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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. Basilar skull fractures
Vitals/turn freq/call light close/ ROM
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

2. Epidural hematoma
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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?
Muscle stiffness - rigidity

3. Linear skull fractures
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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
Blunt trauma

4. 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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following describes decerebrate posturing?
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?
CN III

5. Check the fluid for dextrose with a dipstick
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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 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?

6. CN IX and CN VII
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

7. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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 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?
Muscle stiffness - rigidity
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

8. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Muscle stiffness - rigidity

9. Artificial tears
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

10. Back arched; rigid extension of all four extremities.
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 describes decerebrate posturing?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?

11. Intracranial hemorrhages
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Vitals/turn freq/call light close/ ROM
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?
Muscle stiffness - rigidity

12. Loss of lens elasticity
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
Vitals/turn freq/call light close/ ROM
Which of the following physiologic changes would be expected in a patient with presbyopia?
High - energy transfer - such as a blow from a baseball bat

13. Hyperflexion injuries
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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
Whiplash - shaken baby
Seizures are divided into two broad categories:

14. Immobilize the client's head and neck

15. Hypogeusia
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.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

16. Raise the head of the bed immediately to 90 degrees
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
Blunt trauma
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?

17. Atonic Seizure
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?

18. Evaluate urine specific gravity
are produced by electrical impulses from throughout the entire brain
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?
CN III
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

19. Quadriplegia with gross arm movement and diaphragmic breathing

20. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

21. Rapid dilantin administration can cause cardiac arrhythmias
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Blunt trauma
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

22. Tonic Seizure
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Which of the following describes decerebrate posturing?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Muscle stiffness - rigidity

23. A client with a high cervical spine injury
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Seizures are divided into two broad categories:
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

24. Limiting bladder catherization to once every 12 hours
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.
Unconsciousness - convulsions - muscle rigidity
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?

25. Dopamine
High - energy transfer - such as a blow from a baseball bat
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

26. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Meningies - csf - blood - brain barrier - skull
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

27. Reposition the client to avoid neck flexion
Seizures are divided into two broad categories:
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?
Gap between the dura and the cortical surface 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

28. Wrap her hands in soft 'mitten' restraints
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?

29. The patient should be placed on droplet precautions.
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?
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.
Vitals/turn freq/call light close/ ROM
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

30. Put the client in the high - Fowler's position
High - energy transfer - such as a blow from a baseball bat
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

31. To immobilize the surgical spine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?
Seizures are divided into two broad categories:

32. nsg intervention for spinal injury
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
Vitals/turn freq/call light close/ ROM
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?
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?

33. Noxious stimuli
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 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:
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

34. deceleration injury
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
High - energy transfer - such as a blow from a baseball bat
Collision between a rapidly moving body part and a stationary object
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

35. Generalized seizures
are produced by electrical impulses from throughout the entire brain
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

36. Dilated non reactive pupils
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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
are produced by electrical impulses from throughout the entire brain
A client has been pronounced brain dead. Which findings would the nurse assess?

37. 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.
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

38. Activity of the brain
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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 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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

39. Encourage the client to hyperventilate
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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
Collision between a rapidly moving body part and a stationary object
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

40. Depressed skull fractures
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 respiratory patterns indicate increasing ICP in the brain stem?
Head is suddenly forced to stop or start moving - or to turn rapidly.
High - energy transfer - such as a blow from a baseball bat

41. Subdural hemorrhage
are produced by electrical impulses from throughout the entire brain
Gap between the dura and the cortical surface of the brain.
Blunt trauma
High - energy transfer - such as a blow from a baseball bat

42. Decrease in LOC

43. Laceration of the middle meningeal artery
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
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

44. 'Wake him every hour and assess his orientation to person - time - and place
Which of the following describes decerebrate posturing?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?

45. Myoclonic Seizure
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?
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?
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.
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.

46. Inability to elicit a Babinski's reflex
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
Whiplash - shaken baby
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

47. acceleration injury
Blunt trauma
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.
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

48. Slow - irregular respirations
Seizures are divided into two broad categories:
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

49. Unequal pupil size
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?

50. Parkinson's disease
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 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?
Collision between a rapidly moving body part and a stationary object