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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. Back arched; rigid extension of all four extremities.
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
Which of the following describes decerebrate posturing?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

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

3. 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
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.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

4. Quadriplegia with gross arm movement and diaphragmic breathing

5. Absence Seizure
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
A client 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 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?

6. Hyperflexion injuries
Which of the following describes decerebrate posturing?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?

7. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

8. Equal pupillary constriction in response to light
A client has been pronounced brain dead. Which findings would the nurse assess?
Whiplash - shaken baby
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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?

9. Atonic Seizure
Vitals/turn freq/call light close/ ROM
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Blunt trauma
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

10. Myoclonic Seizure
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
Which of the following describes decerebrate posturing?
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
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

11. Put the client in the high - Fowler's position
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 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?
Which of the following physiologic changes would be expected in a patient with presbyopia?

12. Basilar skull fractures
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 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?
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

13. Limiting bladder catherization to once every 12 hours
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 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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

14. Immobilize the client's head and neck

15. acceleration injury
Head is suddenly forced to stop or start moving - or to turn rapidly.
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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:

16. nsg intervention for spinal injury
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 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?
Vitals/turn freq/call light close/ ROM
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?

17. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
Meningies - csf - blood - brain barrier - skull
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
Head is suddenly forced to stop or start moving - or to turn rapidly.

18. Check the fluid for dextrose with a dipstick
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?
Muscle stiffness - rigidity

19. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Seizures are divided into two broad categories:
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

20. To immobilize the surgical spine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?

21. deceleration injury
Collision between a rapidly moving body part and a stationary object
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client has been pronounced brain dead. Which findings would the nurse assess?

22. Damage to cranial nerve I
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A 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
Meningies - csf - blood - brain barrier - skull
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

23. Subdural hemorrhage
Gap between the dura and the cortical surface of the brain.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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 with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

24. A client with a high cervical spine injury
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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

25. Tonic Seizure
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
Muscle stiffness - rigidity
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?
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?

26. Intracranial hemorrhages
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.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
Blunt trauma

27. Decorticate
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
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?

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

29. Slow - irregular respirations
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?
are produced by electrical impulses from throughout the entire brain
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?

30. generalized and partial (also called local or focal)
Blunt trauma
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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.

31. Epidural hematoma
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A 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 neurotransmitter is responsible for may of the functions of the frontal lobe?
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

32. The patient should be placed on droplet precautions.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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.
Seizures are divided into two broad categories:
Collision between a rapidly moving body part and a stationary object

33. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

34. partial seizures
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Gap between the dura and the cortical surface of the brain.
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A client has been pronounced brain dead. Which findings would the nurse assess?

35. Clonic Seizure
Gap between the dura and the cortical surface of the brain.
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
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

36. Decrease in LOC

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

38. 'The lens is normally transparent
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

39. Laceration of the middle meningeal artery
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?
Vitals/turn freq/call light close/ ROM

40. 'Wake him every hour and assess his orientation to person - time - and place
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
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?
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

41. Linear skull fractures
Blunt trauma
Muscle stiffness - rigidity
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?

42. 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?
High - energy transfer - such as a blow from a baseball bat
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 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?

43. 4 things that protect 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?
Meningies - csf - blood - brain barrier - skull
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 signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

44. Rapid dilantin administration can cause cardiac arrhythmias
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

45. 'Grand Mal' or Generalized tonic - clonic
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?
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
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

46. Artificial tears
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Gap between the dura and the cortical surface of the brain.
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

47. Unequal pupil size
CN III
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?
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

48. Dopamine
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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.

49. Loss of lens elasticity
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following physiologic changes would be expected in a patient with presbyopia?

50. Depressed skull fractures
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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 client has been pronounced brain dead. Which findings would the nurse assess?