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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. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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 signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

2. Immobilize the client's head and neck

3. Generalized seizures
Muscle stiffness - rigidity
Seizures are divided into two broad categories:
Gap between the dura and the cortical surface of the brain.
are produced by electrical impulses from throughout the entire brain

4. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Head is suddenly forced to stop or start moving - or to turn rapidly.
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

5. Dilated non reactive pupils
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A client has been pronounced brain dead. Which findings would the nurse assess?
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 physiologic changes would be expected in a patient with presbyopia?

6. Noxious stimuli
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
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause 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?

7. acceleration injury
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?
Unconsciousness - convulsions - muscle rigidity

8. Quadriplegia with gross arm movement and diaphragmic breathing

9. Activity of the brain
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 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

10. Evaluate urine specific gravity
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.
Seizures are divided into two broad categories:
Which of the following describes decerebrate posturing?
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?

11. Depressed skull fractures
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 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
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?

12. Decorticate
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

13. 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
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?
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?

14. Dopamine
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?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

15. Clonic 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.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

16. 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?
are produced (at least initially) by electrical impulses in a relatively small part 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
CN III

17. Subdural hemorrhage
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
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?
Gap between the dura and the cortical surface of the brain.

18. partial seizures
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Unconsciousness - convulsions - muscle rigidity
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

19. Myoclonic 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?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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.

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

21. A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a 'blown pupil' (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disrup
CN III
A client 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?
Vitals/turn freq/call light close/ ROM
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

22. Encourage the client to hyperventilate
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 comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
A client with 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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

23. 'Wake him every hour and assess his orientation to person - time - and place
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?

24. Check the fluid for dextrose with a dipstick
Gap between the dura and the cortical surface of the brain.
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Muscle stiffness - rigidity
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?

25. Atonic Seizure
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
Vitals/turn freq/call light close/ ROM
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

26. Slow - irregular respirations
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?
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?

27. Tonic Seizure
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Muscle stiffness - rigidity

28. 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?
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?
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 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

29. Inability to elicit a Babinski's reflex
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?
Collision between a rapidly moving body part and a stationary object
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?

30. A client with a high cervical spine injury
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?

31. Absence Seizure
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Blunt trauma
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
CN III

32. The patient should be placed on droplet precautions.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
High - energy transfer - such as a blow from a baseball bat
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 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?

33. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
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
Meningies - csf - blood - brain barrier - skull
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

34. Raise the head of the bed immediately to 90 degrees
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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. nsg intervention for spinal injury
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 physiologic changes would be expected in a patient with presbyopia?
Vitals/turn freq/call light close/ ROM
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

36. Hypogeusia
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
are produced by electrical impulses from throughout the entire brain
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented

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

38. Laceration of the middle meningeal artery
Blunt trauma
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?
CN III
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

39. Intracranial hemorrhages
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
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Blunt trauma
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

40. Decrease in LOC

41. Encouraging compliance with drug therapy to prevent loss of vision
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
CN III
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:

42. 'Grand Mal' or Generalized tonic - clonic
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.
Meningies - csf - blood - brain barrier - skull
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Unconsciousness - convulsions - muscle rigidity

43. Loss of lens elasticity
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

44. Reposition the client to avoid neck flexion
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?
Blunt trauma
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. deceleration injury
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.
Collision between a rapidly moving body part and a stationary object
CN III

46. To immobilize the surgical spine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
The nurse is 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?

47. Artificial tears
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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 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?

48. Rapid dilantin administration can cause cardiac arrhythmias
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 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 subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

49. Epidural hematoma
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

50. Linear skull fractures
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Blunt trauma