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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
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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. Depressed skull fractures
High - energy transfer - such as a blow from a baseball bat
Meningies - csf - blood - brain barrier - skull
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

2. 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
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 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
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?

3. Laceration of the middle meningeal artery
A client has been pronounced brain dead. Which findings would the nurse assess?
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 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 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?

4. Quadriplegia with gross arm movement and diaphragmic breathing

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5. Decorticate
Vitals/turn freq/call light close/ ROM
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

6. Put the client in the high - Fowler's position
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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.
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
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

7. 'Wake him every hour and assess his orientation to person - time - and place
Muscle stiffness - rigidity
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?

8. To immobilize the surgical spine
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?
Blunt trauma
Which of the following describes decerebrate posturing?

9. Back arched; rigid extension of all four extremities.
are produced (at least initially) by electrical impulses in a relatively small part 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
Which of the following describes decerebrate posturing?
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?

10. Absence Seizure
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
are produced by electrical impulses from throughout the entire brain
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

11. Encouraging compliance with drug therapy to prevent loss of vision
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 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?
Unconsciousness - convulsions - muscle rigidity

12. Immobilize the client's head and neck

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13. Damage to cranial nerve I
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Blunt trauma
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

14. Limiting bladder catherization to once every 12 hours
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
are produced by electrical impulses from throughout the entire brain

15. nsg intervention for spinal injury
Seizures are divided into two broad categories:
Vitals/turn freq/call light close/ ROM
Muscle stiffness - rigidity
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. Parkinson's disease
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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

17. A client with a high cervical spine 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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?

18. Unequal pupil size
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?
Unconsciousness - convulsions - muscle rigidity
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.

19. Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Blunt trauma
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
CN III

20. Activity of the brain
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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

21. 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
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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 physiologic changes would be expected in a patient with presbyopia?

22. Hyperflexion injuries
Whiplash - shaken baby
Unconsciousness - convulsions - muscle rigidity
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.

23. generalized and partial (also called local or focal)
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
CN III
Gap between the dura and the cortical surface of the brain.
Seizures are divided into two broad categories:

24. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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 of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

25. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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 physiologic changes would be expected in a patient with presbyopia?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.

26. Myoclonic Seizure
are produced by electrical impulses from throughout the entire brain
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

27. 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
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 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 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?

28. Wrap her hands in soft 'mitten' restraints
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

29. 'Grand Mal' or Generalized tonic - clonic
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 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?
Unconsciousness - convulsions - muscle rigidity
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

30. acceleration injury
CN III
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Head is suddenly forced to stop or start moving - or to turn rapidly.

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?
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 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?
Seizures are divided into two broad categories:

32. CN IX and CN VII
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 has been pronounced brain dead. Which findings would the nurse assess?
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

33. Raise the head of the bed immediately to 90 degrees
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 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 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?

34. Inability to elicit a Babinski's reflex
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Meningies - csf - blood - brain barrier - skull
Whiplash - shaken baby
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

35. 4 things that protect the brain
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
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?
Meningies - csf - blood - brain barrier - skull

36. Reposition the client to avoid neck flexion
Muscle stiffness - rigidity
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?
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?

37. Basilar skull fractures
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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

38. Tonic Seizure
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?
Seizures are divided into two broad categories:
Muscle stiffness - rigidity
Head is suddenly forced to stop or start moving - or to turn rapidly.

39. Dilated non reactive pupils
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?
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.

40. Equal pupillary constriction in response to light
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
A client with 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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

41. Artificial tears
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 physiologic changes would be expected in a patient with presbyopia?
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 describes decerebrate posturing?

42. Slow - irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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

43. Linear skull fractures
Blunt trauma
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

44. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part 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?
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
Muscle stiffness - rigidity

45. Decrease in LOC

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46. deceleration injury
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 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

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

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

49. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Collision between a rapidly moving body part and a stationary object

50. Encourage the client to hyperventilate
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

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NCLEX Neuro

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