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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. Absence Seizure
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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
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?
Muscle stiffness - rigidity

2. Subdural hemorrhage
Seizures are divided into two broad categories:
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
Gap between the dura and the cortical surface of the brain.

3. Epidural hematoma
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?
Blunt trauma
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
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?

4. Hyperflexion injuries
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 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 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?
Whiplash - shaken baby

5. Basilar skull fractures
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 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?
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

6. Encourage the client to hyperventilate
Which of the following physiologic changes would be expected in a patient with presbyopia?
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
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

7. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

8. 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?
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

9. 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?
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 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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

10. Decrease in LOC

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11. Quadriplegia with gross arm movement and diaphragmic breathing

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12. Parkinson's disease
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?
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 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

13. 'The lens is normally transparent
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:
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
are produced by electrical impulses from throughout the entire brain

14. Inability to elicit a Babinski's reflex
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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 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?
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. Back arched; rigid extension of all four extremities.
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?
Which of the following describes decerebrate posturing?
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.

16. The patient should be placed on droplet precautions.
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Unconsciousness - convulsions - muscle rigidity
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

17. Unequal pupil size
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?
Gap between the dura and the cortical surface of the brain.
Unconsciousness - convulsions - muscle rigidity
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

18. Clonic Seizure
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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
Unconsciousness - convulsions - muscle rigidity

19. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?
Gap between the dura and the cortical surface of the brain.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

20. 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?
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.
are produced by electrical impulses from throughout the entire brain
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

21. partial seizures
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 been pronounced brain dead. Which findings would the nurse assess?
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.

22. Atonic Seizure
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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. Immobilize the client's head and neck

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24. Epidural hematoma
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 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?
Which of the following describes decerebrate posturing?

25. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
CN III

26. Dopamine
Vitals/turn freq/call light close/ ROM
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?

27. Equal pupillary constriction in response to light
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?
Seizures are divided into two broad categories:
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

28. Encouraging compliance with drug therapy to prevent loss of vision
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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?

29. A client with a high cervical spine injury
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
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
Seizures are divided into two broad categories:

30. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?
Seizures are divided into two broad categories:

31. 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?
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 subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
Meningies - csf - blood - brain barrier - skull

32. Depressed skull fractures
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
High - energy transfer - such as a blow from a baseball bat
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?

33. deceleration injury
Collision between a rapidly moving body part and a stationary object
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Whiplash - shaken baby

34. Tonic Seizure
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Head is suddenly forced to stop or start moving - or to turn rapidly.
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Muscle stiffness - rigidity

35. Myoclonic Seizure
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:
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
CN III
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.

36. To immobilize the surgical spine
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

37. Limiting bladder catherization to once every 12 hours
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 has been pronounced brain dead. Which findings would the nurse assess?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

38. 4 things that protect the brain
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?
Meningies - csf - blood - brain barrier - skull

39. Check the fluid for dextrose with a dipstick
Muscle stiffness - rigidity
Gap between the dura and the cortical surface of the brain.
A client has been pronounced brain dead. Which findings would the nurse assess?
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?

40. Damage to cranial nerve I
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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
CN III

41. Laceration of the middle meningeal artery
Which of the following physiologic changes would be expected in a patient with presbyopia?
Seizures are divided into two broad categories:
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

42. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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
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 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?
Gap between the dura and the cortical surface of the brain.

43. '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 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
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 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?

44. 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.
Blunt trauma
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?

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

46. Evaluate urine specific gravity
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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 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?
Vitals/turn freq/call light close/ ROM

47. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
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?
Whiplash - shaken baby
Blunt trauma

48. Slow - irregular respirations
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
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 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?

49. 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
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?
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

50. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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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