Test your basic knowledge |

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. Equal pupillary constriction in response to light
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 respiratory patterns indicate increasing ICP in the brain stem?

2. A client with a high cervical spine injury
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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
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?

3. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

4. acceleration injury
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Collision between a rapidly moving body part and a stationary object
Head is suddenly forced to stop or start moving - or to turn rapidly.

5. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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 at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?

6. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

7. 'Wake him every hour and assess his orientation to person - time - and place
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 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:
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

8. Inability to elicit a Babinski's reflex
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
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 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?

9. Raise the head of the bed immediately to 90 degrees
Seizures are divided into two broad categories:
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 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?

10. 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?
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
Seizures are divided into two broad categories:

11. Intracranial hemorrhages
Gap between the dura and the cortical surface of the brain.
Collision between a rapidly moving body part and a stationary object
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:
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

12. Hypogeusia
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which of the following physiologic changes would be expected in a patient with presbyopia?
are produced by electrical impulses from throughout the entire brain

13. 'The lens is normally transparent
Vitals/turn freq/call light close/ ROM
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

14. Artificial tears
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

15. 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.
Meningies - csf - blood - brain barrier - skull
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

16. Noxious stimuli
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 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?
Whiplash - shaken baby
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

17. CN IX and CN VII
Which of the following describes decerebrate posturing?
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?
Unconsciousness - convulsions - muscle rigidity
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

18. 4 things that protect the brain
Meningies - csf - blood - brain barrier - skull
High - energy transfer - such as a blow from a baseball bat
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

19. 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 of the following respiratory patterns indicate increasing ICP in the brain stem?
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?

20. Limiting bladder catherization to once every 12 hours
High - energy transfer - such as a blow from a baseball bat
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 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?

21. Encourage the client to hyperventilate
Muscle stiffness - rigidity
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

22. deceleration injury
Collision between a rapidly moving body part and a stationary object
Seizures are divided into two broad categories:
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

23. Slow - irregular respirations
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Collision between a rapidly moving body part and a stationary object
Which of the following physiologic changes would be expected in a patient with presbyopia?

24. Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

25. partial seizures
Blunt trauma
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.
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?

26. Linear skull fractures
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Blunt trauma
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 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?

27. 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?
Vitals/turn freq/call light close/ ROM
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

28. 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
Blunt trauma
CN III
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
High - energy transfer - such as a blow from a baseball bat

29. Atonic Seizure
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
Whiplash - shaken baby
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

30. Unequal pupil size
Seizures are divided into two broad categories:
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?
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 at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

31. Subdural hemorrhage
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Collision between a rapidly moving body part and a stationary object
Gap between the dura and the cortical surface of the brain.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

32. Encouraging compliance with drug therapy to prevent loss of vision
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 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:
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 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?

33. Quadriplegia with gross arm movement and diaphragmic breathing

34. 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?
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 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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

35. Depressed skull fractures
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 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
Unconsciousness - convulsions - muscle rigidity

36. To immobilize the surgical spine
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Whiplash - shaken baby
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?

37. Epidural hematoma
High - energy transfer - such as a blow from a baseball bat
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
Collision between a rapidly moving body part and a stationary object
Unconsciousness - convulsions - muscle rigidity

38. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
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
are produced by electrical impulses from throughout the entire brain
Head is suddenly forced to stop or start moving - or to turn rapidly.

39. The patient should be placed on droplet precautions.
Which of the following describes decerebrate posturing?
A client has been pronounced brain dead. Which findings would the nurse assess?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

40. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
Meningies - csf - blood - brain barrier - skull
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 a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

41. Laceration of the middle meningeal artery
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?

42. Absence Seizure
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Whiplash - shaken baby
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us

43. Immobilize the client's head and neck

44. Reposition the client to avoid neck flexion
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
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:
Meningies - csf - blood - brain barrier - skull

45. Tonic Seizure
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?
A client has been pronounced brain dead. Which findings would the nurse assess?
Muscle stiffness - rigidity

46. 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 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 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?
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

47. Generalized seizures
Meningies - csf - blood - brain barrier - skull
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.
are produced by electrical impulses from throughout the entire 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

48. 'Grand Mal' or Generalized tonic - clonic
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.
Unconsciousness - convulsions - muscle rigidity
Vitals/turn freq/call light close/ ROM
Seizures are divided into two broad categories:

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?
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?
Whiplash - shaken baby
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

50. Basilar skull fractures
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
CN III
Meningies - csf - blood - brain barrier - skull
Gap between the dura and the cortical surface of the brain.