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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. Generalized seizures
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
are produced by electrical impulses from throughout the entire brain

2. deceleration injury
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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
Collision between a rapidly moving body part and a stationary object
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?

3. Immobilize the client's head and neck
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?
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?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

4. Epidural hematoma
Collision between a rapidly moving body part and a stationary object
Muscle stiffness - rigidity
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

5. generalized and partial (also called local or focal)
Vitals/turn freq/call light close/ ROM
Head is suddenly forced to stop or start moving - or to turn rapidly.
Seizures are divided into two broad categories:
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

6. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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
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?

7. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Gap between the dura and the cortical surface of the brain.
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
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?

8. 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
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented

9. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
Collision between a rapidly moving body part and a stationary object
Unconsciousness - convulsions - muscle rigidity
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

10. 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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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

11. Intracranial hemorrhages
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
CN III
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

12. acceleration injury
Collision between a rapidly moving body part and a stationary object
Blunt trauma
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Head is suddenly forced to stop or start moving - or to turn rapidly.

13. Hyperflexion injuries
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Whiplash - shaken baby
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

14. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?

15. 'The lens is normally transparent
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.
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
Collision between a rapidly moving body part and a stationary object

16. Depressed skull fractures
Which of the following physiologic changes would be expected in a patient with presbyopia?
Whiplash - shaken baby
High - energy transfer - such as a blow from a baseball bat
Blunt trauma

17. Encourage the client to hyperventilate
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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.

18. Linear skull fractures
Blunt trauma
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

19. Limiting bladder catherization to once every 12 hours
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 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 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?
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.

20. Evaluate urine specific gravity
Seizures are divided into two broad categories:
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?
High - energy transfer - such as a blow from a baseball bat
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

21. Back arched; rigid extension of all four extremities.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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
Which of the following describes decerebrate posturing?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

22. CN IX and CN VII
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?

23. Activity of the brain
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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 by electrical impulses from throughout the entire brain

24. Parkinson's disease
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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
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:

25. Atonic Seizure
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?
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 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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

26. Dilated non reactive pupils
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 neurotransmitter is responsible for may of the functions of the frontal lobe?
A client has been pronounced brain dead. Which findings would the nurse assess?

27. Laceration of the middle meningeal artery
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
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

28. Myoclonic Seizure
Unconsciousness - convulsions - muscle rigidity
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.
Vitals/turn freq/call light close/ ROM
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

29. 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?
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?
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
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?

30. Unequal pupil size
Which of the following describes decerebrate posturing?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?

31. Slow - irregular respirations
CN III
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

32. Equal pupillary constriction in response to light
Gap between the dura and the cortical surface of the brain.
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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.

33. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
Gap between the dura and the cortical surface of the brain.
Muscle stiffness - rigidity
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?

34. Basilar skull fractures
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
CN III
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
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

35. Wrap her hands in soft 'mitten' restraints
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 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 client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

36. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 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

37. To immobilize the surgical spine
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?
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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

38. Tonic Seizure
Muscle stiffness - rigidity
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
High - energy transfer - such as a blow from a baseball bat
A client has been pronounced brain dead. Which findings would the nurse assess?

39. Decorticate
are produced by electrical impulses from throughout the entire brain
Seizures are divided into two broad categories:
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?

40. Encouraging compliance with drug therapy to prevent loss of vision
Seizures are divided into two broad categories:
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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:

41. 4 things that protect the brain
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Meningies - csf - blood - brain barrier - skull

42. Inability to elicit a Babinski's reflex
Meningies - csf - blood - brain barrier - skull
Muscle stiffness - rigidity
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?
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?

43. Artificial tears
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?

44. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?
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

45. Reposition the client to avoid neck flexion
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?

46. Put the client in the high - Fowler's position
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?
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

47. Dopamine
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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?

48. '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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

49. Subdural hemorrhage
Gap between the dura and the cortical surface of the brain.
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

50. Epidural hematoma
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 been pronounced brain dead. Which findings would the nurse assess?

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