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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. nsg intervention for spinal injury
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Vitals/turn freq/call light close/ ROM

2. Hyperflexion injuries
Blunt trauma
Whiplash - shaken baby
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Muscle stiffness - rigidity

3. Intracranial hemorrhages
Which of the following physiologic changes would be expected in a patient with presbyopia?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A client has been pronounced brain dead. Which findings would the nurse assess?

4. Reposition the client to avoid neck flexion
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 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:
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?

5. acceleration injury
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.
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
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?

6. Unequal pupil size
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

7. 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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

8. Dopamine
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?
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?
Seizures are divided into two broad categories:

9. Rapid dilantin administration can cause cardiac arrhythmias
High - energy transfer - such as a blow from a baseball bat
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

10. Inability to elicit a Babinski's reflex
Whiplash - shaken baby
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

11. Decorticate
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

12. Tonic Seizure
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
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
Muscle stiffness - rigidity

13. CN IX and CN VII
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Blunt trauma
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?

14. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
are produced by electrical impulses from throughout the entire brain
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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

15. deceleration injury
Collision between a rapidly moving body part and a stationary object
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

16. Generalized seizures
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?
Whiplash - shaken baby
Muscle stiffness - rigidity
are produced by electrical impulses from throughout the entire brain

17. 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
Unconsciousness - convulsions - muscle rigidity
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Vitals/turn freq/call light close/ ROM

18. Encourage the client to hyperventilate
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

19. Immobilize the client's head and neck

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20. '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
Vitals/turn freq/call light close/ ROM
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

21. 'Grand Mal' or Generalized tonic - clonic
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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

22. 4 things that protect the brain
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?
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 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?

23. Damage to cranial nerve I
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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

24. Absence Seizure
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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
Meningies - csf - blood - brain barrier - skull
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

25. Clonic Seizure
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
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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.

26. Loss of lens elasticity
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 physiologic changes would be expected in a patient with presbyopia?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

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

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

29. Basilar skull fractures
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Gap between the dura and the cortical surface of the brain.

30. partial seizures
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Muscle stiffness - 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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

31. Wrap her hands in soft 'mitten' restraints
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 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?
Vitals/turn freq/call light close/ ROM
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

32. Evaluate urine specific gravity
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
Vitals/turn freq/call light close/ ROM
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?

33. Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

34. Laceration of the middle meningeal artery
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?
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

35. Dilated non reactive pupils
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?
Meningies - csf - blood - brain barrier - skull
A client has been pronounced brain dead. Which findings would the nurse assess?
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?

36. Hypogeusia
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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 client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

37. 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 client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
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?

38. The patient should be placed on droplet precautions.
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Which of the following physiologic changes would be expected in a patient with presbyopia?
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.

39. Artificial tears
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Muscle stiffness - rigidity
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

40. Linear skull fractures
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 respiratory patterns indicate increasing ICP in the brain stem?
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?
Blunt trauma

41. Decrease in LOC

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42. Depressed skull fractures
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?
High - energy transfer - such as a blow from a baseball bat
Muscle stiffness - rigidity
Head is suddenly forced to stop or start moving - or to turn rapidly.

43. Quadriplegia with gross arm movement and diaphragmic breathing

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44. 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

45. Raise the head of the bed immediately to 90 degrees
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?

46. 'The lens is normally transparent
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Gap between the dura and the cortical surface of the brain.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

47. A client with a high cervical spine injury
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?

48. Put the client in the high - Fowler's position
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Muscle stiffness - rigidity

49. Atonic Seizure
Whiplash - shaken baby
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?

50. Parkinson's disease
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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
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?

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NCLEX Neuro

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