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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. Encouraging compliance with drug therapy to prevent loss of vision
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?
High - energy transfer - such as a blow from a baseball bat
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:

2. Laceration of the middle meningeal artery
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
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 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?

3. Decrease in LOC

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4. '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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

5. Subdural hemorrhage
CN III
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause 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
Gap between the dura and the cortical surface of the brain.

6. acceleration injury
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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
Head is suddenly forced to stop or start moving - or to turn rapidly.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

7. Decorticate
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following describes decerebrate posturing?

8. Depressed skull fractures
Unconsciousness - convulsions - muscle rigidity
High - energy transfer - such as a blow from a baseball bat
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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

9. deceleration injury
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Collision between a rapidly moving body part and a stationary object
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which of the following physiologic changes would be expected in a patient with presbyopia?

10. Damage to cranial nerve I
Blunt trauma
Which of the following describes decerebrate posturing?
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

11. Generalized seizures
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 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?
are produced by electrical impulses from throughout the entire brain
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

12. Back arched; rigid extension of all four extremities.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Which of the following describes decerebrate posturing?
are produced by electrical impulses from throughout the entire brain
Which of the following physiologic changes would be expected in a patient with presbyopia?

13. To immobilize the surgical spine
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Muscle stiffness - rigidity
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?

14. Inability to elicit a Babinski's reflex
Whiplash - shaken baby
Which of the following describes decerebrate posturing?
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.
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?

15. Slow - irregular respirations
Blunt trauma
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?
are produced by electrical impulses from throughout the entire brain
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

16. 'Grand Mal' or Generalized tonic - clonic
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 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
High - energy transfer - such as a blow from a baseball bat
Unconsciousness - convulsions - muscle rigidity

17. Intracranial hemorrhages
High - energy transfer - such as a blow from a baseball bat
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Unconsciousness - convulsions - muscle rigidity

18. Check the fluid for dextrose with a dipstick
Blunt trauma
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
are produced by electrical impulses from throughout the entire brain
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?

19. 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.
Unconsciousness - convulsions - muscle rigidity
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?

20. Reposition the client to avoid neck flexion
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
CN III
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?
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?

21. Epidural hematoma
Whiplash - shaken baby
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 signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

22. Rapid dilantin administration can cause cardiac arrhythmias
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 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.
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?

23. Noxious stimuli
Gap between the dura and the cortical surface of 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.
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

24. A client with a high cervical spine injury
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?
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

25. Wrap her hands in soft 'mitten' restraints
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

26. Equal pupillary constriction in response to light
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Whiplash - shaken baby
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?

27. 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?
are produced by electrical impulses from throughout the entire brain
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 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?

28. 'The lens is normally transparent
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Whiplash - shaken baby
Unconsciousness - convulsions - muscle rigidity
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

29. nsg intervention for spinal injury
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?
Vitals/turn freq/call light close/ ROM
Head is suddenly forced to stop or start moving - or to turn rapidly.

30. Tonic Seizure
are produced by electrical impulses from throughout the entire brain
Muscle stiffness - rigidity
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Meningies - csf - blood - brain barrier - skull

31. Immobilize the client's head and neck

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32. Activity of the brain
Whiplash - shaken baby
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 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?
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?

33. generalized and partial (also called local or focal)
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following describes decerebrate posturing?
Seizures are divided into two broad categories:
A client has been pronounced brain dead. Which findings would the nurse assess?

34. Encourage the client to hyperventilate
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 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?
Meningies - csf - blood - brain barrier - skull
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

35. Loss of lens elasticity
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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
Which of the following physiologic changes would be expected in a patient with presbyopia?

36. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Unconsciousness - convulsions - muscle rigidity

37. partial seizures
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
CN III

38. Unequal pupil size
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

39. Absence Seizure
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
Which of the following physiologic changes would be expected in a patient with presbyopia?
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

40. Hyperflexion injuries
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Whiplash - shaken baby

41. Artificial tears
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?
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 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

42. The patient should be placed on droplet precautions.
High - energy transfer - such as a blow from a baseball bat
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.
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

43. Dopamine
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 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 subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

44. Linear skull fractures
Which of the following describes decerebrate posturing?
Blunt trauma
Collision between a rapidly moving body part and a stationary object
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

45. 4 things that protect the brain
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Meningies - csf - blood - brain barrier - skull
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?

46. 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?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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

47. Quadriplegia with gross arm movement and diaphragmic breathing

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48. Dilated non reactive pupils
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?
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?

49. Basilar skull fractures
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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 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?

50. Atonic Seizure
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?

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