2: In a NORMAL adult, the toes curl downward (plantar flexion) — this is a NEGATIVE Babinski. Step 3: A POSITIVE Babinski (dorsiflexion of big toe + fanning of other toes) is ABNORMAL in adults and indicates damage to the corticospinal (upper motor neuron) tract. Step 4: This is normal only in infants under 1–2 years old because their corticospinal tracts are not yet fully myelinated. Step 5: Peripheral and lower motor neuron lesions cause flaccidity, decreased reflexes, and muscle atrophy — not a positive Babinski.

Answer: B. Non-contrast CT scan of the head

Step 1 – Identify the clinical problem: The patient has signs of a stroke (sudden focal neurologic deficit). Step 2 – Understand why CT is first: A non-contrast CT scan is done immediately to differentiate ischemic stroke from hemorrhagic stroke. This distinction is CRITICAL because treatment is opposite — thrombolytics help ischemic stroke but are life-threatening in hemorrhagic stroke. Step 3 – Eliminate wrong options: An ECG is important to detect atrial fibrillation (a clot source) but it does not guide immediate treatment. MRI with contrast is more sensitive for early ischemia but takes longer and is not the first step. Carotid Doppler is for workup of carotid stenosis, not an emergency initial test. Step 4 – Key NLE rule: 'CT first, then treat' is the golden rule in stroke management.

Answer: C. tPA should be given within 3 hours of symptom onset (up to 4.5 hours in eligible patients).

Step 1 – Recall the tPA time window: The standard window for IV alteplase is within 3 hours of onset; selected eligible patients may receive it up to 4.5 hours after onset. Step 2 – 'Time is brain': Every minute of delay results in neuronal death, so the exact time the patient was 'last known well' must be established. Step 3 – Eliminate wrong options: The 6-hour window is incorrect for standard IV tPA (extended windows apply only to endovascular thrombectomy for large-vessel occlusion). tPA is absolutely contraindicated in hemorrhagic stroke. tPA dosing is weight-based (0.9 mg/kg IV, max 90 mg), not a flat dose. Step 4 – NLE tip: If onset time is unknown (e.g., patient woke up with symptoms), tPA is generally not given without specialized imaging guidance.