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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. acceleration injury
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?
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?

2. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

3. Unequal pupil size
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
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

4. 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 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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

5. CN IX and CN VII
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?
Collision between a rapidly moving body part and a stationary object
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

6. Tonic Seizure
Muscle stiffness - rigidity
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.
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

7. Hyperflexion injuries
Blunt trauma
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Whiplash - shaken baby
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

8. 'Wake him every hour and assess his orientation to person - time - and place
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.
Gap between the dura and the cortical surface of the brain.
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 with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

9. Myoclonic Seizure
Which of the following physiologic changes would be expected in a patient with presbyopia?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
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.

10. Immobilize the client's head and neck

11. 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?
Whiplash - shaken baby
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 with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

12. Back arched; rigid extension of all four extremities.
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?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?

13. deceleration injury
Collision between a rapidly moving body part and a stationary object
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Whiplash - shaken baby

14. Epidural hematoma
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 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
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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

15. Raise the head of the bed immediately to 90 degrees
Collision between a rapidly moving body part and a stationary object
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?
are produced by electrical impulses from throughout the entire 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?

16. Linear skull fractures
Head is suddenly forced to stop or start moving - or to turn rapidly.
Blunt trauma
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.

17. Atonic Seizure
CN III
are produced by electrical impulses from throughout the entire brain
High - energy transfer - such as a blow from a baseball bat
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

18. 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
Muscle stiffness - rigidity
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Whiplash - shaken baby
CN III

19. 4 things that protect the brain
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?
Meningies - csf - blood - brain barrier - skull
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?

20. Put the client in the high - Fowler's position
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

21. Subdural hemorrhage
Gap between the dura and the cortical surface of the 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?
Which of the following describes decerebrate posturing?
Seizures are divided into two broad categories:

22. Loss of lens elasticity
Muscle stiffness - rigidity
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
Which of the following describes decerebrate posturing?
Which of the following physiologic changes would be expected in a patient with presbyopia?

23. Encouraging compliance with drug therapy to prevent loss of vision
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?
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?
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:

24. Generalized seizures
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
are produced by electrical impulses from throughout the entire brain
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

25. Quadriplegia with gross arm movement and diaphragmic breathing

26. A client with a high cervical spine injury
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

27. Intracranial hemorrhages
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Seizures are divided into two broad categories:
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

28. Reposition the client to avoid neck flexion
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?
Gap between the dura and the cortical surface of the brain.
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?
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?

29. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Whiplash - shaken baby
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

30. Rapid dilantin administration can cause cardiac arrhythmias
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?
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

31. Depressed skull fractures
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.
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?

32. nsg intervention for spinal injury
Head is suddenly forced to stop or start moving - or to turn rapidly.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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:
Vitals/turn freq/call light close/ ROM

33. Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?
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?

34. Check the fluid for dextrose with a dipstick
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 with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
CN III
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:

35. 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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?
Gap between the dura and the cortical surface of the brain.

36. Absence Seizure
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?
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
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

37. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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 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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

38. Limiting bladder catherization to once every 12 hours
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 spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
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.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

39. Clonic Seizure
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 normal sensory change that results in diminished sense of taste. How would this be documented
Muscle stiffness - rigidity
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

40. The patient should be placed on droplet precautions.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Blunt trauma
are produced by electrical impulses from throughout the entire brain
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.

41. 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
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
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?

42. Epidural hematoma
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?
Whiplash - shaken baby
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
CN III

43. Equal pupillary constriction in response to light
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Unconsciousness - convulsions - muscle rigidity
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?

44. Slow - irregular respirations
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

45. Damage to cranial nerve 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
Blunt trauma
Which of the following physiologic changes would be expected in a patient with presbyopia?
CN III

46. 'Grand Mal' or Generalized tonic - clonic
Blunt trauma
Gap between the dura and the cortical surface of the brain.
Unconsciousness - convulsions - muscle rigidity
Which of the following physiologic changes would be expected in a patient with presbyopia?

47. Artificial tears
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 with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Vitals/turn freq/call light close/ ROM
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

48. Dilated non reactive pupils
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following describes decerebrate posturing?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

49. Parkinson's disease
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 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 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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

50. generalized and partial (also called local or focal)
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
Seizures are divided into two broad categories:
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?