Test your basic knowledge |

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. Back arched; rigid extension of all four extremities.
CN III
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 describes decerebrate posturing?
Vitals/turn freq/call light close/ ROM

2. 4 things that protect the brain
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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

3. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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
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?

4. 'Grand Mal' or Generalized tonic - clonic
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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
Unconsciousness - convulsions - muscle 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

5. Subdural hemorrhage
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Collision between a rapidly moving body part and a stationary object
Gap between the dura and the cortical surface of the brain.
CN III

6. Absence 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?
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
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?

7. Dopamine
Collision between a rapidly moving body part and a stationary object
are produced by electrical impulses from throughout the entire brain
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

8. The patient should be placed on droplet precautions.
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
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
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. Hyperflexion injuries
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Muscle stiffness - rigidity
Collision between a rapidly moving body part and a stationary object
Whiplash - shaken baby

10. Dilated non reactive pupils
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?
A client has been pronounced brain dead. Which findings would the nurse assess?
Blunt trauma

11. Intracranial hemorrhages
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Unconsciousness - convulsions - muscle rigidity

12. 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?
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Unconsciousness - convulsions - muscle rigidity

13. Limiting bladder catherization to once every 12 hours
Blunt trauma
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?

14. To immobilize the surgical spine
Meningies - csf - blood - brain barrier - skull
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Muscle stiffness - rigidity

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

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.
Unconsciousness - convulsions - muscle rigidity
High - energy transfer - such as a blow from a baseball bat
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?

17. 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.
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?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

18. Linear skull fractures
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Blunt trauma
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

19. Generalized seizures
are produced by electrical impulses from throughout the entire brain
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
A 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
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

20. Encourage the client to hyperventilate
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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
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. Inability to elicit a Babinski's reflex
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Vitals/turn freq/call light close/ ROM
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?

22. Laceration of the middle meningeal artery
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

23. Put the client in the high - Fowler's position
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?
are produced by electrical impulses from throughout the entire brain

24. Epidural hematoma
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 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?
Gap between the dura and the cortical surface of the brain.
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?

25. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

26. Reposition the client to avoid neck flexion
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?
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.

27. 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
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?

28. 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
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?
Which of the following describes decerebrate posturing?
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?

29. Noxious stimuli
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Blunt trauma
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.

30. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Seizures are divided into two broad categories:
Which of the following describes decerebrate posturing?
Unconsciousness - convulsions - muscle rigidity

31. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Which of the following describes decerebrate posturing?

32. Basilar skull fractures
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 client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 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. Damage to cranial nerve I
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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 has a normal sensory change that results in diminished sense of taste. How would this be documented

34. Equal pupillary constriction in response to light
Whiplash - shaken baby
A client has been pronounced brain dead. Which findings would the nurse assess?
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.
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?

35. Slow - irregular respirations
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 respiratory patterns indicate increasing ICP in the brain stem?
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

36. Decrease in LOC

37. A client with a high cervical spine injury
Blunt trauma
are produced by electrical impulses from throughout the entire brain
Which of the following clients on the rehab unit is most likely to develop 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

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

39. Immobilize the client's head and neck

40. Evaluate urine specific gravity
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 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?
Gap between the dura and the cortical surface of the brain.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

41. Encouraging compliance with drug therapy to prevent loss of vision
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:
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

42. Artificial tears
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Whiplash - shaken baby
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

43. Loss of lens elasticity
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 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 physiologic changes would be expected in a patient with presbyopia?

44. Quadriplegia with gross arm movement and diaphragmic breathing

45. 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
CN III
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:

46. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part of the 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 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?
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. Decorticate
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
CN III
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

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

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

50. deceleration injury
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Collision between a rapidly moving body part and a stationary object