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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. Wrap her hands in soft 'mitten' restraints
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 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?
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. Decrease in LOC

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3. Intracranial hemorrhages
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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?

4. 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?
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
Which of the following physiologic changes would be expected in a patient with presbyopia?
Unconsciousness - convulsions - muscle rigidity

5. Linear skull fractures
Head is suddenly forced to stop or start moving - or to turn rapidly.
Blunt trauma
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments

6. Encourage the client to hyperventilate
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?
Muscle stiffness - rigidity
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

7. Activity of the brain
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 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 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
Vitals/turn freq/call light close/ ROM

8. CN IX and CN VII
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?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
are produced (at least initially) by electrical impulses in a relatively small part of the brain.

9. Hyperflexion injuries
Whiplash - shaken baby
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
Seizures are divided into two broad categories:

10. To immobilize the surgical spine
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?
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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?

11. Laceration of the middle meningeal artery
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?
Vitals/turn freq/call light close/ ROM
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?

12. Decorticate
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Muscle stiffness - rigidity
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

13. deceleration injury
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 respiratory patterns indicate increasing ICP in the brain stem?
Collision between a rapidly moving body part and a stationary object
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?

14. Dilated non reactive pupils
Seizures are divided into two broad categories:
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?
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 has been pronounced brain dead. Which findings would the nurse assess?

15. Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
High - energy transfer - such as a blow from a baseball bat
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Gap between the dura and the cortical surface of the brain.

16. Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
After falling 20' - a 36-year - old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
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
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?

17. Basilar skull fractures
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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 nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.

18. Parkinson's disease
are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Seizures are divided into two broad categories:
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
Which of the following describes decerebrate posturing?

19. Raise the head of the bed immediately to 90 degrees
Gap between the dura and the cortical surface of the brain.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause 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?
are produced by electrical impulses from throughout the entire brain

20. Inability to elicit a Babinski's reflex
Repetitive - rhythmic jerks that involve both sides of the body at the same time.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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?
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?

21. Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
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?
CN III
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

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

23. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
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 has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
A client receiving vent - assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

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

25. Loss of lens elasticity
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?
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
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

26. partial seizures
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?
Unconsciousness - convulsions - muscle rigidity
Gap between the dura and the cortical surface of the brain.

27. generalized and partial (also called local or focal)
Seizures are divided into two broad categories:
Whiplash - shaken baby
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

28. Depressed skull fractures
High - energy transfer - such as a blow from a baseball bat
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
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 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?

29. nsg intervention for spinal injury
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?
Gap between the dura and the cortical surface of the brain.
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:

30. The patient should be placed on droplet precautions.
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 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 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?
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.

31. Myoclonic Seizure
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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.
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

32. Put the client in the high - Fowler's position
are produced by electrical impulses from throughout the entire brain
Collision between a rapidly moving body part and a stationary object
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.
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?

33. Encouraging compliance with drug therapy to prevent loss of vision
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 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?
Head is suddenly forced to stop or start moving - or to turn rapidly.

34. Check the fluid for dextrose with a dipstick
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 patient has a normal sensory change that results in diminished sense of taste. How would this be documented
are produced by electrical impulses from throughout the entire brain

35. Evaluate urine specific gravity
are produced by electrical impulses from throughout the entire brain
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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 has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

36. Tonic 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
Muscle stiffness - rigidity
are produced by electrical impulses from throughout the entire brain
Unconsciousness - convulsions - muscle rigidity

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

38. 'Grand Mal' or Generalized tonic - clonic
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
Muscle stiffness - rigidity
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?
Unconsciousness - convulsions - muscle rigidity

39. Clonic Seizure
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.
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?
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.

40. Epidural hematoma
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 has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
Which neurotransmitter is responsible for may of the functions of the frontal lobe?

41. Absence Seizure
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
Short loss of consciousness (just a few seconds) with few or no symptoms. The patient - most often a child - typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are us
Collision between a rapidly moving body part and a stationary object
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. Damage to cranial nerve I
Blunt trauma
Collision between a rapidly moving body part and a stationary object
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which o
A 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

43. Rapid dilantin administration can cause cardiac arrhythmias
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 signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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?
Which of the following physiologic changes would be expected in a patient with presbyopia?

44. 4 things that protect the brain
Meningies - csf - blood - brain barrier - skull
Gap between the dura and the cortical surface of the brain.
A client with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?
Abnormal posturing that involves rigidity - flexion of the arms - clenched fists - and extended legs.

45. Epidural hematoma
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
During an episode of autonomic dysreflexia in which the client becomes hypertensive - the nurse should perform which of the following interventions?
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 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. 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
Seizures are divided into two broad categories:
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 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?

47. Place a tongue - blade in the patient's mouth to prevent blockage of the airway.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
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 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?
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved

48. 'Wake him every hour and assess his orientation to person - time - and place
Sudden and general loss of muscle tone - particularly in the arms and legs - which often results in a fall.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Which of the following physiologic changes would be expected in a patient with presbyopia?
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?

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

50. Slow - irregular respirations
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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 with a cervical spine injury has Gardner - Wells tongs inserted for which of the following reasons?