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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. Decorticate
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Seizures are divided into two broad categories:
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?

2. Limiting bladder catherization to once every 12 hours
Collision between a rapidly moving body part and a stationary object
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
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

3. Tonic Seizure
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Muscle stiffness - rigidity
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?

4. 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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

5. 4 things that protect the brain
Which of the following physiologic changes would be expected in a patient with presbyopia?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Meningies - csf - blood - brain barrier - skull
Blunt trauma

6. Encourage the client to hyperventilate
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?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

7. acceleration injury
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
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Head is suddenly forced to stop or start moving - or to turn rapidly.

8. Laceration of the middle meningeal artery
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
CN III
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?

9. 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
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Blunt trauma
Unconsciousness - convulsions - muscle rigidity

10. deceleration injury
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?
Collision between a rapidly moving body part and a stationary object
CN III

11. Damage to cranial nerve I
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?
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
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

12. Inability to elicit a Babinski's reflex
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 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 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
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?

13. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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.

14. 'The lens is normally transparent
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
High - energy transfer - such as a blow from a baseball bat
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

15. Raise the head of the bed immediately to 90 degrees
Collision between a rapidly moving body part and a stationary object
Seizures are divided into two broad categories:
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

16. Back arched; rigid extension of all four extremities.
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?
Muscle stiffness - rigidity
Which of the following describes decerebrate posturing?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

17. 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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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.

18. Dopamine
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?
are produced by electrical impulses from throughout the entire brain
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

19. Put the client in the high - Fowler's position
Meningies - csf - blood - brain barrier - skull
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Collision between a rapidly moving body part and a stationary object
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

20. Hyperflexion injuries
Whiplash - shaken baby
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?

21. Basilar skull fractures
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 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
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

22. Depressed skull fractures
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Muscle stiffness - rigidity
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?
High - energy transfer - such as a blow from a baseball bat

23. To immobilize the surgical spine
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?
Gap between the dura and the cortical surface of the brain.
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?

24. 'Grand Mal' or Generalized tonic - clonic
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Unconsciousness - convulsions - muscle 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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

25. 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 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?

26. Check the fluid for dextrose with a dipstick
A client has been pronounced brain dead. Which findings would the nurse assess?
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
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?

27. Equal pupillary constriction in response to light
Gap between the dura and the cortical surface of the 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?

28. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

29. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Collision between a rapidly moving body part and a stationary object
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

30. Artificial tears
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Gap between the dura and the cortical surface 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?
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?

31. Evaluate urine specific gravity
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?
Muscle stiffness - rigidity
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?

32. Loss of lens elasticity
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

33. CN IX and CN VII
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

34. Decrease in LOC
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
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

35. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?
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.

36. Atonic Seizure
Collision between a rapidly moving body part and a stationary object
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Seizures are divided into two broad categories:
A client has been pronounced brain dead. Which findings would the nurse assess?

37. Intracranial hemorrhages
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Meningies - csf - blood - brain barrier - skull

38. 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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

39. Epidural hematoma
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
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?
Collision between a rapidly moving body part and a stationary object

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

41. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?
Collision between a rapidly moving body part and a stationary object

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

43. Quadriplegia with gross arm movement and diaphragmic breathing
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Whiplash - shaken baby
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
High - energy transfer - such as a blow from a baseball bat

44. Generalized seizures
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following describes decerebrate posturing?
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?
are produced by electrical impulses from throughout the entire brain

45. Hypogeusia
are produced by electrical impulses from throughout the entire brain
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

46. 'Wake him every hour and assess his orientation to person - time - and place
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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.

47. Linear skull fractures
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 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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Blunt trauma

48. Encouraging compliance with drug therapy to prevent loss of vision
Whiplash - shaken baby
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 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 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:

49. Rapid dilantin administration can cause cardiac arrhythmias
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?
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?
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.

50. Clonic Seizure
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
are produced by electrical impulses from throughout the entire brain
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?

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