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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. Back arched; rigid extension of all four extremities.
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
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:

2. Loss of lens elasticity
Collision between a rapidly moving body part and a stationary object
Meningies - csf - blood - brain barrier - skull
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
Which of the following physiologic changes would be expected in a patient with presbyopia?

3. 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
Whiplash - shaken baby
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

4. Epidural hematoma
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
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 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?

5. Noxious stimuli
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Unconsciousness - convulsions - muscle rigidity

6. acceleration injury
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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Head is suddenly forced to stop or start moving - or to turn rapidly.
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.

7. 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?
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 with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
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. Encourage the client to hyperventilate
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?
Meningies - csf - blood - brain barrier - skull
Seizures are divided into two broad categories:

9. Generalized seizures
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
are produced by electrical impulses from throughout the entire brain
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

10. 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 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 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?
are produced by electrical impulses from throughout the entire brain

11. Immobilize the client's head and neck

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12. Quadriplegia with gross arm movement and diaphragmic breathing

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13. Subdural hemorrhage
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Gap between the dura and the cortical surface of the brain.

14. Damage to cranial nerve I
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 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?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

15. Check the fluid for dextrose with a dipstick
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?
Which of the following describes decerebrate posturing?
High - energy transfer - such as a blow from a baseball bat

16. Inability to elicit a Babinski's reflex
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 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
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

17. 4 things that protect the brain
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 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?
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

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

19. Encouraging compliance with drug therapy to prevent loss of vision
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:
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?

20. generalized and partial (also called local or focal)
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Seizures are divided into two broad categories:
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?

21. 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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Vitals/turn freq/call light close/ ROM
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:

22. Wrap her hands in soft 'mitten' restraints
CN III
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

23. Laceration of the middle meningeal artery
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?
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
Muscle stiffness - rigidity
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?

24. CN IX and CN VII
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
High - energy transfer - such as a blow from a baseball bat
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Head is suddenly forced to stop or start moving - or to turn rapidly.

25. Clonic Seizure
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 in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
A client with 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:
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

26. Atonic Seizure
High - energy transfer - such as a blow from a baseball bat
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

27. Depressed skull fractures
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
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 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?

28. Decorticate
Blunt trauma
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Muscle stiffness - rigidity

29. The patient should be placed on droplet precautions.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

30. 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?
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 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:
High - energy transfer - such as a blow from a baseball bat

31. Myoclonic Seizure
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
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 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?

32. Tonic Seizure
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Collision between a rapidly moving body part and a stationary object
Muscle stiffness - rigidity

33. Slow - irregular respirations
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

34. Linear skull fractures
CN III
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:
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

35. deceleration 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?
Collision between a rapidly moving body part and a stationary object
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

36. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
Muscle stiffness - rigidity
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 neurotransmitter is responsible for may of the functions of the frontal lobe?

37. Basilar skull fractures
Gap between the dura and the cortical surface of the brain.
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?
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. Intracranial hemorrhages
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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:
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.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

39. 'Wake him every hour and assess his orientation to person - time - and place
are produced by electrical impulses from throughout the entire brain
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?
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

40. 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 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?
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?
CN III

41. Hyperflexion injuries
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?
Whiplash - shaken baby
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Vitals/turn freq/call light close/ ROM

42. 'The lens is normally transparent
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.
are produced by electrical impulses from throughout the entire brain
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?

43. Absence Seizure
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?
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Whiplash - shaken baby

44. partial seizures
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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. Dilated non reactive pupils
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 physiologic changes would be expected in a patient with presbyopia?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client has been pronounced brain dead. Which findings would the nurse assess?

46. Raise the head of the bed immediately to 90 degrees
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?
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
Gap between the dura and the cortical surface of the brain.
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:

47. Rapid dilantin administration can cause cardiac arrhythmias
Unconsciousness - convulsions - muscle rigidity
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?
Gap between the dura and the cortical surface of the brain.

48. Limiting bladder catherization to once every 12 hours
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
are produced by electrical impulses from throughout the entire brain
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 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:

49. Unequal pupil size
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
Vitals/turn freq/call light close/ ROM
High - energy transfer - such as a blow from a baseball bat
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

50. Epidural hematoma
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.
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
CN III