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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.
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. 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
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
CN III
Which of the following physiologic changes would be expected in a patient with presbyopia?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

2. Artificial tears
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
are produced by electrical impulses from throughout the entire brain
Which of the following physiologic changes would be expected in a patient with presbyopia?
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.

3. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A client has been pronounced brain dead. Which findings would the nurse assess?

4. Check the fluid for dextrose with a dipstick
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
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?

5. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Seizures are divided into two broad categories:
Whiplash - shaken baby
Meningies - csf - blood - brain barrier - skull

6. Loss of lens elasticity
Whiplash - shaken baby
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following physiologic changes would be expected in a patient with presbyopia?

7. Wrap her hands in soft 'mitten' restraints
High - energy transfer - such as a blow from a baseball bat
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
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

8. Damage to cranial nerve I
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause 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

9. Slow - irregular respirations
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?

10. The patient should be placed on droplet precautions.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?
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.

11. nsg intervention for spinal injury
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?
Vitals/turn freq/call light close/ ROM
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Blunt trauma

12. Subdural hemorrhage
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Gap between the dura and the cortical surface of the brain.

13. 'The lens is normally transparent
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Seizures are divided into two broad categories:
Gap between the dura and the cortical surface of the brain.

14. 'Wake him every hour and assess his orientation to person - time - and place
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Unconsciousness - convulsions - muscle rigidity
High - energy transfer - such as a blow from a baseball bat
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?

15. Encouraging compliance with drug therapy to prevent loss of vision
Muscle stiffness - rigidity
Unconsciousness - convulsions - muscle rigidity
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
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?

16. Depressed skull fractures
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 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?
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

17. A client with a high cervical spine injury
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Unconsciousness - convulsions - muscle rigidity
A client has been pronounced brain dead. Which findings would the nurse assess?

18. Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?

19. 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 who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A patient 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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

20. Equal pupillary constriction in response to light
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

21. Dilated non reactive pupils
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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.

22. Unequal pupil size
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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

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

24. acceleration injury
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 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.
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

25. Decorticate
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Head is suddenly forced to stop or start moving - or to turn rapidly.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

26. Reposition the client to avoid neck flexion
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Blunt trauma
CN III

27. Quadriplegia with gross arm movement and diaphragmic breathing

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28. Hypogeusia
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
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?

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

30. Atonic Seizure
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

31. Immobilize the client's head and neck

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32. CN IX and CN VII
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?
Whiplash - shaken baby

33. Noxious stimuli
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause 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
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

34. 4 things that protect 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
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
Meningies - csf - blood - brain barrier - skull
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?

35. Rapid dilantin administration can cause cardiac arrhythmias
Collision between a rapidly moving body part and a stationary object
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?
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

36. Parkinson's disease
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
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.
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

37. Laceration of the middle meningeal artery
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?
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 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 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?

38. 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
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?
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

39. Raise the head of the bed immediately to 90 degrees
Gap between the dura and the cortical surface of 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?
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?
High - energy transfer - such as a blow from a baseball bat

40. Evaluate urine specific gravity
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Gap between the dura and the cortical surface of the brain.
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Head is suddenly forced to stop or start moving - or to turn rapidly.

41. 'Grand Mal' or Generalized tonic - clonic
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
Unconsciousness - convulsions - muscle rigidity
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

42. Activity of the brain
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
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
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

43. To immobilize the surgical spine
Gap between the dura and the cortical surface of the brain.
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?

44. Decrease in LOC

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45. Generalized seizures
are produced by electrical impulses from throughout the entire brain
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 working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

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

47. Linear skull fractures
Blunt trauma
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.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?

48. Myoclonic Seizure
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

49. Put the client in the high - Fowler's position
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 neurotransmitter is responsible for may of the functions of the frontal lobe?

50. partial seizures
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
Which of the following describes decerebrate posturing?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

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