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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
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
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:
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?

2. Tonic Seizure
Blunt trauma
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 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

3. Loss of lens elasticity
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?
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?

4. Activity of the brain
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Collision between a rapidly moving body part and a stationary object
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

5. Immobilize the client's head and neck

6. 'Wake him every hour and assess his orientation to person - time - and place
A client has been pronounced brain dead. Which findings would the nurse assess?
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 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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

7. 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?
Blunt trauma
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Collision between a rapidly moving body part and a stationary object

8. Dilated non reactive pupils
Collision between a rapidly moving body part and a stationary object
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.
CN III

9. 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?
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?
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 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

10. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

11. partial seizures
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Muscle stiffness - rigidity

12. Generalized seizures
are produced by electrical impulses from throughout the entire brain
Which of the following describes decerebrate posturing?
High - energy transfer - such as a blow from a baseball bat
Blunt trauma

13. 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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?

14. 'Grand Mal' or Generalized tonic - clonic
High - energy transfer - such as a blow from a baseball bat
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Unconsciousness - convulsions - muscle rigidity
Vitals/turn freq/call light close/ ROM

15. Decorticate
Meningies - csf - blood - brain barrier - skull
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 clients on the rehab unit is most likely to develop autonomic dysreflexia?

16. deceleration injury
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 cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Unconsciousness - convulsions - muscle rigidity
Collision between a rapidly moving body part and a stationary object

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

18. 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?
are produced by electrical impulses from throughout the entire brain
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?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.

19. Decrease in LOC

20. acceleration injury
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

21. 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 22-year - old client with quadriplegia is apprehensive and flushed - with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
The nurse is 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?
Which of the following describes decerebrate posturing?

22. Hyperflexion injuries
A client has been pronounced brain dead. Which findings would the nurse assess?
Whiplash - shaken baby
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

23. 'The lens is normally transparent
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
An 18-year - old client was hit in the head with a baseball during practice. When discharging him to the care of his mother - the nurse gives which of the following instructions?
A client has been pronounced brain dead. Which findings would the nurse assess?
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?

24. Reposition the client to avoid neck flexion
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?
Gap between the dura and the cortical surface of the brain.
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?

25. 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 describes decerebrate posturing?
Blunt trauma
Gap between the dura and the cortical surface of the brain.

26. Quadriplegia with gross arm movement and diaphragmic breathing

27. Basilar skull fractures
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?
Vitals/turn freq/call light close/ ROM
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
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.

28. Wrap her hands in soft 'mitten' restraints
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
CN III
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?
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.

29. The patient should be placed on droplet precautions.
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?
CN III
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.

30. Absence Seizure
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache - stiff neck - subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit.
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?
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?

31. A client with a high cervical spine injury
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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?
Seizures are divided into two broad categories:

32. Check the fluid for dextrose with a dipstick
Muscle stiffness - rigidity
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 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 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?

33. Back arched; rigid extension of all four extremities.
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?

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

35. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
A client has been pronounced brain dead. Which findings would the nurse assess?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Meningies - csf - blood - brain barrier - skull

36. Encourage the client to hyperventilate
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
CN III
Which of the following physiologic changes would be expected in a patient with presbyopia?
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

37. Epidural hematoma
Whiplash - shaken baby
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 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.
Blunt trauma

38. 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?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Which of the following describes decerebrate posturing?
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?

39. 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?
Vitals/turn freq/call light close/ ROM
Which of the following physiologic changes would be expected in a patient with presbyopia?
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. 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?
Unconsciousness - convulsions - muscle rigidity
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?
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.

41. Clonic Seizure
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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 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?
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?

42. Epidural hematoma
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 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.
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?

43. 4 things that protect the brain
Blunt trauma
Meningies - csf - blood - brain barrier - skull
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

44. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

45. Linear skull fractures
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Blunt trauma
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

46. 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
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
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?
Vitals/turn freq/call light close/ ROM

47. Myoclonic Seizure
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?
CN III
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.

48. Dopamine
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?
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Whiplash - shaken baby

49. Slow - irregular respirations
Meningies - csf - blood - brain barrier - skull
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

50. Noxious stimuli
Whiplash - shaken baby
Gap between the dura and the cortical surface of the brain.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?