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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. Myoclonic Seizure
Muscle stiffness - rigidity
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?
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

2. Noxious stimuli
are produced by electrical impulses from throughout the entire brain
Unconsciousness - convulsions - muscle rigidity
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

3. Wrap her hands in soft 'mitten' restraints
Blunt trauma
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 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

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

5. 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?
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?
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?

6. Equal pupillary constriction in response to light
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 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 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?

7. Check the fluid for dextrose with a dipstick
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

8. Basilar skull fractures
Blunt trauma
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?
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

9. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
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
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

10. Put the client in the high - Fowler's position
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Collision between a rapidly moving body part and a stationary object
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

11. 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:
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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
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.

12. Immobilize the client's head and neck

13. 'The lens is normally transparent
Collision between a rapidly moving body part and a stationary object
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

14. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Vitals/turn freq/call light close/ ROM
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

15. 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?
are produced by electrical impulses from throughout the entire 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?

16. Back arched; rigid extension of all four extremities.
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 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?
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?

17. Decrease in LOC

18. Unequal pupil size
Seizures are divided into two broad categories:
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Meningies - csf - blood - brain barrier - skull

19. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
High - energy transfer - such as a blow from a baseball bat
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

20. Depressed skull fractures
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
High - energy transfer - such as a blow from a baseball bat
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

21. Rapid dilantin administration can cause cardiac arrhythmias
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
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

22. Generalized seizures
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 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.
Muscle stiffness - rigidity
are produced by electrical impulses from throughout the entire brain

23. To immobilize the surgical spine
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

24. Quadriplegia with gross arm movement and diaphragmic breathing

25. Limiting bladder catherization to once every 12 hours
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.
Vitals/turn freq/call light close/ ROM
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?

26. The patient should be placed on droplet precautions.
Vitals/turn freq/call light close/ ROM
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Unconsciousness - convulsions - muscle rigidity

27. Linear skull fractures
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Blunt trauma
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?

28. Parkinson's disease
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 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 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
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

29. Inability to elicit a Babinski's reflex
Collision between a rapidly moving body part and a stationary object
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?

30. Hyperflexion injuries
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 neurotransmitter is responsible for may of the functions of the frontal lobe?
Whiplash - shaken baby

31. partial seizures
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?
CN III

32. 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
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?
CN III
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.
Vitals/turn freq/call light close/ ROM

33. Artificial tears
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Muscle stiffness - rigidity
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:

34. Raise the head of the bed immediately to 90 degrees
Meningies - csf - blood - brain barrier - skull
Whiplash - shaken baby
Gap between the dura and the cortical surface of 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?

35. 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?
Seizures are divided into two broad categories:
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 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

36. acceleration injury
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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

37. A client with a high cervical spine 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
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

38. deceleration injury
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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
Which of the following physiologic changes would be expected in a patient with presbyopia?

39. Tonic Seizure
Muscle stiffness - rigidity
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Collision between a rapidly moving body part and a stationary object
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

40. CN IX and CN VII
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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

41. Atonic 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.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

42. 'Grand Mal' or Generalized tonic - clonic
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which
Unconsciousness - convulsions - muscle rigidity
Muscle stiffness - rigidity

43. generalized and partial (also called local or focal)
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Head is suddenly forced to stop or start moving - or to turn rapidly.
Seizures are divided into two broad categories:
A client has been pronounced brain dead. Which findings would the nurse assess?

44. Dilated non reactive pupils
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 neurotransmitter is responsible for may of the functions of the frontal lobe?
A client has been pronounced brain dead. Which findings would the nurse assess?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

45. 4 things that protect 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?
Which of the following describes decerebrate posturing?
Muscle stiffness - rigidity
Meningies - csf - blood - brain barrier - skull

46. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 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?

47. Damage to cranial nerve I
Whiplash - shaken baby
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
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?

48. Encourage the client to hyperventilate
Seizures are divided into two broad categories:
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 client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

49. Evaluate urine specific gravity
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A client with 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?
Gap between the dura and the cortical surface of the brain.

50. Subdural hemorrhage
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?
Gap between the dura and the cortical surface of the brain.
A client has been pronounced brain dead. Which findings would the nurse assess?
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