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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. Raise the head of the bed immediately to 90 degrees
High - energy transfer - such as a blow from a baseball bat
Seizures are divided into two broad categories:
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 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?

2. Wrap her hands in soft 'mitten' restraints
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
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
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?

3. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
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?
Gap between the dura and the cortical surface of the 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?

4. Decorticate
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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.
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?

5. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which
High - energy transfer - such as a blow from a baseball bat
CN III

6. Basilar skull fractures
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 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. Tonic Seizure
Seizures are divided into two broad categories:
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 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?

8. Damage to cranial nerve I
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?

9. deceleration injury
Which of the following describes decerebrate posturing?
Collision between a rapidly moving body part and a stationary object
Meningies - csf - blood - brain barrier - skull
Unconsciousness - convulsions - muscle rigidity

10. generalized and partial (also called local or focal)
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?
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?
Seizures are divided into two broad categories:

11. '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?
Meningies - csf - blood - brain barrier - skull
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

12. Myoclonic 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
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:
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.
High - energy transfer - such as a blow from a baseball bat

13. Intracranial hemorrhages
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Unconsciousness - convulsions - muscle rigidity
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

14. Rapid dilantin administration can cause cardiac arrhythmias
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?
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

15. Loss of lens elasticity
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following physiologic changes would be expected in a patient with presbyopia?
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 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?

16. Hyperflexion injuries
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?
Vitals/turn freq/call light close/ ROM

17. Parkinson's disease
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?
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 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

18. 'Grand Mal' or Generalized tonic - clonic
A client has been pronounced brain dead. Which findings would the nurse assess?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Unconsciousness - convulsions - muscle rigidity

19. Unequal pupil size
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 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
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?

20. 'The lens is normally transparent
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

21. Epidural hematoma
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?
Whiplash - shaken baby
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

22. Immobilize the client's head and neck

23. Generalized seizures
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?
are produced by electrical impulses from throughout the entire brain
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

24. Absence Seizure
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
Vitals/turn freq/call light close/ ROM
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?
Gap between the dura and the cortical surface of the brain.

25. Noxious stimuli
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

26. acceleration injury
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
A 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

27. 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 signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

28. Clonic Seizure
Muscle stiffness - rigidity
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

29. Reposition the client to avoid neck flexion
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?
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?
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. Decrease in LOC

31. Encourage the client to hyperventilate
Muscle stiffness - 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
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

32. Linear skull fractures
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Blunt trauma
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

33. Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 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?

34. Check the fluid for dextrose with a dipstick
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Gap between the dura and the cortical surface of the brain.
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?
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

35. 4 things that protect the brain
Whiplash - shaken baby
Meningies - csf - blood - brain barrier - skull
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

36. Limiting bladder catherization to once every 12 hours
A client has been pronounced brain dead. Which findings would the nurse assess?
are produced by electrical impulses from throughout the entire brain
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?

37. Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?

38. Evaluate urine specific gravity
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?

39. Subdural hemorrhage
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?
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?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

40. 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?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Collision between a rapidly moving body part and a stationary object

41. Equal pupillary constriction in response to light
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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
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?

42. The patient should be placed on droplet precautions.
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.
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
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.

43. 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
High - energy transfer - such as a blow from a baseball bat
Vitals/turn freq/call light close/ ROM
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?

44. Laceration of the middle meningeal artery
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 describes decerebrate posturing?
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?

45. CN IX and CN VII
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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
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.

46. Put the client in the high - Fowler's position
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.
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?

47. Slow - irregular respirations
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 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 respiratory patterns indicate increasing ICP in the brain stem?
Blunt trauma

48. partial seizures
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?
are produced (at least initially) by electrical impulses in a relatively small part 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?
Collision between a rapidly moving body part and a stationary object

49. 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
CN III
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 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
Unconsciousness - convulsions - muscle rigidity

50. Encouraging compliance with drug therapy to prevent loss of vision
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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:
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?