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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.
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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. Dilated non reactive pupils
are produced by electrical impulses from throughout the entire brain
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 been pronounced brain dead. Which findings would the nurse assess?

2. Decrease in LOC

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3. Artificial tears
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented

4. deceleration injury
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Collision between a rapidly moving body part and a stationary object

5. Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
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 respiratory patterns indicate increasing ICP in the brain stem?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

6. Generalized seizures
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
are produced by electrical impulses from throughout the entire brain
Seizures are divided into two broad categories:
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

7. acceleration injury
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
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Head is suddenly forced to stop or start moving - or to turn rapidly.
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

8. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following describes decerebrate posturing?
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.

9. A client with a high cervical spine injury
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Seizures are divided into two broad categories:
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
are produced by electrical impulses from throughout the entire brain

10. Absence Seizure
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?
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 normal sensory change that results in diminished sense of taste. How would this be documented

11. Encouraging compliance with drug therapy to prevent loss of vision
Which of the following physiologic changes would be expected in a patient with presbyopia?
Blunt trauma
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:
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

12. Subdural hemorrhage
Gap between the dura and the cortical surface of the brain.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

13. 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
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?
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?

14. Rapid dilantin administration can cause cardiac arrhythmias
Gap between the dura and the cortical surface of the brain.
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
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 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?

15. To immobilize the surgical spine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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 respiratory patterns indicate increasing ICP in the brain stem?
Collision between a rapidly moving body part and a stationary object

16. 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
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

17. nsg intervention for spinal injury
CN III
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Seizures are divided into two broad categories:
Vitals/turn freq/call light close/ ROM

18. Basilar skull fractures
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 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?
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

19. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Unconsciousness - convulsions - muscle rigidity
Blunt trauma
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Gap between the dura and the cortical surface of the brain.

20. Quadriplegia with gross arm movement and diaphragmic breathing

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21. Hyperflexion injuries
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Whiplash - shaken baby
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

22. Put the client in the high - Fowler's position
Meningies - csf - blood - brain barrier - skull
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 respiratory patterns indicate increasing ICP in the brain stem?
High - energy transfer - such as a blow from a baseball bat

23. Parkinson's disease
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 normal sensory change that results in diminished sense of taste. How would this be documented
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

24. 'Wake him every hour and assess his orientation to person - time - and place
Muscle stiffness - rigidity
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 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?

25. Reposition the client to avoid neck flexion
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?
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 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?

26. Tonic Seizure
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which
Muscle stiffness - rigidity
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
CN III

27. Limiting bladder catherization to once every 12 hours
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
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

28. Dopamine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which of the following describes decerebrate posturing?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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

29. 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 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?
CN III
Meningies - csf - blood - brain barrier - skull
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

30. Encourage the client to hyperventilate
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

31. Equal pupillary constriction in response to light
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?
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:
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

32. Slow - irregular respirations
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client has been pronounced brain dead. Which findings would the nurse assess?
Unconsciousness - convulsions - muscle rigidity

33. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?

34. Depressed skull fractures
High - energy transfer - such as a blow from a baseball bat
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

35. Myoclonic Seizure
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which of the following describes decerebrate posturing?

36. partial seizures
Which of the following describes decerebrate posturing?
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?
High - energy transfer - such as a blow from a baseball bat

37. Clonic Seizure
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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?

38. Atonic Seizure
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

39. Immobilize the client's head and neck

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40. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Muscle stiffness - 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?
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.

41. Loss of lens elasticity
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 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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

42. Hypogeusia
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 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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

43. Check the fluid for dextrose with a dipstick
Seizures are divided into two broad categories:
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which of the following describes decerebrate posturing?

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

45. generalized and partial (also called local or focal)
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?
CN III
Vitals/turn freq/call light close/ ROM
Seizures are divided into two broad categories:

46. 4 things that protect 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?
Collision between a rapidly moving body part and a stationary object
Meningies - csf - blood - brain barrier - skull
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us

47. Damage to cranial nerve I
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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 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?

48. Intracranial hemorrhages
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
Muscle stiffness - rigidity

49. 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?
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?
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?

50. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle 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:
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

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NCLEX Neuro

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