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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. To immobilize the surgical spine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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 normal sensory change that results in diminished sense of taste. How would this be documented
High - energy transfer - such as a blow from a baseball bat

2. 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
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?
CN III
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?

3. Laceration of the middle meningeal artery
Blunt trauma
Gap between the dura and the cortical surface of 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?
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?

4. Put the client in the high - Fowler's position
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

5. Decorticate
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

6. Immobilize the client's head and neck

7. generalized and partial (also called local or focal)
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?
Which of the following describes decerebrate posturing?
Seizures are divided into two broad categories:

8. Depressed skull fractures
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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
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?
High - energy transfer - such as a blow from a baseball bat

9. Limiting bladder catherization to once every 12 hours
Which of the following physiologic changes would be expected in a patient with presbyopia?
Whiplash - shaken baby
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?

10. Check the fluid for dextrose with a dipstick
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?
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?
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?

11. Basilar skull fractures
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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

12. Subdural hemorrhage
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?
Which of the following describes decerebrate posturing?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Gap between the dura and the cortical surface of the brain.

13. Evaluate urine specific gravity
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

14. Epidural hematoma
Which of the following physiologic changes would be expected in a patient with presbyopia?
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 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?

15. 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?
CN III
Unconsciousness - convulsions - muscle rigidity
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

16. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?
Meningies - csf - blood - brain barrier - skull
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

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
Head is suddenly forced to stop or start moving - or to turn rapidly.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

18. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Gap between the dura and the cortical surface of the brain.
CN III
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

19. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Meningies - csf - blood - brain barrier - skull

20. Wrap her hands in soft 'mitten' restraints
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A 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?

21. Generalized seizures
are produced by electrical impulses from throughout the entire brain
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Seizures are divided into two broad categories:

22. Parkinson's disease
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
Collision between a rapidly moving body part and a stationary object
Vitals/turn freq/call light close/ ROM
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

23. Quadriplegia with gross arm movement and diaphragmic breathing

24. Rapid dilantin administration can cause cardiac arrhythmias
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 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
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
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

25. Decrease in LOC

26. Tonic Seizure
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 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?
Muscle stiffness - rigidity
Seizures are divided into two broad categories:

27. Activity of the brain
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
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
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
Meningies - csf - blood - brain barrier - skull

28. nsg intervention for spinal injury
Vitals/turn freq/call light close/ ROM
Seizures are divided into two broad categories:
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

29. CN IX and CN VII
Blunt trauma
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
CN III
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

30. Hyperflexion injuries
Whiplash - shaken baby
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Vitals/turn freq/call light close/ ROM

31. Clonic Seizure
Blunt trauma
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

32. Back arched; rigid extension of all four extremities.
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 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

33. deceleration injury
Collision between a rapidly moving body part and a stationary object
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?
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?

34. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Vitals/turn freq/call light close/ ROM
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

35. Encourage the client to hyperventilate
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 has a normal sensory change that results in diminished sense of taste. How would this be documented

36. partial seizures
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 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 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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

37. Atonic Seizure
Muscle stiffness - rigidity
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

38. A client with a high cervical spine injury
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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
Seizures are divided into two broad categories:

39. 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 client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Seizures are divided into two broad categories:
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

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

41. 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
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

42. Myoclonic Seizure
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

43. Artificial tears
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?

44. Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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
Unconsciousness - convulsions - muscle rigidity

45. 'Wake him every hour and assess his orientation to person - time - and place
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
An 18-year - old client 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?

46. Intracranial hemorrhages
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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 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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

47. acceleration injury
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.
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

48. Noxious stimuli
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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
CN III

49. Linear skull fractures
CN III
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
Blunt trauma
Whiplash - shaken baby

50. 4 things that protect the brain
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved