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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. Basilar skull fractures
Meningies - csf - blood - brain barrier - skull
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
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?

2. Artificial tears
Meningies - csf - blood - brain barrier - skull
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?

3. Parkinson's disease
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
CN III
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

4. generalized and partial (also called local or focal)
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Seizures are divided into two broad categories:
Which of the following physiologic changes would be expected in a patient with presbyopia?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

5. Evaluate urine specific gravity
Vitals/turn freq/call light close/ ROM
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
CN III

6. Rapid dilantin administration can cause cardiac arrhythmias
Vitals/turn freq/call light close/ ROM
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 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?

7. Immobilize the client's head and neck
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 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 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?

8. A client with a high cervical spine injury
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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.

9. nsg intervention for spinal injury
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
Muscle stiffness - rigidity
Vitals/turn freq/call light close/ ROM
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?

10. To immobilize the surgical spine
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

11. 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
A client has been pronounced brain dead. Which findings would the nurse assess?
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?

12. Back arched; rigid extension of all four extremities.
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 describes decerebrate posturing?
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 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?

13. Quadriplegia with gross arm movement and diaphragmic breathing
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
CN III
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?

14. Put the client in the high - Fowler's position
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?
Whiplash - shaken baby
Gap between the dura and the cortical surface of the brain.

15. Activity of the brain
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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
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.

16. Decorticate
Meningies - csf - blood - brain barrier - skull
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

17. Intracranial hemorrhages
Seizures are divided into two broad categories:
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following describes decerebrate posturing?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

18. Atonic Seizure
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 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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

19. 'Grand Mal' or Generalized tonic - clonic
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Unconsciousness - convulsions - muscle rigidity

20. Check the fluid for dextrose with a dipstick
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?
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
Seizures are divided into two broad categories:

21. 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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

22. Slow - irregular respirations
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 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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

23. Encourage the client to hyperventilate
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?
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 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:

24. Epidural hematoma
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Unconsciousness - convulsions - muscle rigidity
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 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?

25. Unequal pupil size
Seizures are divided into two broad categories:
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A client has been pronounced brain dead. Which findings would the nurse assess?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

26. Encouraging compliance with drug therapy to prevent loss of vision
Unconsciousness - convulsions - muscle rigidity
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:
Head is suddenly forced to stop or start moving - or to turn rapidly.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

27. partial seizures
CN III
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
are produced by electrical impulses from throughout the entire brain

28. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Unconsciousness - convulsions - muscle rigidity
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

29. 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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Which of the following describes decerebrate posturing?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

30. acceleration injury
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
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?

31. Myoclonic Seizure
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?
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.
Whiplash - shaken baby
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

32. 'Wake him every hour and assess his orientation to person - time - and place
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 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?

33. Absence Seizure
are produced by electrical impulses from throughout the entire brain
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

34. Wrap her hands in soft 'mitten' restraints
CN III
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?

35. Hyperflexion injuries
A client has been pronounced brain dead. Which findings would the nurse assess?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Whiplash - shaken baby
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

36. Epidural hematoma
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
CN III
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

37. 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
Vitals/turn freq/call light close/ ROM
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
CN III
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

38. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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
Collision between a rapidly moving body part and a stationary object

39. deceleration injury
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?
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
Collision between a rapidly moving body part and a stationary object

40. Tonic Seizure
Which of the following describes decerebrate posturing?
Muscle stiffness - rigidity
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 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?

41. 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 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?
Unconsciousness - convulsions - muscle rigidity
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

42. Generalized seizures
Collision between a rapidly moving body part and a stationary object
are produced by electrical impulses from throughout the entire brain
Gap between the dura and the cortical surface of the brain.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

43. Reposition the client to avoid neck flexion
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 describes decerebrate posturing?
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?
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.

44. Decrease in LOC
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 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 client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

45. The patient should be placed on droplet precautions.
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?
Which of the following clients on the rehab unit is most likely to develop 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
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.

46. Equal pupillary constriction in response to light
Seizures are divided into two broad categories:
Meningies - csf - blood - brain barrier - skull
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?
Collision between a rapidly moving body part and a stationary object

47. Hypogeusia
Whiplash - shaken baby
Blunt trauma
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

48. Dopamine
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?
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.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

49. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

50. 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?
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 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:

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