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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. 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
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
CN III
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?

2. Check the fluid for dextrose with a dipstick
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

3. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
Which of the following physiologic changes would be expected in a patient with presbyopia?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

4. Hyperflexion injuries
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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?

5. Equal pupillary constriction in response to light
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 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?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

6. 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.
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?
Blunt trauma

7. 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?
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 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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

8. Dilated non reactive pupils
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 been pronounced brain dead. Which findings would the nurse assess?
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

9. Laceration of the middle meningeal artery
CN III
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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 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?

10. Quadriplegia with gross arm movement and diaphragmic breathing

11. Rapid dilantin administration can cause cardiac arrhythmias
Meningies - csf - blood - brain barrier - skull
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?
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?

12. Immobilize the client's head and neck

13. Activity 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?
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
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

14. Hypogeusia
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

15. Dopamine
CN III
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?

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

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?
are produced by electrical impulses from throughout the entire brain
A client has been pronounced brain dead. Which findings would the nurse assess?
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

18. Subdural hemorrhage
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
Gap between the dura and the cortical surface of the brain.
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?

19. Depressed skull fractures
CN III
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
Muscle stiffness - rigidity

20. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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 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?

21. '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?
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
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?

22. 4 things that protect the 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.
Meningies - csf - blood - brain barrier - skull
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?

23. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Blunt trauma
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?

24. Limiting bladder catherization to once every 12 hours
are produced by electrical impulses from throughout the entire brain
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?
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?

25. Myoclonic Seizure
are produced by electrical impulses from throughout the entire 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?
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?
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.

26. Inability to elicit a Babinski's reflex
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?
Meningies - csf - blood - brain barrier - skull
Vitals/turn freq/call light close/ ROM
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

27. Epidural hematoma
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?
Blunt trauma
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

28. Intracranial hemorrhages
Meningies - csf - blood - brain barrier - skull
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

29. Encouraging compliance with drug therapy to prevent loss of vision
Collision between a rapidly moving body part and a stationary object
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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 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?

30. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

31. Atonic Seizure
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

32. Put the client in the high - Fowler's position
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

33. deceleration injury
Gap between the dura and the cortical surface of the brain.
Collision between a rapidly moving body part and a stationary object
CN III
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

34. Raise the head of the bed immediately to 90 degrees
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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.
Unconsciousness - convulsions - muscle rigidity

35. Decrease in LOC

36. Linear skull fractures
Blunt trauma
A client has been pronounced brain dead. Which findings would the nurse assess?
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

37. Absence Seizure
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Meningies - csf - blood - brain barrier - skull
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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

38. Tonic Seizure
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Unconsciousness - convulsions - muscle rigidity
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?
Muscle stiffness - rigidity

39. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 respiratory patterns indicate increasing ICP in the brain stem?
Which of the following describes decerebrate posturing?

40. 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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Muscle stiffness - rigidity
CN III
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?

41. Encourage the client to hyperventilate
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
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

42. Loss of lens elasticity
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:
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
Which of the following physiologic changes would be expected in a patient with presbyopia?

43. 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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 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?

44. 'The lens is normally transparent
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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 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?

45. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Blunt trauma
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

46. A client with a high cervical spine injury
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

47. Back arched; rigid extension of all four extremities.
Blunt trauma
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?
Unconsciousness - convulsions - muscle rigidity
Which of the following describes decerebrate posturing?

48. acceleration injury
Collision between a rapidly moving body part and a stationary object
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

49. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 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

50. Unequal pupil size
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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
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.
Gap between the dura and the cortical surface of the brain.