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. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Meningies - csf - blood - brain barrier - skull

2. Dilated non reactive pupils
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 has been pronounced brain dead. Which findings would the nurse assess?
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented

3. deceleration injury
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 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
Head is suddenly forced to stop or start moving - or to turn rapidly.
Collision between a rapidly moving body part and a stationary object

4. Encouraging compliance with drug therapy to prevent loss of vision
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:
Whiplash - shaken baby
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

5. Decrease in LOC

6. Generalized seizures
are produced by electrical impulses from throughout the entire brain
CN III
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

7. A client with a high cervical spine injury
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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

8. Linear skull fractures
Blunt trauma
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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

9. 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
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?
CN III
Collision between a rapidly moving body part and a stationary object

10. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Blunt trauma
Meningies - csf - blood - brain barrier - skull
Head is suddenly forced to stop or start moving - or to turn rapidly.

11. Decorticate
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
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 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?

12. Epidural hematoma
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?
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 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?

13. Reposition the client to avoid neck flexion
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?
Vitals/turn freq/call light close/ ROM
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?

14. Damage to cranial nerve I
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Whiplash - shaken baby
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

15. Intracranial hemorrhages
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
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?

16. Equal pupillary constriction in response to light
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Unconsciousness - convulsions - muscle rigidity
Gap between the dura and the cortical surface of the brain.

17. Slow - irregular respirations
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 respiratory patterns indicate increasing ICP in the brain stem?
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

18. Dopamine
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
CN III
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

19. Myoclonic Seizure
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
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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.

20. Hyperflexion injuries
Whiplash - shaken baby
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?
Vitals/turn freq/call light close/ ROM

21. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?
Seizures are divided into two broad categories:
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

22. Evaluate urine specific gravity
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 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 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?
CN III

23. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
Gap between the dura and the cortical surface of the brain.
Whiplash - shaken baby
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

24. Rapid dilantin administration can cause cardiac arrhythmias
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 respiratory patterns indicate increasing ICP in the brain stem?
CN III
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. Put the client in the high - Fowler's position
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?

26. Wrap her hands in soft 'mitten' restraints
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?
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 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?
High - energy transfer - such as a blow from a baseball bat

27. Quadriplegia with gross arm movement and diaphragmic breathing

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

29. Artificial tears
Which of the following physiologic changes would be expected in a patient with presbyopia?
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Muscle stiffness - rigidity

30. Unequal pupil size
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

31. 'Wake him every hour and assess his orientation to person - time - and place
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
CN III
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

32. 4 things that protect the brain
Which of the following describes decerebrate posturing?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Meningies - csf - blood - brain barrier - skull
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. To immobilize the surgical spine
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?
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?

34. Immobilize the client's head and neck

35. The patient should be placed on droplet precautions.
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.
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented

36. CN IX and CN VII
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.
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

37. Epidural hematoma
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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?

38. Raise the head of the bed immediately to 90 degrees
Blunt trauma
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 client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

39. Atonic 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
are produced by electrical impulses from throughout the entire brain
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?

40. acceleration injury
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Gap between the dura and the cortical surface of the brain.

41. Limiting bladder catherization to once every 12 hours
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

42. Laceration of the middle meningeal artery
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?

43. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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.
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 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

44. Loss of lens elasticity
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
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

45. Inability to elicit a Babinski's reflex
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

46. 'The lens is normally transparent
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 question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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

47. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
Muscle stiffness - rigidity
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

48. Basilar skull fractures
Blunt trauma
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 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 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?

49. Clonic Seizure
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 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.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

50. Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
Head is suddenly forced to stop or start moving - or to turn rapidly.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?