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

2. Basilar skull fractures
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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 been pronounced brain dead. Which findings would the nurse assess?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

3. Reposition the client to avoid neck flexion
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:
are produced by electrical impulses from throughout the entire brain
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

4. Loss of lens elasticity
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

5. Dilated non reactive pupils
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 been pronounced brain dead. Which findings would the nurse assess?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

6. Back arched; rigid extension of all four extremities.
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 has been pronounced brain dead. Which findings would the nurse assess?
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?

7. 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
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
High - energy transfer - such as a blow from a baseball bat
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?

8. Rapid dilantin administration can cause cardiac arrhythmias
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 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?
High - energy transfer - such as a blow from a baseball bat

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

10. Absence Seizure
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
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?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

11. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
Unconsciousness - convulsions - muscle rigidity
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 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:

12. Myoclonic Seizure
High - energy transfer - such as a blow from a baseball bat
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 been pronounced brain dead. Which findings would the nurse assess?
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.

13. 'The lens is normally transparent
CN III
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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 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?

14. A client with a high cervical spine injury
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

15. Equal pupillary constriction in response to light
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
Unconsciousness - convulsions - muscle rigidity
Meningies - csf - blood - brain barrier - skull

16. Epidural hematoma
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 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
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 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?

17. Damage to cranial nerve I
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
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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

18. Laceration of the middle meningeal artery
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?

19. 4 things that protect the brain
Meningies - csf - blood - brain barrier - skull
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Collision between a rapidly moving body part and a stationary object

20. Slow - irregular respirations
Meningies - csf - blood - brain barrier - skull
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
CN III
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

21. Intracranial hemorrhages
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

22. 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?
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 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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

23. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Unconsciousness - convulsions - muscle rigidity

24. Generalized seizures
are produced by electrical impulses from throughout the entire brain
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 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?

25. 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
Whiplash - shaken baby
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
CN III
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?

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

27. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Seizures are divided into two broad categories:
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?
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

28. Evaluate urine specific gravity
Blunt trauma
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 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 physiologic changes would be expected in a patient with presbyopia?

29. Unequal pupil size
are produced (at least initially) by electrical impulses in a relatively small part of 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?
Gap between the dura and the cortical surface of the brain.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

30. Check the fluid for dextrose with a dipstick
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 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 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?

31. 'Grand Mal' or Generalized tonic - clonic
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
Unconsciousness - convulsions - muscle rigidity
Which of the following describes decerebrate posturing?

32. acceleration injury
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?

33. Put the client in the high - Fowler's position
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Gap between the dura and the cortical surface of the brain.

34. Hyperflexion injuries
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
Muscle stiffness - rigidity
Whiplash - shaken baby

35. Encourage the client to hyperventilate
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

36. 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?
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?
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

37. Tonic Seizure
Muscle stiffness - rigidity
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 respiratory patterns indicate increasing ICP in the brain stem?
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

38. Quadriplegia with gross arm movement and diaphragmic breathing

39. Wrap her hands in soft 'mitten' restraints
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
A client has been pronounced brain dead. Which findings would the nurse assess?

40. The patient should be placed on droplet precautions.
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.
Which of the following describes decerebrate posturing?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

41. Decrease in LOC

42. Atonic Seizure
A client has been pronounced brain dead. Which findings would the nurse assess?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

43. Encouraging compliance with drug therapy to prevent loss of vision
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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:
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

44. partial seizures
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Gap between the dura and the cortical surface of the brain.
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

45. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Seizures are divided into two broad categories:
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 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
Whiplash - shaken baby

46. Limiting bladder catherization to once every 12 hours
High - energy transfer - such as a blow from a baseball bat
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Seizures are divided into two broad categories:
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

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

48. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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 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?

49. Parkinson's disease
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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 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?

50. Artificial tears
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?