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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

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

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

1. Intracranial hemorrhages
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
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

2. 'The lens is normally transparent
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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 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?

3. Evaluate urine specific gravity
are produced by electrical impulses from throughout the entire brain
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?
Seizures are divided into two broad categories:
Vitals/turn freq/call light close/ ROM

4. Wrap her hands in soft 'mitten' restraints
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 (at least initially) by electrical impulses in a relatively small part of the brain.
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?

5. partial seizures
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

6. Encouraging compliance with drug therapy to prevent loss of vision
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

7. Tonic Seizure
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?
Muscle stiffness - rigidity
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 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?

8. Put the client in the high - Fowler's position
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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.

9. Slow - irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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
Whiplash - shaken baby
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?

10. Unequal pupil size
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

11. Atonic Seizure
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Which of the following describes decerebrate posturing?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?

12. 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?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Vitals/turn freq/call light close/ ROM
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?

13. Encourage the client to hyperventilate
Which of the following describes decerebrate posturing?
Vitals/turn freq/call light close/ ROM
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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:

14. Quadriplegia with gross arm movement and diaphragmic breathing

15. Inability to elicit a Babinski's reflex
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?
High - energy transfer - such as a blow from a baseball bat
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?
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?

16. Generalized seizures
are produced by electrical impulses from throughout the entire brain
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Seizures are divided into two broad categories:
Unconsciousness - convulsions - muscle rigidity

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

18. Limiting bladder catherization to once every 12 hours
CN III
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?
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

19. Decorticate
High - energy transfer - such as a blow from a baseball bat
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?

20. Loss of lens elasticity
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
Meningies - csf - blood - brain barrier - skull

21. Damage to cranial nerve I
Seizures are divided into two broad categories:
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

22. Linear skull fractures
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?
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
Muscle stiffness - rigidity
Blunt trauma

23. Decrease in LOC

24. Reposition the client to avoid neck flexion
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

25. deceleration injury
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?
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
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

26. Myoclonic Seizure
A client has been pronounced brain dead. Which findings would the nurse assess?
Which of the following describes decerebrate posturing?
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.
High - energy transfer - such as a blow from a baseball bat

27. acceleration injury
are produced (at least initially) by electrical impulses in a relatively small part 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
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following describes decerebrate posturing?

28. 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?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.

29. Back arched; rigid extension of all four extremities.
Seizures are divided into two broad categories:
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?
Vitals/turn freq/call light close/ ROM
Which of the following describes decerebrate posturing?

30. Dopamine
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:
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 neurotransmitter is responsible for may of the functions of the frontal lobe?
Gap between the dura and the cortical surface of the brain.

31. 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.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Vitals/turn freq/call light close/ ROM

32. Activity of the brain
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 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?

33. Artificial tears
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Seizures are divided into two broad categories:
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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:

34. Dilated non reactive pupils
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.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client has been pronounced brain dead. Which findings would the nurse assess?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

35. 'Wake him every hour and assess his orientation to person - time - and place
are produced (at least initially) by electrical impulses in a relatively small part 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?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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

36. generalized and partial (also called local or focal)
Head is suddenly forced to stop or start moving - or to turn rapidly.
Gap between the dura and the cortical surface of the brain.
Seizures are divided into two broad categories:
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?

37. Hyperflexion injuries
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Whiplash - shaken baby
A client has been pronounced brain dead. Which findings would the nurse assess?
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:

38. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
are produced by electrical impulses from throughout the entire brain
Blunt trauma
Which of the following describes decerebrate posturing?

39. Raise the head of the bed immediately to 90 degrees
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?
Unconsciousness - convulsions - muscle rigidity
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 has been pronounced brain dead. Which findings would the nurse assess?

40. 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
Unconsciousness - convulsions - muscle rigidity
High - energy transfer - such as a blow from a baseball bat
Vitals/turn freq/call light close/ ROM

41. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

42. 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 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 subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
CN III

43. 4 things that protect the brain
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?
CN III
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?

44. 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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Vitals/turn freq/call light close/ ROM
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

45. 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 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?
Meningies - csf - blood - brain barrier - skull
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

46. Absence Seizure
Muscle stiffness - rigidity
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Gap between the dura and the cortical surface of the 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

47. Immobilize the client's head and neck

48. Parkinson's disease
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 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
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

49. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
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?
Blunt trauma
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

50. 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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 has been pronounced brain dead. Which findings would the nurse assess?