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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. Intracranial hemorrhages
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 has been pronounced brain dead. Which findings would the nurse assess?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

2. Put the client in the high - Fowler's position
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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:
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

3. Dilated non reactive pupils
Meningies - csf - blood - brain barrier - skull
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A client has been pronounced brain dead. Which findings would the nurse assess?
Vitals/turn freq/call light close/ ROM

4. Loss of lens elasticity
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.
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

5. Hyperflexion injuries
Whiplash - shaken baby
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 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

6. CN IX and CN VII
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

7. Check the fluid for dextrose with a dipstick
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
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?
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?

8. Encourage the client to hyperventilate
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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 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?

9. Linear skull fractures
Blunt trauma
Vitals/turn freq/call light close/ ROM
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?
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.

10. Immobilize the client's head and neck

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11. Evaluate urine specific gravity
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
Whiplash - shaken baby
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?

12. generalized and partial (also called local or focal)
Whiplash - shaken baby
Gap between the dura and the cortical surface of the brain.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Seizures are divided into two broad categories:

13. Atonic Seizure
Which of the following physiologic changes would be expected in a patient with presbyopia?
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.
Meningies - csf - blood - brain barrier - skull

14. Depressed skull fractures
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
High - energy transfer - such as a blow from a baseball bat
CN III
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?

15. Generalized seizures
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
are produced by electrical impulses from throughout the entire brain

16. Rapid dilantin administration can cause cardiac arrhythmias
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?
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

17. Wrap her hands in soft 'mitten' restraints
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.
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 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A 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?

18. Laceration of the middle meningeal artery
High - energy transfer - such as a blow from a baseball bat
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?
Vitals/turn freq/call light close/ ROM
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

19. Tonic Seizure
Unconsciousness - convulsions - muscle rigidity
Muscle stiffness - rigidity
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Collision between a rapidly moving body part and a stationary object

20. Back arched; rigid extension of all four extremities.
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
Which of the following describes decerebrate posturing?
Meningies - csf - blood - brain barrier - skull
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

21. 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.
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?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

22. Limiting bladder catherization to once every 12 hours
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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

23. Reposition the client to avoid neck flexion
Gap between the dura and the cortical surface of the brain.
Meningies - csf - blood - brain barrier - skull
High - energy transfer - such as a blow from a baseball bat
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?

24. Raise the head of the bed immediately to 90 degrees
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Collision between a rapidly moving body part and a stationary object

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
Muscle stiffness - rigidity
Meningies - csf - blood - brain barrier - skull
CN III

26. Parkinson's disease
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 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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

27. The patient should be placed on droplet precautions.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
CN III
A client has been pronounced brain dead. Which findings would the nurse assess?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

28. 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 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
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.

29. Clonic Seizure
CN III
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which of the following physiologic changes would be expected in a patient with presbyopia?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

30. 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
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 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 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:

31. To immobilize the surgical spine
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
Which of the following describes decerebrate posturing?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

32. Inability to elicit a Babinski's reflex
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
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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.

33. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?
Vitals/turn freq/call light close/ ROM
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.

34. 4 things that protect 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?
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?
Meningies - csf - blood - brain barrier - skull
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?

35. 'The lens is normally transparent
Which of the following describes decerebrate posturing?
Vitals/turn freq/call light close/ ROM
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?

36. Epidural hematoma
A 78-year - old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patien
A 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 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 arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

37. Decorticate
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

38. Noxious stimuli
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?

39. acceleration injury
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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.
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. Slow - irregular respirations
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

41. Dopamine
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A 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?

42. Subdural hemorrhage
Gap between the dura and the cortical surface of the brain.
Whiplash - shaken baby
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

43. partial seizures
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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

44. 'Grand Mal' or Generalized tonic - clonic
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Whiplash - shaken baby
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Unconsciousness - convulsions - muscle rigidity

45. Activity of the brain
are produced by electrical impulses from throughout the entire brain
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

46. Basilar 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?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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
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?

47. Decrease in LOC

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48. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?

49. deceleration injury
Which of the following describes decerebrate posturing?
Collision between a rapidly moving body part and a stationary object
Gap between the dura and the cortical surface of the brain.
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

50. A client with a high cervical spine injury
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Muscle stiffness - rigidity
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?