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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. 'The lens is normally transparent
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?
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?

2. acceleration injury
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Head is suddenly forced to stop or start moving - or to turn rapidly.

3. Linear skull fractures
Which of the following physiologic changes would be expected in a patient with presbyopia?
Blunt trauma
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?

4. Myoclonic Seizure
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Whiplash - shaken baby
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 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

5. Encourage the client to hyperventilate
Unconsciousness - convulsions - muscle rigidity
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

6. 4 things that protect the brain
Meningies - csf - blood - brain barrier - skull
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 been pronounced brain dead. Which findings would the nurse assess?

7. Back arched; rigid extension of all four extremities.
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.
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which
Which of the following describes decerebrate posturing?

8. To immobilize the surgical spine
High - energy transfer - such as a blow from a baseball bat
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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

9. 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
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Blunt trauma

10. Absence Seizure
Which of the following describes decerebrate posturing?
Whiplash - shaken baby
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 respiratory patterns indicate increasing ICP in the brain stem?

11. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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.
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?
Meningies - csf - blood - brain barrier - skull

12. Quadriplegia with gross arm movement and diaphragmic breathing

13. The patient should be placed on droplet precautions.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
Blunt trauma
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

14. Loss of lens elasticity
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?
Muscle stiffness - rigidity
A client has been pronounced brain dead. Which findings would the nurse assess?

15. nsg intervention for spinal injury
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Vitals/turn freq/call light close/ ROM
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?
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

16. Artificial tears
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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 spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

17. deceleration injury
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Collision between a rapidly moving body part and a stationary object
Which of the following clients on the rehab unit is most likely to develop 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?

18. Atonic Seizure
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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
Which of the following describes decerebrate posturing?

19. Inability to elicit a Babinski's reflex
Collision between a rapidly moving body part and a stationary object
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Gap between the dura and the cortical surface of the brain.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

20. Depressed skull fractures
Which of the following describes decerebrate posturing?
Collision between a rapidly moving body part and a stationary object
Meningies - csf - blood - brain barrier - skull
High - energy transfer - such as a blow from a baseball bat

21. 'Wake him every hour and assess his orientation to person - time - and place
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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.
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?
are produced by electrical impulses from throughout the entire brain

22. Encouraging compliance with drug therapy to prevent loss of vision
Which of the following describes decerebrate posturing?
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?
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?

23. Intracranial hemorrhages
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 of the following describes decerebrate posturing?
Unconsciousness - convulsions - muscle rigidity
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

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

25. Equal pupillary constriction in response to light
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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?

26. Subdural hemorrhage
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
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.

27. Hyperflexion injuries
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Whiplash - shaken baby

28. Basilar skull fractures
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
Unconsciousness - convulsions - muscle 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?
Collision between a rapidly moving body part and a stationary object

29. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Meningies - csf - blood - brain barrier - skull

30. Activity of the brain
High - energy transfer - such as a blow from a baseball bat
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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
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?

31. 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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
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

32. Tonic Seizure
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 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 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?

33. Rapid dilantin administration can cause cardiac arrhythmias
Vitals/turn freq/call light close/ ROM
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

34. Slow - irregular respirations
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Vitals/turn freq/call light close/ ROM
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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

35. Limiting bladder catherization to once every 12 hours
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

36. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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 client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Which of the following physiologic changes would be expected in a patient with presbyopia?

37. Put the client in the high - Fowler's position
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 with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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

38. A client with a high cervical spine injury
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?
Which of the following describes decerebrate posturing?

39. Parkinson's disease
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?
Meningies - csf - blood - brain barrier - skull
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?

40. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

41. Laceration of the middle meningeal artery
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
High - energy transfer - such as a blow from a baseball bat
Whiplash - shaken baby

42. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?

43. Wrap her hands in soft 'mitten' restraints
Blunt trauma
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?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

44. Check the fluid for dextrose with a dipstick
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 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?
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?

45. 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?
Whiplash - shaken baby
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?
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?

46. Clonic Seizure
Gap between the dura and the cortical surface of the brain.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
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?

47. Raise the head of the bed immediately to 90 degrees
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?
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

48. Generalized seizures
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?
are produced by electrical impulses from throughout the entire brain
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

49. Decrease in LOC

50. CN IX and CN VII
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
Muscle stiffness - rigidity
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved