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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. Slow - irregular respirations
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 respiratory patterns indicate increasing ICP in the brain stem?
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?
High - energy transfer - such as a blow from a baseball bat

2. 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
High - energy transfer - such as a blow from a baseball bat
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

3. Absence Seizure
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
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?
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?

4. Tonic Seizure
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?
Muscle stiffness - rigidity
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

5. Epidural hematoma
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

6. Clonic Seizure
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
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

7. Atonic Seizure
CN III
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

8. deceleration injury
Collision between a rapidly moving body part and a stationary object
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
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

9. Unequal pupil size
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

10. Put the client in the high - Fowler's position
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

11. 'Wake him every hour and assess his orientation to person - time - and place
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 neurotransmitter is responsible for may of the functions of the frontal lobe?

12. A client with a high cervical spine injury
Muscle stiffness - rigidity
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
are produced by electrical impulses from throughout the entire 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

13. Inability to elicit a Babinski's reflex
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 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?

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

15. Reposition the client to avoid neck flexion
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 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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

16. Back arched; rigid extension of all four extremities.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Which of the following describes decerebrate posturing?

17. Limiting bladder catherization to once every 12 hours
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?
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.

18. acceleration 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
Blunt trauma
Head is suddenly forced to stop or start moving - or to turn rapidly.
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

19. Encouraging compliance with drug therapy to prevent loss of vision
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 with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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

20. Quadriplegia with gross arm movement and diaphragmic breathing

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21. Linear 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 patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Blunt trauma

22. Wrap her hands in soft 'mitten' restraints
Blunt trauma
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?
Unconsciousness - convulsions - muscle rigidity

23. Depressed skull fractures
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

24. Damage to cranial nerve 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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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
Which of the following describes decerebrate posturing?

25. Myoclonic Seizure
Meningies - csf - blood - brain barrier - skull
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

26. Laceration of the middle meningeal artery
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

27. Dopamine
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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

28. Epidural hematoma
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
High - energy transfer - such as a blow from a baseball bat
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 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

29. Subdural hemorrhage
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?
Unconsciousness - convulsions - muscle rigidity

30. 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.
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 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?
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.

31. 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
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
Blunt trauma
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?

32. Decrease in LOC

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33. 'The lens is normally transparent
Vitals/turn freq/call light close/ ROM
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?

34. Check the fluid for dextrose with a dipstick
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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 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 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?

35. 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?

36. Hyperflexion injuries
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 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?
Whiplash - shaken baby
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

37. Noxious stimuli
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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

38. To immobilize the surgical spine
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?
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?

39. Equal pupillary constriction in response to light
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?
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?
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?
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

40. Immobilize the client's head and neck

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41. 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.
Which of the following describes decerebrate posturing?
High - energy transfer - such as a blow from a baseball bat
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?

42. 4 things that protect the brain
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?
Meningies - csf - blood - brain barrier - skull
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

43. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
High - energy transfer - such as a blow from a baseball bat
Muscle stiffness - 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

44. Activity of the brain
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?
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

45. 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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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. Encourage the client to hyperventilate
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
High - energy transfer - such as a blow from a baseball bat
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

47. Generalized seizures
Unconsciousness - convulsions - muscle rigidity
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
are produced by electrical impulses from throughout the entire brain

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

49. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Whiplash - shaken baby
Collision between a rapidly moving body part and a stationary object
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

50. generalized and partial (also called local or focal)
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 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?
Seizures are divided into two broad categories: