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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

2. Intracranial hemorrhages
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

3. Generalized seizures
Muscle stiffness - rigidity
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
are produced by electrical impulses from throughout the entire brain

4. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i

5. Quadriplegia with gross arm movement and diaphragmic breathing

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6. partial seizures
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?

7. Decorticate
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Seizures are divided into two broad categories:
Which of the following describes decerebrate posturing?

8. Evaluate urine specific gravity
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following describes decerebrate posturing?

9. Wrap her hands in soft 'mitten' restraints
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?

10. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

11. Epidural hematoma
High - energy transfer - such as a blow from a baseball bat
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?

12. 'Grand Mal' or Generalized tonic - clonic
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i
Head is suddenly forced to stop or start moving - or to turn rapidly.
Unconsciousness - convulsions - muscle rigidity
Which of the following describes decerebrate posturing?

13. The patient should be placed on droplet precautions.
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
Which of the following describes decerebrate posturing?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

14. Laceration of the middle meningeal artery
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

15. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Vitals/turn freq/call light close/ ROM
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

16. Linear skull fractures
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Meningies - csf - blood - brain barrier - skull
Blunt trauma

17. 'The lens is normally transparent
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Gap between the dura and the cortical surface of the brain.

18. Subdural hemorrhage
Seizures are divided into two broad categories:
Gap between the dura and the cortical surface of the brain.
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

19. Activity of the brain
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
A client has been pronounced brain dead. Which findings would the nurse assess?
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

20. 'Wake him every hour and assess his orientation to person - time - and place
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

21. Basilar skull fractures
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes

22. A client with a high cervical spine injury
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

23. Encouraging compliance with drug therapy to prevent loss of vision
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

24. 4 things that protect the brain
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
are produced by electrical impulses from throughout the entire brain
Meningies - csf - blood - brain barrier - skull

25. Decrease in LOC

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26. Raise the head of the bed immediately to 90 degrees
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

27. Dopamine
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
CN III

28. Tonic Seizure
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i
Muscle stiffness - rigidity
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which

29. Atonic Seizure
Whiplash - shaken baby
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A client has been pronounced brain dead. Which findings would the nurse assess?

30. Back arched; rigid extension of all four extremities.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which of the following describes decerebrate posturing?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?

31. Rapid dilantin administration can cause cardiac arrhythmias
A client has been pronounced brain dead. Which findings would the nurse assess?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

32. Clonic Seizure
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

33. Encourage the client to hyperventilate
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

34. Check the fluid for dextrose with a dipstick
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
Whiplash - shaken baby
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us

35. Reposition the client to avoid neck flexion
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
Which of the following describes decerebrate posturing?

36. Limiting bladder catherization to once every 12 hours
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i
A client has been pronounced brain dead. Which findings would the nurse assess?
A client 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?

37. Put the client in the high - Fowler's position
Meningies - csf - blood - brain barrier - skull
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

38. Equal pupillary constriction in response to light
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
Head is suddenly forced to stop or start moving - or to turn rapidly.
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

39. Noxious stimuli
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Which of the following describes decerebrate posturing?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

40. deceleration injury
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Collision between a rapidly moving body part and a stationary object

41. Immobilize the client's head and neck

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42. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

43. Epidural hematoma
Vitals/turn freq/call light close/ ROM
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i

44. Dilated non reactive pupils
Head is suddenly forced to stop or start moving - or to turn rapidly.
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A client has been pronounced brain dead. Which findings would the nurse assess?

45. Hyperflexion injuries
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Whiplash - shaken baby
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

46. Depressed skull fractures
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A client 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?
High - energy transfer - such as a blow from a baseball bat
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i

47. Artificial tears
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

48. Damage to cranial nerve I
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A client 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 client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

49. Myoclonic Seizure
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

50. A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a 'blown pupil' (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disrup
CN III
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

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NCLEX Neuro

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