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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. Decorticate
Collision between a rapidly moving body part and a stationary object
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

2. Evaluate urine specific gravity
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?
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 neurotransmitter is responsible for may of the functions of the frontal lobe?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

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

4. Reposition the client to avoid neck flexion
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
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?

5. 'Grand Mal' or Generalized tonic - clonic
Gap between the dura and the cortical surface of the brain.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Unconsciousness - convulsions - muscle rigidity
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

6. 'Wake him every hour and assess his orientation to person - time - and place
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.
High - energy transfer - such as a blow from a baseball bat
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

7. Activity of the brain
are produced by electrical impulses from throughout the entire brain
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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.
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

8. Wrap her hands in soft 'mitten' restraints
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
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?

9. 'The lens is normally transparent
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Collision between a rapidly moving body part and a stationary object
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

10. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Collision between a rapidly moving body part and a stationary object
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Unconsciousness - convulsions - muscle rigidity

11. Equal pupillary constriction in response to light
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?
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?

12. Basilar skull fractures
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
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
Seizures are divided into two broad categories:
Collision between a rapidly moving body part and a stationary object

13. Check the fluid for dextrose with a dipstick
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 a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i

14. Raise the head of the bed immediately to 90 degrees
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?
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Seizures are divided into two broad categories:

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

17. 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
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?
Blunt trauma
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

18. generalized and partial (also called local or focal)
A client has been pronounced brain dead. Which findings would the nurse assess?
Seizures are divided into two broad categories:
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Which of the following physiologic changes would be expected in a patient with presbyopia?

19. Epidural hematoma
Gap between the dura and the cortical surface of the brain.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

20. Generalized seizures
are produced by electrical impulses from throughout the entire 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?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Meningies - csf - blood - brain barrier - skull

21. 4 things that protect the brain
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Meningies - csf - blood - brain barrier - skull

22. Put the client in the high - Fowler's position
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
High - energy transfer - such as a blow from a baseball bat
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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

23. Intracranial hemorrhages
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 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.

24. Decrease in LOC

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25. 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
are produced by electrical impulses from throughout the entire brain
Whiplash - shaken baby
Which of the following describes decerebrate posturing?

26. Hyperflexion injuries
Head is suddenly forced to stop or start moving - or to turn rapidly.
Gap between the dura and the cortical surface of the brain.
Which of the following physiologic changes would be expected in a patient with presbyopia?
Whiplash - shaken baby

27. Loss of lens elasticity
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Collision between a rapidly moving body part and a stationary object
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

28. CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

29. 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?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Caused by a blow to the back of the head - characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:

30. Rapid dilantin administration can cause cardiac arrhythmias
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A client with a 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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

31. acceleration injury
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
You are 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.
Head is suddenly forced to stop or start moving - or to turn rapidly.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

32. Dopamine
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Gap between the dura and the cortical surface of the brain.
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:

33. Encourage the client to hyperventilate
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

34. Unequal pupil size
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 at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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?
Seizures are divided into two broad categories:

35. partial seizures
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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 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?

36. Absence Seizure
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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
Collision between a rapidly moving body part and a stationary object

37. Limiting bladder catherization to once every 12 hours
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?
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?
Collision between a rapidly moving body part and a stationary object

38. Depressed skull fractures
High - energy transfer - such as a blow from a baseball bat
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
A client 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?

39. Linear skull fractures
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?
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?

40. 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 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 with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Gap between the dura and the cortical surface of the brain.

41. Artificial tears
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

42. The patient should be placed on droplet precautions.
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
Which of the following physiologic changes would be expected in a patient with presbyopia?
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

43. Myoclonic Seizure
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?
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 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 client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

44. Back arched; rigid extension of all four extremities.
Meningies - csf - blood - brain barrier - skull
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 of the following describes decerebrate posturing?
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?

45. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Vitals/turn freq/call light close/ ROM
Which of the following describes decerebrate posturing?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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?

46. deceleration injury
Which of the following describes decerebrate posturing?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Collision between a rapidly moving body part and a stationary object
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?

47. Encouraging compliance with drug therapy to prevent loss of vision
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.
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:

48. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect

49. Noxious stimuli
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?
Collision between a rapidly moving body part and a stationary object
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

50. Atonic Seizure
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?
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