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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. Evaluate urine specific gravity
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Unconsciousness - convulsions - muscle rigidity
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

2. Slow - irregular respirations
Collision between a rapidly moving body part and a stationary object
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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.
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?

3. 'Grand Mal' or Generalized tonic - clonic
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?
Gap between the dura and the cortical surface of the brain.
Unconsciousness - convulsions - muscle rigidity

4. Tonic Seizure
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
Muscle stiffness - rigidity

5. partial seizures
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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
CN III

6. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 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 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?

7. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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
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 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 a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

8. deceleration injury
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Collision between a rapidly moving body part and a stationary object
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?

9. Encourage the client to hyperventilate
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Vitals/turn freq/call light close/ ROM
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?

10. Back arched; rigid extension of all four extremities.
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.
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
Which of the following describes decerebrate posturing?
Muscle stiffness - rigidity

11. Epidural hematoma
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 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?
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?

12. Activity of the brain
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?
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

13. Quadriplegia with gross arm movement and diaphragmic breathing

14. Artificial tears
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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?

15. Reposition the client to avoid neck flexion
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 client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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.

16. 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?
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?

17. 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
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
CN III
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?

18. Dilated non reactive pupils
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A client has been pronounced brain dead. Which findings would the nurse assess?
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

19. 'Wake him every hour and assess his orientation to person - time - and place
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?
Blunt trauma
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
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

20. Put the client in the high - Fowler's position
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 respiratory patterns indicate increasing ICP in the brain stem?

21. Immobilize the client's head and neck

22. generalized and partial (also called local or focal)
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 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?
Unconsciousness - convulsions - muscle rigidity
Seizures are divided into two broad categories:

23. Subdural hemorrhage
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?
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.

24. Encouraging compliance with drug therapy to prevent loss of vision
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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:
Meningies - csf - blood - brain barrier - skull
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

25. Laceration of the middle meningeal artery
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

26. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:

27. Clonic Seizure
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

28. CN IX and CN VII
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 client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Collision between a rapidly moving body part and a stationary object
A client has been pronounced brain dead. Which findings would the nurse assess?

29. 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
Meningies - csf - blood - brain barrier - skull
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Gap between the dura and the cortical surface of the brain.

30. 4 things that protect the brain
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?
Meningies - csf - blood - brain barrier - skull
High - energy transfer - such as a blow from a baseball bat

31. Rapid dilantin administration can cause cardiac arrhythmias
Vitals/turn freq/call light close/ ROM
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 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?
Meningies - csf - blood - brain barrier - skull

32. Depressed skull fractures
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
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 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?

33. Limiting bladder catherization to once every 12 hours
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
Which of the following physiologic changes would be expected in a patient with presbyopia?

34. Parkinson's disease
are produced by electrical impulses from throughout the entire 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 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 neurotransmitter is responsible for may of the functions of the frontal lobe?

35. Dopamine
Which of the following describes decerebrate posturing?
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?

36. Decorticate
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.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Blunt trauma

37. Epidural hematoma
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
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
Seizures are divided into two broad categories:

38. Hyperflexion injuries
Blunt trauma
Whiplash - shaken baby
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

39. acceleration injury
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 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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Head is suddenly forced to stop or start moving - or to turn rapidly.

40. To immobilize the surgical spine
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?
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 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?

41. Myoclonic Seizure
Seizures are divided into two broad categories:
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.
Whiplash - shaken baby
Head is suddenly forced to stop or start moving - or to turn rapidly.

42. 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?
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?
Blunt trauma
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

43. Decrease in LOC

44. 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
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 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:
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

45. Raise the head of the bed immediately to 90 degrees
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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 respiratory patterns indicate increasing ICP in the brain stem?

46. Intracranial hemorrhages
Meningies - csf - blood - brain barrier - skull
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

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

48. Atonic Seizure
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

49. Linear skull fractures
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

50. 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.
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 subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
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