Neurological Nursing Questions for the Prometric Exam 2026: 20 MCQs with Answers on Stroke and Thrombolysis, Glasgow Coma Scale, Raised Intracranial Pressure, Seizures, Spinal Cord Injury, Meningitis, Parkinson's Disease, Multiple Sclerosis, Myasthenia Gravis and Guillain-Barré Syndrome

Neurological nursing is a steady 8 to 12 questions on the registered nurse paper, spread across the medical-surgical and critical care domains, and stroke units and neuroscience ICUs are major Gulf recruiters: stroke presents a decade earlier in Gulf populations and road traffic injury rates are among the highest in the world. The exam tests recognition and timing (stroke windows, seizure duration, deterioration on the GCS), the nursing measures that protect the brain, and the drug rules for the chronic conditions. This set covers what recurs.

Stroke

Question 1

A 68-year-old man develops sudden right-sided facial droop, right arm weakness and slurred speech at 10:00. He arrives in the emergency department at 10:40. The nurse's priority actions are:

1. Give aspirin 300 mg immediately and arrange a ward bed
2. Activate the stroke pathway, document the exact time of symptom onset (last known well), check glucose, obtain an urgent non-contrast CT (and CT angiography) to exclude haemorrhage and identify large vessel occlusion, assess with the NIHSS, keep nil by mouth, and prepare for intravenous thrombolysis within 4.5 hours of onset or thrombectomy within 6 to 24 hours for selected large vessel occlusions; aspirin is withheld until haemorrhage is excluded and for 24 hours after thrombolysis
3. Lie the patient flat and give oxygen at 15 L/min
4. Wait for the neurologist's morning round

Answer: B. Door-to-needle under 60 minutes is the standard; blood pressure must be below 185/110 mmHg before thrombolysis and is kept below 180/105 for 24 hours after.

Question 2

After intravenous alteplase, the nurse monitors for which complication and how?

1. Hyperglycaemia; glucose every 8 hours
2. Symptomatic intracranial haemorrhage and angio-oedema: neurological observations and blood pressure every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly to 24 hours; any new headache, nausea, vomiting, falling GCS or rising blood pressure means stopping the infusion, urgent CT and calling the stroke team; no antiplatelets, anticoagulants, nasogastric tubes, urinary catheters or arterial punctures for 24 hours unless essential
3. Deep vein thrombosis only
4. Fever only

Answer: B. Orolingual angio-oedema is more common in patients on ACE inhibitors and can threaten the airway.

Question 3

A patient with a left hemisphere stroke has right hemiparesis, aphasia and a right visual field loss. Which nursing care is appropriate?

1. Approach and place belongings on the right side to force the patient to turn
2. Approach from the unaffected (left) side initially and place the call bell and essentials within the intact visual field, then gradually encourage scanning to the affected side; use short sentences, yes/no questions, gestures and picture boards for aphasia, allow time to respond, position the affected arm supported to prevent shoulder subluxation, and begin early mobilisation with the therapy team
3. Speak loudly because the patient is deaf
4. Restrain the affected arm

Answer: B. Expressive (Broca's) aphasia follows left frontal damage; receptive (Wernicke's) aphasia follows left temporal damage. Neglect is typical of right hemisphere stroke.

Question 4

Before giving a stroke patient anything by mouth, the nurse must:

1. Give a glass of water to check for coughing
2. Complete a validated bedside swallow screen (and keep the patient nil by mouth, including oral medications, if it is failed or not yet done), with speech and language therapy assessment within 24 hours, because dysphagia affects up to half of stroke patients and aspiration pneumonia is a leading cause of death after stroke; medications are given by an alternative route or in the recommended texture
3. Puree all food permanently
4. Insert a nasogastric tube in every stroke patient

Answer: B. Oral hygiene and upright positioning at 90 degrees for meals reduce aspiration risk.

Consciousness and intracranial pressure

Question 5

A head-injured patient opens his eyes to voice, is confused but converses, and localises to painful stimulus. His GCS is:

1. 15
2. 13 (E3 V4 M5)
3. 11
4. 9

Answer: B. Eye opening scores 1 to 4, verbal 1 to 5, motor 1 to 6; the best response is recorded, each component is documented, and a drop of two points or more (or any drop in motor score) is reported urgently. Flexion to pain (decorticate) scores M3 and extension (decerebrate) M2.

Question 6

During neurological observations the nurse notes a patient's right pupil has become dilated and sluggish while the left is 3 mm and brisk. The nurse should:

1. Document and recheck in an hour
2. Recognise a possible sign of expanding intracranial lesion compressing the third cranial nerve (uncal herniation), check for other changes in GCS and vital signs, notify the medical team immediately and prepare for urgent CT and possible neurosurgical intervention
3. Instil mydriatic drops to equalise the pupils
4. Assume the patient has had eye drops

Answer: B. Cushing's triad (hypertension with widening pulse pressure, bradycardia and irregular respirations) is a late sign of raised intracranial pressure and impending herniation.

Question 7

Which nursing measures help control raised intracranial pressure in a ventilated patient with traumatic brain injury?

1. Head of bed flat, frequent suctioning and clustering all care at once
2. Head of bed at 30 degrees with the head and neck in neutral alignment (no hip flexion over 90 degrees, no tight tracheostomy ties or collars), spacing nursing activities, pre-oxygenation and brief suctioning only when needed, preventing coughing and straining, controlling fever and pain, maintaining normal carbon dioxide and oxygen, avoiding hypotonic fluids, keeping the environment calm and monitoring ICP, CPP and neurological status, with hyperosmolar therapy and CSF drainage as prescribed
3. Vigorous chest physiotherapy every two hours
4. Routine hyperventilation for 48 hours

Answer: B. Sustained ICP above 20 to 22 mmHg is treated; cerebral perfusion pressure (MAP minus ICP) is kept at 60 to 70 mmHg. Steroids are not used in traumatic brain injury.

Question 8

After a craniotomy for a tumour, which finding requires the nurse to call the surgeon immediately?

1. A mild headache controlled with paracetamol
2. A fall in GCS, new weakness, unequal pupils, new seizure, clear fluid leaking from the wound or nose (CSF leak), excessive drain output, or a rising temperature with neck stiffness suggesting meningitis
3. Periorbital swelling on the operated side
4. Reluctance to eat on the first day

Answer: B. Post-operative haematoma presents within hours as declining consciousness; patients after supratentorial surgery are nursed with the head up 30 degrees, and after infratentorial surgery as instructed, often flat or at a low angle initially.

Seizures

Question 9

A patient on the ward has a generalised tonic-clonic seizure. The nurse's actions during the seizure are:

1. Restrain the limbs and insert an oral airway between the teeth
2. Note the time, protect from injury by moving hazards and cushioning the head, loosen tight clothing, do not restrain or put anything in the mouth, turn onto the side as soon as possible to protect the airway, give oxygen, stay with the patient, observe and document the seizure's features and duration, and call for help and prepare a benzodiazepine (intravenous lorazepam, buccal midazolam or rectal diazepam) if it lasts beyond five minutes
3. Give oral fluids to prevent dehydration
4. Leave to fetch the doctor

Answer: B. Postictal care includes airway protection, reassurance, checking glucose and injuries, and documenting the post-seizure state; a seizure over 5 minutes or recurrent seizures without recovery is status epilepticus.

Question 10

A patient with epilepsy on phenytoin has nystagmus, ataxia, slurred speech and drowsiness, with a phenytoin level of 32 mg/L. The nurse recognises:

1. A new seizure type
2. Phenytoin toxicity (therapeutic range about 10 to 20 mg/L); hold the dose, notify the prescriber, institute falls precautions and monitor the ECG, and review interacting drugs; phenytoin has saturable kinetics so small dose changes cause large level changes, and it must be given slowly intravenously (no faster than 50 mg/min) with cardiac monitoring and never with dextrose
3. Normal side effects to be tolerated
4. Hypoglycaemia

Answer: B. Gingival hyperplasia, hirsutism and rash are chronic effects; sodium valproate and carbamazepine have their own monitoring (liver function and platelets, sodium and blood counts respectively), and women on valproate need pregnancy prevention counselling.

Question 11

Discharge teaching for a newly diagnosed adult with epilepsy includes:

1. Medication can be stopped once seizure-free for a month
2. Take antiseizure medication at the same times every day and never stop abruptly, keep a seizure diary, know the common triggers (missed doses, sleep deprivation, alcohol, illness, flashing lights for photosensitive epilepsy), follow local driving restrictions (which in Gulf states usually require a seizure-free period certified by a neurologist), avoid swimming or bathing alone and working at heights, carry identification, and teach the family seizure first aid and when to call emergency services
3. Avoid all exercise
4. Drive only short distances

Answer: B. Sudden withdrawal precipitates status epilepticus; contraception interactions with enzyme-inducing drugs are discussed with women of childbearing age.

Spinal cord injury

Question 12

A patient with a T4 complete spinal cord injury suddenly develops a pounding headache, blood pressure of 210/120 mmHg, flushing above the lesion and sweating, with a heart rate of 50. The nurse should:

1. Lie the patient flat and give fluids
2. Recognise autonomic dysreflexia, sit the patient upright and lower the legs, loosen tight clothing, check and empty the bladder (catheter blockage is the commonest trigger), check for bowel impaction and other noxious stimuli below the lesion (pressure injury, ingrown toenail), monitor blood pressure every two to five minutes, and give a rapid-acting antihypertensive such as nifedipine or GTN as prescribed if the pressure stays high
3. Give a beta blocker
4. Ignore it, since paralysed patients cannot feel pain

Answer: B. Autonomic dysreflexia occurs in injuries at T6 and above and can cause stroke; prevention is regular bladder and bowel management.

Question 13

In the first days after a cervical spinal cord injury, which respiratory and circulatory problems should the nurse anticipate?

1. Hypertension and tachycardia
2. Neurogenic shock (hypotension with bradycardia and warm skin from loss of sympathetic tone, needing fluids, vasopressors and atropine as prescribed), ascending oedema that can compromise the diaphragm (C3 to C5), ineffective cough and secretion retention needing assisted cough and respiratory monitoring with vital capacity, paralytic ileus requiring nasogastric decompression, urinary retention needing catheterisation, and high VTE risk requiring prophylaxis
3. Hyperthermia only
4. No respiratory concerns below C8

Answer: B. Spinal immobilisation with log-rolling, pressure area care every two hours and early psychological support complete the acute nursing priorities.

Infection and inflammation

Question 14

A 20-year-old student presents with fever, severe headache, neck stiffness, photophobia and a spreading non-blanching purpuric rash. The nurse's priorities are:

1. Wait for the lumbar puncture result before any treatment
2. Recognise probable meningococcal sepsis and meningitis, place the patient in droplet isolation, obtain blood cultures and ensure intravenous antibiotics (for example ceftriaxone) are given within an hour without waiting for lumbar puncture, give dexamethasone as prescribed, start the sepsis pathway, monitor neurological status and for raised intracranial pressure, and arrange chemoprophylaxis for close contacts and notification to public health
3. Give oral antibiotics and discharge
4. Apply standard precautions only

Answer: B. Droplet precautions continue for 24 hours after effective antibiotics; a lumbar puncture is deferred if there are signs of raised pressure, focal deficit or coagulopathy.

Question 15

After a lumbar puncture, a patient reports a severe headache that is worse when sitting up and relieved lying flat. The nurse's management is:

1. Sit the patient upright to drain the fluid
2. Recognise a post-dural puncture headache, keep the patient lying flat as tolerated, encourage fluids and caffeine, give simple analgesia as prescribed, and notify the team if it persists beyond 24 to 48 hours or is severe, when an epidural blood patch may be offered; monitor for fever, neck stiffness or neurological change suggesting another cause
3. Give a triptan
4. Restrict fluids

Answer: B. Using a smaller atraumatic needle reduces incidence; routine prolonged bed rest after lumbar puncture does not prevent it.

Chronic neurological conditions

Question 16

A patient with Parkinson's disease is admitted for a hip replacement. Which medication principle is most important?

1. Hold all Parkinson's medication while fasting
2. Give levodopa and other dopaminergic drugs on time, every time, including during fasting (with a sip of water) and in the perioperative period, because missed or late doses cause rigidity, dysphagia, falls and, rarely, a parkinsonism-hyperpyrexia syndrome; avoid dopamine antagonists such as metoclopramide, prochlorperazine and haloperidol (domperidone or ondansetron are alternatives for nausea), and give protein-rich meals apart from levodopa doses where absorption is an issue
3. Give doses whenever the medication round happens to be
4. Switch to metoclopramide for nausea

Answer: B. "Get it on time" campaigns exist because late doses cause measurable harm; sudden withdrawal is dangerous.

Question 17

A 30-year-old woman with relapsing-remitting multiple sclerosis presents with three days of worsening blurred vision and painful eye movements in one eye. The nurse anticipates:

1. Antibiotics for conjunctivitis
2. Optic neuritis as an MS relapse; assessment for other new symptoms and exclusion of infection or fever (which can mimic a relapse), high-dose intravenous or oral methylprednisolone for three to five days as prescribed with glucose and mood monitoring, safety measures for visual loss, and review of disease-modifying therapy, with education about heat sensitivity (Uhthoff phenomenon), fatigue management, bladder care and avoiding infections
3. Eye patching for a month
4. Immediate plasma exchange

Answer: B. MS prevalence in the Gulf has risen sharply; disease-modifying therapies (interferons, oral agents, monoclonal antibodies) each carry monitoring requirements the nurse supports.

Question 18

A patient with myasthenia gravis has increasing difficulty swallowing, weak voice, drooping eyelids and a falling forced vital capacity after a chest infection. The nurse should:

1. Encourage oral intake to keep up strength
2. Recognise impending myasthenic crisis, keep nil by mouth if swallowing is unsafe, monitor forced vital capacity and negative inspiratory force every two to four hours (vital capacity below about 15 to 20 mL/kg prompts ICU review), prepare for possible intubation, give pyridostigmine on time, avoid medications that worsen myasthenia (aminoglycosides, fluoroquinolones, beta blockers, magnesium, neuromuscular blockers), and anticipate intravenous immunoglobulin or plasma exchange
3. Give a sedative for anxiety
4. Administer magnesium for the weakness

Answer: B. Cholinergic crisis from excess pyridostigmine presents with salivation, sweating, miosis and cramps; the distinction is clinical and both can cause weakness. Oxygen saturation falls late in neuromuscular respiratory failure, so bedside spirometry is the monitoring tool.

Question 19

A 40-year-old develops ascending weakness and tingling in both legs over four days, two weeks after a diarrhoeal illness, with absent reflexes. The nurse's priorities are:

1. Encourage ambulation to maintain strength
2. Recognise probable Guillain-Barré syndrome, monitor respiratory function with serial forced vital capacity and swallow, monitor for autonomic instability (labile blood pressure, arrhythmias, urinary retention, ileus), prevent complications of immobility (VTE prophylaxis, pressure care, passive movement, pain management for neuropathic pain), and prepare for intravenous immunoglobulin or plasma exchange and possible ICU transfer
3. Give steroids, which are the standard treatment
4. Discharge with physiotherapy

Answer: B. About a quarter of patients need ventilation; corticosteroids do not help in Guillain-Barré syndrome. Campylobacter infection is the classic trigger.

Question 20

A patient with a severe traumatic brain injury has been declared brain dead according to the hospital's protocol, and the family asks the nurse what this means. The appropriate response includes:

1. "The patient is in a coma and may wake up."
2. Explaining in plain language, with the physician, that brain death is death: all brain function including the brainstem has irreversibly ceased, the ventilator is moving air but the patient cannot breathe or recover, and that this has been confirmed by formal testing; allowing time, offering religious and cultural support (including an imam or chaplain) and private time with the patient, and, where the national programme applies, allowing the trained donor coordinator to discuss organ donation separately from the death conversation
3. Avoiding the conversation entirely
4. Telling the family the decision to stop the ventilator is theirs

Answer: B. Gulf states recognise brain death legally and have organ donation programmes; the nurse's role is honest communication, compassion and support, not the diagnosis itself.

How to practise

• Learn the time windows and thresholds: thrombolysis 4.5 hours, status epilepticus 5 minutes, GCS drop of two points, vital capacity triggers, blood pressure limits after thrombolysis.
• Know the nursing measures that protect the brain: positioning, ICP precautions, swallow screening, seizure first aid, isolation for meningitis.
• Know the drug rules: phenytoin levels and administration, levodopa timing and contraindicated antiemetics, drugs that worsen myasthenia.

Neurological chapters with explanations are in the Registered Nurse bank; related sets are the critical care questions, medical-surgical questions, geriatric questions and pharmacology questions. Neurologists have their own set (neurology questions).

Frequently asked questions

How many neurological questions are in the Prometric nursing exam?

About 8 to 12 of 150, within the medical-surgical and critical care domains.

Which neurological nursing topics come up most?

Stroke pathway and post-thrombolysis care, GCS and pupil assessment, raised intracranial pressure measures, seizure first aid, autonomic dysreflexia and myasthenic crisis monitoring.

Do I need to know the NIHSS?

At the level of its purpose and the main components; detailed scoring is not required for the licensing exam.

Which guidelines does the exam follow?

Current AHA/ASA stroke guidance, Brain Trauma Foundation recommendations and standard neuroscience nursing textbooks.

Are these real exam questions?

No. They are original practice questions written to the published blueprint. Real exam content is confidential.