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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. Immobilize the client's head and neck

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2. 4 things that protect the brain
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?
Meningies - csf - blood - brain barrier - skull
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

3. A client with a high cervical spine injury
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
are produced by electrical impulses from throughout the entire 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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

4. 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?
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 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?

5. Dilated non reactive pupils
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A client has been pronounced brain dead. Which findings would the nurse assess?
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
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?

6. 'Grand Mal' or Generalized tonic - clonic
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Unconsciousness - convulsions - muscle rigidity
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

7. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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 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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

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

9. acceleration injury
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 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

10. Depressed skull fractures
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
High - energy transfer - such as a blow from a baseball bat
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?

11. Decrease in LOC

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12. generalized and partial (also called local or focal)
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?
Seizures are divided into two broad categories:
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?

13. Slow - irregular respirations
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
CN III
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:

14. 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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

15. Tonic Seizure
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
Muscle stiffness - rigidity
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

16. Clonic Seizure
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Muscle stiffness - rigidity
A client has been pronounced brain dead. Which findings would the nurse assess?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

17. Reposition the client to avoid neck flexion
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:
are produced by electrical impulses from throughout the entire brain
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?

18. Intracranial hemorrhages
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

19. Epidural hematoma
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
High - energy transfer - such as a blow from a baseball bat
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

20. Myoclonic Seizure
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 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?
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.
Muscle stiffness - rigidity

21. Raise the head of the bed immediately to 90 degrees
A client has been pronounced brain dead. Which findings would the nurse assess?
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 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?
Vitals/turn freq/call light close/ ROM

22. Quadriplegia with gross arm movement and diaphragmic breathing

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23. Decorticate
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

24. Wrap her hands in soft 'mitten' restraints
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
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
Head is suddenly forced to stop or start moving - or to turn rapidly.

25. Inability to elicit a Babinski's reflex
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.
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 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?

26. 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?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

27. Generalized seizures
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
are produced by electrical impulses from throughout the entire 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:

28. 'Wake him every hour and assess his orientation to person - time - and place
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?
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.

29. Parkinson's disease
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 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
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Unconsciousness - convulsions - muscle rigidity

30. Atonic Seizure
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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.
Unconsciousness - convulsions - muscle rigidity

31. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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 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?
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.

32. CN IX and CN VII
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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
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

33. nsg intervention for spinal injury
High - energy transfer - such as a blow from a baseball bat
Which of the following physiologic changes would be expected in a patient with presbyopia?
Vitals/turn freq/call light close/ ROM
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

34. Damage to cranial nerve I
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?
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
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?

35. The patient should be placed on droplet precautions.
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?
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?
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. Loss of lens elasticity
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?
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

37. Put the client in the high - Fowler's position
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Unconsciousness - convulsions - muscle rigidity
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

38. Dopamine
are produced (at least initially) by electrical impulses in a relatively small part of 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?
are produced by electrical impulses from throughout the entire brain
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

39. 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
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?
CN III
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?

40. Check the fluid for dextrose with a dipstick
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 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 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?

41. '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?
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:
A client has been pronounced brain dead. Which findings would the nurse assess?

42. Rapid dilantin administration can cause cardiac arrhythmias
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
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?

43. Activity of the brain
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
You are 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.

44. Subdural hemorrhage
Gap between the dura and the cortical surface of the brain.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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?

45. Artificial tears
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
Which of the following physiologic changes would be expected in a patient with presbyopia?

46. Hypogeusia
Muscle stiffness - rigidity
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
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

47. Evaluate urine specific gravity
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?
Unconsciousness - convulsions - muscle rigidity
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?

48. Encouraging compliance with drug therapy to prevent loss of vision
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 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

49. Equal pupillary constriction in response to light
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?

50. Back arched; rigid extension of all four extremities.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following describes decerebrate posturing?
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.