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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. Artificial tears
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 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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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?

2. Wrap her hands in soft 'mitten' restraints
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.
Which of the following describes decerebrate posturing?
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?

3. Depressed skull fractures
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?
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?

4. Laceration of the middle meningeal artery
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
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 is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?

5. Dilated non reactive pupils
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 client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
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?

6. Unequal pupil size
Muscle stiffness - rigidity
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Which of the following physiologic changes would be expected in a patient with presbyopia?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

7. 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?
Vitals/turn freq/call light close/ ROM
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 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?

8. 'The lens is normally transparent
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?
are produced by electrical impulses from throughout the entire brain

9. Put the client in the high - Fowler's position
Muscle stiffness - rigidity
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 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?

10. Back arched; rigid extension of all four extremities.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which of the following describes decerebrate posturing?
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

11. acceleration injury
Vitals/turn freq/call light close/ ROM
Head is suddenly forced to stop or start moving - or to turn rapidly.
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

12. Basilar skull fractures
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 of the following describes decerebrate posturing?
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:
Seizures are divided into two broad categories:

13. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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 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?

14. 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
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 physiologic changes would be expected in a patient with presbyopia?
CN III
are produced by electrical impulses from throughout the entire brain

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

16. Subdural hemorrhage
Gap between the dura and the cortical surface of the brain.
Seizures are divided into two broad categories:
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
The nurse is 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

17. deceleration injury
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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
Collision between a rapidly moving body part and a stationary object

18. Myoclonic Seizure
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 patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
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.

19. The patient should be placed on droplet precautions.
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 receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
High - energy transfer - such as a blow from a baseball bat

20. Quadriplegia with gross arm movement and diaphragmic breathing

21. Inability to elicit a Babinski's reflex
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 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?

22. 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?
Unconsciousness - convulsions - muscle rigidity
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 describes decerebrate posturing?

23. Linear skull fractures
Blunt trauma
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 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

24. Immobilize the client's head and neck

25. 4 things that protect the brain
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Meningies - csf - blood - brain barrier - skull
Head is suddenly forced to stop or start moving - or to turn rapidly.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

26. Encourage the client to hyperventilate
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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.
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

27. nsg intervention for spinal injury
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 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?
Vitals/turn freq/call light close/ ROM

28. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
Meningies - csf - blood - brain barrier - skull
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
Which of the following describes decerebrate posturing?

29. generalized and partial (also called local or focal)
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Seizures are divided into two broad categories:
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?
Whiplash - shaken baby

30. A client with a high cervical spine injury
Meningies - csf - blood - brain barrier - skull
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?
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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

31. Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?
Muscle stiffness - rigidity
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?

32. Intracranial hemorrhages
Seizures are divided into two broad categories:
Unconsciousness - convulsions - muscle rigidity
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

33. Noxious stimuli
Seizures are divided into two broad categories:
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Head is suddenly forced to stop or start moving - or to turn rapidly.

34. Slow - irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?
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?

35. Hypogeusia
Meningies - csf - blood - brain barrier - skull
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented

36. Reposition the client to avoid neck flexion
Vitals/turn freq/call light close/ ROM
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 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 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?

37. Generalized seizures
Seizures are divided into two broad categories:
are produced by electrical impulses from throughout the entire brain
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

38. To immobilize the surgical spine
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?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Whiplash - shaken baby
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?

39. Activity 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 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
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 been pronounced brain dead. Which findings would the nurse assess?

40. Decrease in LOC

41. Equal pupillary constriction in response to light
Which of the following physiologic changes would be expected in a patient with presbyopia?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.
Vitals/turn freq/call light close/ ROM
You are the nurse assigned to perform an eye assessment on an 80-year - old client. Which of the following findings during the assessment is considered normal?

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

43. Encouraging compliance with drug therapy to prevent loss of vision
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:
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 of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Vitals/turn freq/call light close/ ROM

44. CN IX and CN VII
CN III
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?
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

45. Evaluate urine specific gravity
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 respiratory patterns indicate increasing ICP in the brain stem?
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?
are produced by electrical impulses from throughout the entire brain

46. partial seizures
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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.
Whiplash - shaken baby

47. 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?
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?
Muscle stiffness - rigidity
Gap between the dura and the cortical surface of the brain.

48. Tonic Seizure
Muscle stiffness - rigidity
Collision between a rapidly moving body part and a stationary object
Vitals/turn freq/call light close/ ROM
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?

49. Limiting bladder catherization to once every 12 hours
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
An 18-year - old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

50. Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?