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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
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?
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.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

2. Epidural hematoma
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
CN III
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

3. Linear skull fractures
Blunt trauma
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 client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

4. deceleration injury
Muscle stiffness - rigidity
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?
Collision between a rapidly moving body part and a stationary object

5. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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. Noxious stimuli
High - energy transfer - such as a blow from a baseball bat
Gap between the dura and the cortical surface of the brain.
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

7. Inability to elicit a Babinski's reflex
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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

8. 'Wake him every hour and assess his orientation to person - time - and place
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?
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

9. Depressed skull fractures
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Meningies - csf - blood - brain barrier - skull
High - energy transfer - such as a blow from a baseball bat
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

10. 'Grand Mal' or Generalized tonic - clonic
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Unconsciousness - convulsions - muscle rigidity
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 client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

11. Tonic Seizure
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
Muscle stiffness - rigidity
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.

12. Basilar skull fractures
are produced by electrical impulses from throughout the entire brain
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?

13. CN IX and CN VII
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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
Unconsciousness - convulsions - muscle rigidity
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

14. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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
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.

15. Damage to cranial nerve I
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 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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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

16. Put the client in the high - Fowler's position
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?
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?

17. Slow - irregular respirations
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 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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

18. Generalized seizures
are produced by electrical impulses from throughout the entire brain
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Vitals/turn freq/call light close/ ROM

19. Evaluate urine specific gravity
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
are produced by electrical impulses from throughout the entire brain
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?

20. Subdural hemorrhage
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Gap between the dura and the cortical surface of the brain.
Muscle stiffness - rigidity

21. Hyperflexion injuries
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:
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?
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?

22. Parkinson's disease
CN III
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
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

23. Epidural hematoma
A client has been pronounced brain dead. Which findings would the nurse assess?
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 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?

24. Back arched; rigid extension of all four extremities.
Blunt trauma
Which of the following describes decerebrate posturing?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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. Wrap her hands in soft 'mitten' restraints
A client has been pronounced brain dead. Which findings would the nurse assess?
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

26. 4 things that protect the brain
Meningies - csf - blood - brain barrier - skull
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
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

27. The patient should be placed on droplet precautions.
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?
are produced by electrical impulses from throughout the entire brain
Blunt trauma
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.

28. Limiting bladder catherization to once every 12 hours
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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 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?

29. Absence Seizure
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 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
Blunt trauma
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

30. Quadriplegia with gross arm movement and diaphragmic breathing

31. 'The lens is normally transparent
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?
High - energy transfer - such as a blow from a baseball bat

32. 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
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

33. Reposition the client to avoid neck flexion
Which of the following describes decerebrate posturing?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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 respiratory patterns indicate increasing ICP in the brain stem?

34. Dopamine
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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
are produced by electrical impulses from throughout the entire brain

35. Equal pupillary constriction in response to light
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 arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
You are 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:

36. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?

37. acceleration injury
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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

38. Decorticate
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following describes decerebrate posturing?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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

39. 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?
Whiplash - shaken baby
Muscle stiffness - rigidity
Head is suddenly forced to stop or start moving - or to turn rapidly.

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

41. Clonic Seizure
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

42. Loss of lens elasticity
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
Which of the following physiologic changes would be expected in a patient with presbyopia?
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
Muscle stiffness - rigidity

43. Artificial tears
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 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?

44. Atonic Seizure
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:
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following describes decerebrate posturing?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

45. 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?
Gap between the dura and the cortical surface of the brain.
Vitals/turn freq/call light close/ ROM
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?

46. A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a 'blown pupil' (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disrup
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.
Blunt trauma
CN III

47. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?

48. Immobilize the client's head and neck

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

50. Intracranial hemorrhages
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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.
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 physiologic changes would be expected in a patient with presbyopia?