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NCLEX Neuro

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
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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. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
A client 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 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:
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

2. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client has been pronounced brain dead. Which findings would the nurse assess?
are produced by electrical impulses from throughout the entire brain
Gap between the dura and the cortical surface of the brain.

3. Damage to cranial nerve I
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 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 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?
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

4. 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.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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?
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?

5. CN IX and CN VII
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Muscle stiffness - rigidity
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

6. nsg intervention for spinal injury
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?
CN III
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?
Vitals/turn freq/call light close/ ROM

7. Hypogeusia
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
CN III
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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:

8. Reposition the client to avoid neck flexion
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

9. Epidural hematoma
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
Muscle stiffness - rigidity
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

10. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
High - energy transfer - such as a blow from a baseball bat
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 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?

11. partial seizures
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 with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

12. Equal pupillary constriction in response to light
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
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?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

13. Inability to elicit a Babinski's reflex
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
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:
Which of the following describes decerebrate posturing?
Gap between the dura and the cortical surface of the brain.

14. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
Vitals/turn freq/call light close/ ROM
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:
Gap between the dura and the cortical surface of the brain.

15. 4 things that protect the 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?
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?
Meningies - csf - blood - brain barrier - skull

16. Quadriplegia with gross arm movement and diaphragmic breathing

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17. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

18. Slow - irregular respirations
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 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?
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

19. 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
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
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?

20. Depressed skull fractures
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
High - energy transfer - such as a blow from a baseball bat

21. Atonic Seizure
Vitals/turn freq/call light close/ ROM
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
Meningies - csf - blood - brain barrier - skull
A 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?

22. 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
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
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

23. Rapid dilantin administration can cause cardiac arrhythmias
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?
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 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?

24. Wrap her hands in soft 'mitten' restraints
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 patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
A client with 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:

25. Back arched; rigid extension of all four extremities.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
Which of the following describes decerebrate posturing?
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?

26. 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?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?

27. Activity 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?
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
Meningies - csf - blood - brain barrier - skull

28. Absence Seizure
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
Whiplash - shaken baby
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?

29. Decrease in LOC

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30. Dilated non reactive pupils
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.
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Collision between a rapidly moving body part and a stationary object

31. Tonic Seizure
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
Muscle stiffness - rigidity
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

32. Generalized seizures
Meningies - csf - blood - brain barrier - skull
are produced by electrical impulses from throughout the entire 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:
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?

33. Unequal pupil size
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

34. Noxious stimuli
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 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?
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?

35. Artificial tears
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

36. deceleration injury
Collision between a rapidly moving body part and a stationary object
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action - knowing this i
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Which of the following physiologic changes would be expected in a patient with presbyopia?

37. Subdural hemorrhage
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.
Unconsciousness - convulsions - muscle rigidity
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Gap between the dura and the cortical surface of the brain.

38. Encourage the client to hyperventilate
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which of the following physiologic changes would be expected in a patient with presbyopia?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

39. Check the fluid for dextrose with a dipstick
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A 23-year - old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?

40. Intracranial hemorrhages
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 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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

41. Dopamine
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?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Collision between a rapidly moving body part and a stationary object

42. 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?
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.
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 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?

43. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
are produced by electrical impulses from throughout the entire brain
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 physiologic changes would be expected in a patient with presbyopia?

44. A client with a high cervical spine injury
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?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

45. 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?
Collision between a rapidly moving body part and a stationary object
Unconsciousness - convulsions - muscle 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

46. '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?
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:
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Blunt trauma

47. acceleration injury
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Head is suddenly forced to stop or start moving - or to turn rapidly.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

48. 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?
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?
Collision between a rapidly moving body part and a stationary object
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:

49. Encouraging compliance with drug therapy to prevent loss of vision
Muscle stiffness - rigidity
are produced (at least initially) by electrical impulses in a relatively small part 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?
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:

50. Immobilize the client's head and neck

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NCLEX Neuro

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