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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. To immobilize the surgical spine
A client with a 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 a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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?

2. Immobilize the client's head and neck

3. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
Head is suddenly forced to stop or start moving - or to turn rapidly.
CN III
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

4. The patient should be placed on droplet precautions.
CN III
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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.

5. Noxious stimuli
CN III
Unconsciousness - convulsions - muscle rigidity
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
High - energy transfer - such as a blow from a baseball bat

6. Activity of the brain
Blunt trauma
Gap between the dura and the cortical surface 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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented

7. Evaluate urine specific gravity
Gap between the dura and the cortical surface of the brain.
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

8. Encouraging compliance with drug therapy to prevent loss of vision
Which of the following describes decerebrate posturing?
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
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?

9. 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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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.

10. Rapid dilantin administration can cause cardiac arrhythmias
Which of the following describes decerebrate posturing?
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
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 has been pronounced brain dead. Which findings would the nurse assess?

11. 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
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?
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
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

12. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

13. Hyperflexion injuries
Whiplash - shaken baby
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 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
Vitals/turn freq/call light close/ ROM

14. 4 things that protect the brain
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Meningies - csf - blood - brain barrier - skull
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?

15. Reposition the client to avoid neck flexion
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?
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 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?

16. CN IX and CN VII
Collision between a rapidly moving body part and a stationary object
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?

17. Loss of lens elasticity
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Muscle stiffness - rigidity
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

18. Intracranial hemorrhages
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

19. Artificial tears
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

20. Generalized seizures
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Which of the following physiologic changes would be expected in a patient with presbyopia?
are produced by electrical impulses from throughout the entire brain
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. Slow - irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?
Blunt trauma
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?

22. Linear skull fractures
Blunt trauma
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 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?

23. 'The lens is normally transparent
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 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 patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
CN III

24. Dilated non reactive pupils
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client has been pronounced brain dead. Which findings would the nurse assess?

25. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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 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?
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?

26. deceleration injury
Collision between a rapidly moving body part and a stationary object
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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.

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

28. Unequal pupil size
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 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 at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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

29. Laceration of the middle meningeal artery
Meningies - csf - blood - brain barrier - skull
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?
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

30. Absence Seizure
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Vitals/turn freq/call light close/ ROM
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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

31. Quadriplegia with gross arm movement and diaphragmic breathing

32. nsg intervention for spinal injury
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
Muscle stiffness - rigidity
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Vitals/turn freq/call light close/ ROM

33. acceleration injury
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
Meningies - csf - blood - brain barrier - skull
Head is suddenly forced to stop or start moving - or to turn rapidly.
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

34. Back arched; rigid extension of all four extremities.
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Which of the following describes decerebrate posturing?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

35. Hypogeusia
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
CN III
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A client has been pronounced brain dead. Which findings would the nurse assess?

36. Clonic Seizure
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Head is suddenly forced to stop or start moving - or to turn rapidly.

37. Limiting bladder catherization to once every 12 hours
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?
Muscle stiffness - rigidity
High - energy transfer - such as a blow from a baseball bat

38. Inability to elicit a Babinski's reflex
A client has been pronounced brain dead. Which findings would the nurse assess?
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 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 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

39. 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
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?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

40. generalized and partial (also called local or focal)
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?
Seizures are divided into two broad categories:
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

41. A client with a high cervical spine injury
Unconsciousness - convulsions - muscle rigidity
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 neurotransmitter is responsible for may of the functions of the frontal lobe?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

42. 'Wake him every hour and assess his orientation to person - time - and place
CN III
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?
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 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?

43. Epidural hematoma
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 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 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 in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?

44. Subdural hemorrhage
Gap between the dura and the cortical surface of the 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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

45. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
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?
Gap between the dura and the cortical surface of the brain.

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

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

48. Raise the head of the bed immediately to 90 degrees
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.
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?
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?

49. Depressed skull fractures
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
High - energy transfer - such as a blow from a baseball bat

50. Decrease in LOC