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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. Wrap her hands in soft 'mitten' restraints
Collision between a rapidly moving body part and a stationary object
CN III
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

2. nsg intervention for spinal 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?
Blunt trauma
Vitals/turn freq/call light close/ ROM
A client has been pronounced brain dead. Which findings would the nurse assess?

3. Unequal pupil size
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

4. Generalized seizures
are produced by electrical impulses from throughout the entire brain
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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client with head trauma develops a urine output of 300 ml/hr - dry skin - and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

5. Encouraging compliance with drug therapy to prevent loss of vision
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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:
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

6. Decrease in LOC

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7. Slow - irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

8. Artificial tears
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

9. To immobilize the surgical spine
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?

10. 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?
CN III
Which of the following clients on the rehab unit is most likely to develop 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.

11. Limiting bladder catherization to once every 12 hours
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?
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 noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

12. 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
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?
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?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

13. 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 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
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

14. generalized and partial (also called local or focal)
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
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?

15. Depressed skull fractures
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
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.

16. Inability to elicit a Babinski's reflex
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
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?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

17. Rapid dilantin administration can cause cardiac arrhythmias
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 question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
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?

18. A client with a high cervical spine injury
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.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

19. CN IX and CN VII
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?
Whiplash - shaken baby
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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

20. acceleration injury
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
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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

21. Decorticate
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
CN III

22. Quadriplegia with gross arm movement and diaphragmic breathing

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23. Absence Seizure
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
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Blunt trauma

24. Tonic Seizure
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Collision between a rapidly moving body part and a stationary object
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

25. Atonic Seizure
Muscle stiffness - rigidity
Which of the following physiologic changes would be expected in a patient with presbyopia?
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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

26. 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
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 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?
Seizures are divided into two broad categories:

27. Encourage the client to hyperventilate
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Meningies - csf - blood - brain barrier - skull

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

29. Intracranial hemorrhages
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.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A client with a subarachnoid hemorrhage is prescribed a 1 -000- mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

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 client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

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

32. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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?
Sporadic jerks - usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent - these seizures may result in dropping or involuntarily throwing objects.
A patient 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?

33. 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?
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
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

34. Clonic Seizure
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?
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

35. 'Grand Mal' or Generalized tonic - clonic
Unconsciousness - convulsions - muscle rigidity
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
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

36. Laceration of the middle meningeal artery
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
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?

37. Reposition the client to avoid neck flexion
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?
High - energy transfer - such as a blow from a baseball bat
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?

38. Equal pupillary constriction in response to light
CN III
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?
A client has been pronounced brain dead. Which findings would the nurse assess?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

39. Check the fluid for dextrose with a dipstick
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.
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?

40. Hyperflexion injuries
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?
Whiplash - shaken baby

41. Basilar skull fractures
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Blunt trauma
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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

42. 'Wake him every hour and assess his orientation to person - time - and place
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 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?
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?
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?

43. Raise the head of the bed immediately to 90 degrees
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
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client has been pronounced brain dead. Which findings would the nurse assess?
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?

44. Noxious stimuli
A client has been pronounced brain dead. Which findings would the nurse assess?
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?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?

45. deceleration injury
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Collision between a rapidly moving body part and a stationary object
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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.

46. 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?
Whiplash - shaken baby
Muscle stiffness - rigidity
Blunt trauma

47. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
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
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

48. Back arched; rigid extension of all four extremities.
Which of the following physiologic changes would be expected in a patient with presbyopia?
Blunt trauma
Which of the following describes decerebrate posturing?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

49. 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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

50. Immobilize the client's head and neck

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NCLEX Neuro

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