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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. Back arched; rigid extension of all four extremities.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which of the following describes decerebrate posturing?
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

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
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
Gap between the dura and the cortical surface of the brain.
CN III

3. 'Wake him every hour and assess his orientation to person - time - and place
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

4. 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 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 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?
Unconsciousness - convulsions - muscle rigidity

5. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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
CN III

6. Linear skull fractures
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Blunt trauma
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.
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

7. Put the client in the high - Fowler's position
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

8. Intracranial hemorrhages
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

9. Depressed skull fractures
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?
High - energy transfer - such as a blow from a baseball bat
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?

10. Raise the head of the bed immediately to 90 degrees
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
A client with 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 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?
Seizures are divided into two broad categories:

11. 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?
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.
Head is suddenly forced to stop or start moving - or to turn rapidly.
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

12. 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 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 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 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?

13. Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
Vitals/turn freq/call light close/ ROM
High - energy transfer - such as a blow from a baseball bat
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

14. Encouraging compliance with drug therapy to prevent loss of vision
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
A client 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?

15. Equal pupillary constriction in response to light
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
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?
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?

16. Slow - irregular respirations
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 respiratory patterns indicate increasing ICP in the brain stem?
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 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?

17. Unequal pupil size
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

18. Epidural hematoma
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?
CN III
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?

19. Basilar skull fractures
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?
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

20. CN IX and CN VII
are produced by electrical impulses from throughout the entire brain
Blunt trauma
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

21. '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?
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

22. Inability to elicit a Babinski's reflex
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?
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 subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

23. deceleration injury
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?
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
Unconsciousness - convulsions - muscle rigidity
Collision between a rapidly moving body part and a stationary object

24. partial seizures
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
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

25. Hyperflexion injuries
Whiplash - shaken baby
Meningies - csf - blood - brain barrier - skull
High - energy transfer - such as a blow from a baseball bat
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

26. 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.
Which of the following describes decerebrate posturing?
Collision between a rapidly moving body part and a stationary object
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

27. Encourage the client to hyperventilate
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Whiplash - shaken baby
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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. Activity of the brain
are produced by electrical impulses from throughout the entire 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
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
Gap between the dura and the cortical surface of the brain.

29. Check the fluid for dextrose with a dipstick
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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 signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

30. Parkinson's disease
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Collision between a rapidly moving body part and a stationary object
Which of the following clients on the rehab unit is most likely to develop 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

31. Immobilize the client's head and neck

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32. 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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Unconsciousness - convulsions - muscle rigidity
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?

33. 'Grand Mal' or Generalized tonic - clonic
Whiplash - shaken baby
Unconsciousness - convulsions - muscle rigidity
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

34. Hypogeusia
Unconsciousness - convulsions - muscle rigidity
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?

35. Loss of lens elasticity
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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

36. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
A client has been pronounced brain dead. Which findings would the nurse assess?
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 comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
Meningies - csf - blood - brain barrier - skull

37. Decrease in LOC

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38. Clonic Seizure
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.
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
Seizures are divided into two broad categories:

39. Subdural hemorrhage
Blunt trauma
are produced by electrical impulses from throughout the entire brain
Gap between the dura and the cortical surface of the brain.
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?

40. A client with a high cervical spine injury
Unconsciousness - convulsions - muscle rigidity
Which of the following clients on the rehab unit is most likely to develop 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?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

41. Epidural hematoma
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
A client 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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

42. Generalized seizures
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
are produced by electrical impulses from throughout the entire brain
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

43. Damage to cranial nerve I
Blunt trauma
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

44. Atonic Seizure
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
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
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?

45. Wrap her hands in soft 'mitten' restraints
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 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 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 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?

46. generalized and partial (also called local or focal)
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Seizures are divided into two broad categories:
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
Vitals/turn freq/call light close/ ROM

47. nsg intervention for spinal 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?
Vitals/turn freq/call light close/ ROM
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 subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

48. The patient should be placed on droplet precautions.
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?
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 signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

49. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Collision between a rapidly moving body part and a stationary object
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
Which of the following describes decerebrate posturing?

50. Limiting bladder catherization to once every 12 hours
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.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Blunt trauma