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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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1. Loss of lens elasticity
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?
Collision between a rapidly moving body part and a stationary object
Which of the following physiologic changes would be expected in a patient with presbyopia?
Seizures are divided into two broad categories:

2. A client with a high cervical spine injury
Vitals/turn freq/call light close/ ROM
are produced (at least initially) by electrical impulses in a relatively small part 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
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

3. Limiting bladder catherization to once every 12 hours
Collision between a rapidly moving body part and a stationary object
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?
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 physiologic changes would be expected in a patient with presbyopia?

4. Atonic Seizure
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 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?

5. Hypogeusia
Seizures are divided into two broad categories:
Gap between the dura and the cortical surface of the brain.
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

6. Encourage the client to hyperventilate
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

7. Parkinson's disease
Seizures are divided into two broad categories:
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 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?
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. Rapid dilantin administration can cause cardiac arrhythmias
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?
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 a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

9. Absence 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?
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
Which of the following physiologic changes would be expected in a patient with presbyopia?

10. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
Blunt trauma
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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.

11. Decrease in LOC

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12. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 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

13. 4 things that protect the brain
Whiplash - shaken baby
Meningies - csf - blood - brain barrier - skull
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

14. To immobilize the surgical spine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Muscle stiffness - rigidity
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

15. Noxious stimuli
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Head is suddenly forced to stop or start moving - or to turn rapidly.

16. Myoclonic Seizure
are produced by electrical impulses from throughout the entire brain
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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.

17. partial seizures
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

18. Immobilize the client's head and neck

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19. Check the fluid for dextrose with a dipstick
Vitals/turn freq/call light close/ ROM
Seizures are divided into two broad categories:
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 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?

20. Reposition the client to avoid neck flexion
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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
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?

21. 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
CN III
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 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 has a normal sensory change that results in diminished sense of taste. How would this be documented

22. Dilated non reactive pupils
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A client has been pronounced brain dead. Which findings would the nurse assess?
Muscle stiffness - rigidity
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:

23. Unequal pupil size
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Blunt trauma

24. acceleration injury
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
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 neurotransmitter is responsible for may of the functions of the frontal lobe?
Head is suddenly forced to stop or start moving - or to turn rapidly.

25. Intracranial hemorrhages
Meningies - csf - blood - brain barrier - skull
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

26. Slow - irregular respirations
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Muscle stiffness - rigidity
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?

27. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Blunt trauma
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Gap between the dura and the cortical surface of the brain.

28. Wrap her hands in soft 'mitten' restraints
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?
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?

29. Dopamine
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
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 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?

30. Evaluate urine specific gravity
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
Whiplash - shaken baby
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

31. Inability to elicit a Babinski's reflex
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
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Meningies - csf - blood - brain barrier - skull

32. Decorticate
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
High - energy transfer - such as a blow from a baseball bat
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

33. Damage to cranial nerve I
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
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?
Blunt trauma

34. Laceration of the middle meningeal artery
are produced by electrical impulses from throughout the entire brain
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 who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?

35. 'Wake him every hour and assess his orientation to person - time - and place
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

36. Tonic Seizure
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Muscle stiffness - rigidity
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?

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

38. Epidural hematoma
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 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 has been pronounced brain dead. Which findings would the nurse assess?

39. Clonic Seizure
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.
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Unconsciousness - convulsions - muscle rigidity

40. Generalized seizures
are produced by electrical impulses from throughout the entire brain
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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

41. Linear skull fractures
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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?

42. generalized and partial (also called local or focal)
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?
Seizures are divided into two broad categories:
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?

43. Activity of the 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
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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?

44. Quadriplegia with gross arm movement and diaphragmic breathing

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45. Subdural hemorrhage
Meningies - csf - blood - brain barrier - skull
Which of the following physiologic changes would be expected in a patient with presbyopia?
Gap between the dura and the cortical surface of the 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?

46. Encouraging compliance with drug therapy to prevent loss of vision
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause 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
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 describes decerebrate posturing?

47. Hyperflexion injuries
Head is suddenly forced to stop or start moving - or to turn rapidly.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

48. nsg intervention for spinal injury
Seizures are divided into two broad categories:
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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Vitals/turn freq/call light close/ ROM

49. 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?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
are produced by electrical impulses from throughout the entire brain
Blunt trauma

50. Raise the head of the bed immediately to 90 degrees
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
Collision between a rapidly moving body part and a stationary object

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NCLEX Neuro

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