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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. A client with a high cervical spine injury
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?
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.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A client has been pronounced brain dead. Which findings would the nurse assess?

2. Noxious stimuli
are produced by electrical impulses from throughout the entire brain
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

3. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
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 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 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. Generalized seizures
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 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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
are produced by electrical impulses from throughout the entire brain

5. Wrap her hands in soft 'mitten' restraints
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?

6. partial seizures
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
are produced (at least initially) by electrical impulses in a relatively small part 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

7. Put the client in the high - Fowler's position
High - energy transfer - such as a blow from a baseball bat
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?
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.

8. Equal pupillary constriction in response to light
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

9. Rapid dilantin administration can cause cardiac arrhythmias
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Unconsciousness - convulsions - muscle rigidity
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?
Whiplash - shaken baby

10. Inability to elicit a Babinski's reflex
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
The nurse is 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?
Seizures are divided into two broad categories:
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

11. 'Grand Mal' or Generalized tonic - clonic
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?
Blunt trauma
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Unconsciousness - convulsions - muscle rigidity

12. nsg intervention for spinal injury
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Vitals/turn freq/call light close/ ROM
CN III

13. 'Wake him every hour and assess his orientation to person - time - and place
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?
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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

14. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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?
Vitals/turn freq/call light close/ ROM
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

15. Unequal pupil size
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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
are produced by electrical impulses from throughout the entire brain

16. Tonic Seizure
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?
Muscle stiffness - rigidity
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:

17. 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?
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?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

18. Raise the head of the bed immediately to 90 degrees
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 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

19. Reposition the client to avoid neck flexion
Unconsciousness - convulsions - muscle rigidity
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?
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

20. Encouraging compliance with drug therapy to prevent loss of vision
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:
Unconsciousness - convulsions - muscle rigidity
are produced by electrical impulses from throughout the entire brain
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

21. Hypogeusia
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Which of the following describes decerebrate posturing?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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

22. Subdural hemorrhage
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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
Muscle stiffness - rigidity
Gap between the dura and the cortical surface of the brain.

23. Check the fluid for dextrose with a dipstick
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?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
Blunt trauma

24. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
Seizures are divided into two broad categories:
Meningies - csf - blood - brain barrier - skull

25. Linear 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?
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?
Blunt trauma
Which of the following describes decerebrate posturing?

26. Depressed skull fractures
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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
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?

27. Quadriplegia with gross arm movement and diaphragmic breathing

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28. acceleration injury
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 respiratory patterns indicate increasing ICP in the brain stem?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Head is suddenly forced to stop or start moving - or to turn rapidly.

29. deceleration injury
A client has been pronounced brain dead. Which findings would the nurse assess?
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 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:
Collision between a rapidly moving body part and a stationary object

30. Activity of the brain
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 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
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

31. Clonic Seizure
Which of the following physiologic changes would be expected in a patient with presbyopia?
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

32. Limiting bladder catherization to once every 12 hours
Whiplash - shaken baby
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
A client with 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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

33. Back arched; rigid extension of all four extremities.
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which of the following describes decerebrate posturing?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

34. 'The lens is normally transparent
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
High - energy transfer - such as a blow from a baseball bat
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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

35. Damage to cranial nerve I
Seizures are divided into two broad categories:
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
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 (at least initially) by electrical impulses in a relatively small part of the brain.

36. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Head is suddenly forced to stop or start moving - or to turn rapidly.
Unconsciousness - convulsions - muscle rigidity
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

37. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?
Gap between the dura and the cortical surface of the brain.

38. Decrease in LOC

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39. Evaluate urine specific gravity
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?
Seizures are divided into two broad categories:
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 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?

40. Parkinson's disease
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 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?
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?

41. Dilated non reactive pupils
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 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?
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?

42. Immobilize the client's head and neck

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43. The patient should be placed on droplet precautions.
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 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?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

44. To immobilize the surgical spine
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?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

45. 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
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A client 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?

46. 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
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?
Seizures are divided into two broad categories:
CN III

47. 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.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Collision between a rapidly moving body part and a stationary object
Blunt trauma

48. CN IX and CN VII
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following physiologic changes would be expected in a patient with presbyopia?

49. Slow - irregular respirations
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Seizures are divided into two broad categories:
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

50. Epidural hematoma
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?
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
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.