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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. 'Grand Mal' or Generalized tonic - clonic
Seizures are divided into two broad categories:
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
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
Unconsciousness - convulsions - muscle rigidity

2. Limiting bladder catherization to once every 12 hours
are produced by electrical impulses from throughout the entire brain
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 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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

3. Rapid dilantin administration can cause cardiac arrhythmias
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
A client 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:
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?

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

5. Reposition the client to avoid neck flexion
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
Whiplash - shaken baby
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. Absence Seizure
Collision between a rapidly moving body part and a stationary object
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 describes decerebrate posturing?
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?

7. Raise the head of the bed immediately to 90 degrees
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 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 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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

8. Atonic Seizure
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
High - energy transfer - such as a blow from a baseball bat

9. Damage to cranial nerve I
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

10. To immobilize the surgical spine
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Blunt trauma

11. Evaluate urine specific gravity
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?
High - energy transfer - such as a blow from a baseball bat
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?

12. Epidural hematoma
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?
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 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 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. Slow - irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
High - energy transfer - such as a blow from a baseball bat
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?

14. 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.
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Whiplash - shaken baby

15. Epidural hematoma
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 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 of the following respiratory patterns indicate increasing ICP in the brain stem?
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?

16. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
CN III
Collision between a rapidly moving body part and a stationary object

17. partial seizures
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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

18. Check the fluid for dextrose with a dipstick
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Meningies - csf - blood - brain barrier - skull

19. Intracranial hemorrhages
A client has been pronounced brain dead. Which findings would the nurse assess?
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

20. Laceration of the middle meningeal artery
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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

21. 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 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 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?

22. generalized and partial (also called local or focal)
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Seizures are divided into two broad categories:
Meningies - csf - blood - brain barrier - skull
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

23. Loss of lens elasticity
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 physiologic changes would be expected in a patient with presbyopia?

24. 'The lens is normally transparent
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 question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Seizures are divided into two broad categories:

25. Basilar skull fractures
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
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 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 of the following respiratory patterns indicate increasing ICP in the brain stem?

26. Hypogeusia
Muscle stiffness - rigidity
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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

27. Quadriplegia with gross arm movement and diaphragmic breathing

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28. 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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
CN III
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

29. Immobilize the client's head and neck

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30. 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 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?
Gap between the dura and the cortical surface of the brain.

31. Decrease in LOC

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32. Depressed skull fractures
High - energy transfer - such as a blow from a baseball bat
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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

33. acceleration injury
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 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

34. Inability to elicit a Babinski's reflex
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?

35. Subdural hemorrhage
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
Gap between the dura and the cortical surface of the brain.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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. Unequal pupil size
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Head is suddenly forced to stop or start moving - or to turn rapidly.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Collision between a rapidly moving body part and a stationary object

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

38. Myoclonic Seizure
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.
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

39. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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
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?
Vitals/turn freq/call light close/ ROM

40. nsg intervention for spinal injury
High - energy transfer - such as a blow from a baseball bat
Vitals/turn freq/call light close/ ROM
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Which of the following physiologic changes would be expected in a patient with presbyopia?

41. Tonic Seizure
Whiplash - shaken baby
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Muscle stiffness - rigidity

42. Put the client in the high - Fowler's position
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?

43. Decorticate
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Muscle stiffness - rigidity

44. Encourage the client to hyperventilate
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 physiologic changes would be expected in a patient with presbyopia?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

45. Clonic Seizure
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?
Collision between a rapidly moving body part and a stationary object
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

46. Wrap her hands in soft 'mitten' restraints
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?
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
A client has been pronounced brain dead. Which findings would the nurse assess?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

47. Encouraging compliance with drug therapy to prevent loss of vision
are produced by electrical impulses from throughout the entire brain
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.
Blunt trauma
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:

48. Artificial tears
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
Which of the following describes decerebrate posturing?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

49. Linear skull fractures
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Blunt trauma
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

50. 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?
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?
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Seizures are divided into two broad categories: