Ratio - Neuro (VR 2.O)

1.
If a male client experienced a CVA that damaged the hypothalamus, the nurse would
anticipate that the client has problems with:
a. Body temperature
b. Balance and equilibrium - refers to cerebellar damage
c. Visual acuity - optic nerve damage
d. Thinking and reasoning - damage to cerebrum
Rationale: https://quizlet.com/202270381/neurologic-2-flash-cards/
The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause
problems of body temperature control.
2. A female client admitted to an acute care facility after a car accident develops signs and
symptoms of increased ICP. The client is intubated and placed on mechanical
ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning,
the nurse anticipates administering which drug endotracheally before suctioning?
a. Phenytoin (dilantin) - prevent seizure (IV)
b. Mannitol (osmitrol) - diuretic (IV)
c. Lidocaine (xylocaine)
d. Furosemide (lasix) - diuretic (IV or PO)
Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by
suctioning.
3. After striking his head on a tree while falling from a ladder, a young man age 18 is
admitted to the emergency department. He’s unconscious and his pupils are
nonreactive. Which intervention would be the most dangerous for the client?
a. Give him a barbiturate - prevent seizures (+)
b. Place him in on mechanical ventilation - facilitate breathing (+)
c. Perform a lumbar puncture - invasive procedure that can increase ICP (-)
d. Elevate the head of the bed - decreased ICP (+)
Rationale:https://quizlet.com/202270381/neurologic-2-flash-cards/
The client's history and assessment suggest that he may have increased intracranial pressure
(ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly
decompress the central nervous system and, thereby, cause additional damage.
4. When obtaining the health history from a client with retinal detachment, the nurse
expects the client to report:
a. Light flashes and floaters in front of the eyes
b. A recent driving accident while changing lanes - glaucoma
c. Headaches, nausea, and redness of the eyes - glaucoma; characterized by loss
of peripheral vision
d. Frequent episodes of double vision - diplopia; manifestation of cataract
The sudden appearance of light flashes and floaters in front of the affected eye is
characteristic of retinal detachment.
5. Which nursing diagnosis takes the highest priority for a client with Parkinson’s Disease?
a. Imbalanced nutrition: less than body requirements
b. Ineffective airway clearance - most life threatening
c. Impaired urinary elimination
d. Risk for injury
In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually

immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and
pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of
these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority.
Although the other options also are appropriate, they aren't immediately life-threatening.
6. To encourage adequate nutritional intake for a female client with Alzheimer’s Disease, the
nurse should:
a. Stay with the client and encourage him to eat - at the same time, you can teach the
client how to eat again
b. Help the client fill out his menu
c. Give the client privacy during meals - no guarantee that the client will eat his food
d. Fill out the menu for the client
Staying with the client and encouraging him to feed himself will ensure adequate food intake.
A client with Alzheimer's disease can forget how to eat.
7. The nurse is performing a mental status examination on a male diagnosed with subdural
hematoma. This test assesses which of the following?
a. Cerebellar function - cerebellum (coordination & balance)
b. Intellectual function
c. Cerebral function
d. Sensory function - pain or sensation
8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops
status epilepticus. The physician orders diazepam (Valium) 10 mg IV stat. How soon can the
nurse administer a second dose of diazepam, if needed as prescribed?
a. In 30 to 45 seconds
b. In 10 to 15 minutes - at times, clients can be prescribed every 5 minutes of diazepam
as long as the don’t exceed 100 mg/day
c. In 30 to 45 minutes
d. In 1 to 2 hours
When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as
needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if
necessary, but the total dose shouldn't exceed 100 mg in 24 hours.
9. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her
right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil - a condition
resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the
physician prescribes atropine sulfate, two drops of 0.5% solution in the right eye twice daily.
Atropine sulfate belongs to which of the following classification?
a. Parasympathomimetic agent
b. Sympatholytic agent
c. Adrenergic agent
d. Cholinergic blocker - blocks the action of acetylcholine from binding to cholinergic
receptors
Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a

sympatholytic agent, or an adrenergic blocker.
10. Emergency medical technicians transport a 27-year-old iron worker to the emergency
department. They tell the nurse, “he fell from a two-story building. He has a large contusion on
his left chest and a hematoma in the left parietal area. He has a compound fracture of his left
femur and he’s comatose. We intubated him and maintained an arterial oxygen saturation of
92% by pulse and a manual-resuscitation bag. Which intervention by the nurse has the highest
priority?
a. Assessing the left leg - check if the wound is bleeding (can lead to shock)
b. Assessing the pupils
c. Placing the client in Trendelenburg - used for shock
d. Assessing the level of consciousness
In the scenario, airway and breathing are established so the nurse's next priority should be
circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding;
therefore, the nurse should assess the site.
11. An auto mechanic accidentally has battery acid splashed in his eyes. His co-workers irrigate
his eyes with water for 20 minutes and then take him to the emergency department of a nearby
hospital, where he receives emergency care for corneal injury. The physician prescribes a
dexamethasone, two drops of 0.1% solution to be instilled initially into the conjunctival sacs of
both eyes every hour; and a polymyxin B sulfate 0.5% ointment to be places in the
conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect
by:
a. Increasing the exudative reaction of ocular tissue - dexamethasone decreases
b. Decreasing leukocyte infiltration at the site of ocular inflammation
c. Inhibiting the action of carbonic anhydrase - dexamethasone will prohibit
d. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the
iris
Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of
ocular inflammation. This reduces the exudative reaction of diseased tissue, lessening
edema, redness, and scarring.
12. Nurse April is caring for a client who underwent lumbar laminectomy 2 days ago. Which of
the following findings should the nurse consider abnormal?
a. More back pain than the first postoperative day - normal because anesthesia will be
wearing off (prescribed pain medication) normal
b. Paresthesia in the dermatomes near the wounds - normal
c. Urine retention or incontinence - complication; manifestation of cauda equina
syndrome which can lead to paralysis of the legs
d. Temperature of 99.2F (37.3C) - normal
Urine retention or incontinence may indicate cauda equina syndrome, which requires
immediate surgery.
13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The
physician pilocarpine ophthalmic solution, 0.25% gtt i OU qid. Based on the prescription, the
nurse should teach the client or family member to administer the drug by:
a. Installing one drop of pilocarpine 0.25% into both eyes daily
b. Installing one drop of pilocarpine 0.25% into both eyes four times daily
c. Installing one drop of pilocarpine 0.25% into the right eye daily
d. Installing one drop of pilocarpine 0.25% into the left eye daily
The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, OU
signifies both eyes, and "q.i.d." means four times a day. Therefore, one drop of pilocarpine
0.25% should be instilled into both eyes four times daily.
14. A female client who’s paralyzed on the left side has been receiving physical therapy and
attending teaching sessions about safety. Which behavior indicates that the client accurately
understands safety measures related to paralysis?
a. The client leaves the side rails down - it should always be up to prevent injuries
b. The client uses a mirror to inspect the skin - checks skin integrity
c. The client repositions only after being reminded to do so - should always turn every hour
d. The client hangs the left arm over the side of the wheelchair - very risky; can impair
circulation
Using a mirror enables the client to inspect all areas of the skin for signs of breakdown
without the help of staff or family members.
15. A male client in the emergency department has a suspected neurologic disorder. To assess
gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half
circle. To document the client’s gait, the nurse should use which term?
a. Ataxic - staggering and unsteady gait
b. Dystrophic - waddles of the leg far apart
c. Helicopod
d. Stoppage - feet and toes are high then drop with the heel
A helicopod gait is an abnormal gait in which the client's feet make a half circle with each
step.
16. A client, age 22, is admitted with bacterial meningitis. Which hospital norm would be the
best choice for this client?
a. A private room down the hall from the nurses’ station - no monitoring (it will be difficult)
b. An isolation room three doors from the nurses’ station - monitoring is important
because clients can lose LOC rapidly which may indicate complications associated with
bacterial meningitis
c. A semi-private room with a 32 year old who has viral meningitis - can be fatal to both
patients
d. A two-bed room with a client who previously had bacterial meningitis
A client with bacterial meningitis should be kept in isolation for at least 24 hours after
admission.
17. A physician diagnoses a client with myasthenia gravis prescribing pyridostigmine,

60mg PO every 3 hours. Before administering this anticholinesterase agent, the nurse reviews
the client’s history. Which presenting condition would contraindicate the use of pyridostigmine:
a. Ulcerative colitis
b. Blood dyscrasia
c. Intestinal obstruction - with this condition, the client cannot secrete the medication
d. Spinal cord injury
Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a

mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to
anticholinesterase agents.
18. A female client is admitted to the facility for investigation of balance and coordination
problems, including possible Meniere’s disease. When assessing this client, the nurse expects
to note:
a. Vertigo, tinnitus, and hearing loss
b. Vertigo, vomiting, and nystagmus - indicative of labyrinthitis
c. Vertigo, pain, and hearing impairment
d. Vertigo, blurred vision, and fever
Ménière's disease, an inner ear disease, is characterized by the symptom triad of vertigo,
tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests
labyrinthitis. Ménière's disease rarely causes pain, blurred vision, or fever.
19. A male client with a conductive hearing disorder caused by the ankylosis of the stapes in
the oval window undergoes a stapedectomy to remove the stapes and replace the impaired
bone with a prosthesis. After the stapedectomy, the nurse should provide which client
instruction?
a. Lie in bed with your head elevated and refrain from blowing your nose for 24 hours
b. Try to ambulate independently after 24 hours
c. Shampoo your hair every day for 10 days and help prevent ear infection - this can
introduce water and other chemicals to the ear
d. Don't fly in an airplane, climb to high altitude, make sudden movements, or
expose yourself to loud sounds for 30 days
For 30 days after a stapedectomy, the client should avoid air travel, sudden movements that
may cause trauma, and exposure to loud sounds and pressure changes (such as from high
altitudes).
20. Nurse Oliver is monitoring a client for adverse reactions to dantrolene. Which adverse
reaction is most common?
a. Excessive tearing
b. Urine retention
c. Muscle weakness
d. Slurred speech
The most common adverse reaction to dantrolene is muscle weakness. The drug also may
depress liver function or cause idiosyncratic hepatitis.
21. The nurse is monitoring a male client for adverse reactions to atropine sulfate eye drops.
Systemic absorption of atropine sulfate through the conjunctive can cause which adverse
reaction?
a. Tachycardia - together with flushing and palpitations
b. Increased salivation
c. Hypotension
d. Apnea
Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin,
ataxia, and confusion. To minimize systemic absorption, the client should apply digital
pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops.
22. A male client is admitted with a cervical spine injury sustained during a diving accident.
When planning the client’s care, the nurse should assign highest priority to which nursing
diagnosis?
a. Impaired physical mobility
b. Ineffective breathing pattern
c. Disturbed sensory perception (tactile)
d. Self-care deficit: dressing/grooming
Because a cervical spine injury can cause respiratory distress, the nurse should take
immediate action to maintain a patent airway and provide adequate oxygenation.
23. A male client has a history of painful, continuous muscle spasms. He has taken several
skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam
(Valium) 2 mg PO twice daily. In addition to being used to relieve painful muscle spasms,
diazepam also is recommended for:
a. Long-term treatment of epilepsy - because diazepam is given via IV
b. Post-operative pain management of laminectomy clients
c. Post-operative pain management of discectomy clients
d. Treatment of spasticity associated with spinal cord lesions
In addition to relieving painful muscle spasms, Diazepam also is recommended for treatment
of spasticity associated with spinal cord lesions. Diazepam's use is limited by its central
nervous system effects and the tolerance that develops with prolonged use.
24. A female client who has been found unconscious is brought to the hospital by a rescue
squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye)
response by:
a. Introducing ice water into the external auditory canal - checking for oculovestibular
response
b. Touching the cornea with a wisp of cotton - for corneal response
c. Turning the client’s head suddenly while holding the eyelids open
d. Shining a bright light into the pupil - brainstem
To elicit the oculocephalic response, which detects cranial nerve compression, the nurse
turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from
side to side when the head is turned; in an abnormal response, the eyes remain fixed.
25. While reviewing a client’s chart, the nurse notices that the female client has myasthenia
gravis. Which of the following statements about neuromuscular blocking agents is true for a
client with this condition?
a. The client may be less sensitive to the effects of a neuromuscular blocking agent
b. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage
c. Pancuronium should not be used; succinylcholine may be used in a lower dosage
d. Pancuronium and succinylcholine both require cautious administration -
succinylcholine is administered by anesthesiologist
The nurse must cautiously administer pancuronium, succinylcholine, and any other
neuromuscular blocking agent to a client with myasthenia gravis.
26. A male client is color blind. The nurse understands that this client has a problem with:
a. Rods - not discriminate to deter color
b. Cones - daylight vision
c. Lens - focus images
d. Aqueous humor - fluid in the eye to prevent it from becoming dry
Cones provide daylight color vision, and their stimulation is interpreted as color. If one or
more types of cones are absent or defective, color blindness occurs.
27. A female client who was trapped in a car for hours after a head-on collision is rushed to the
emergency room with multiple injuries. During the neurologic examination, the client responds to
painful stimuli with decerebrate posturing. This finding indicated damage to which part of the
brain?
a. Diencephalon - decorticate posturing
b. Medulla - flaccidity
c. Midbrain
d. Cortex - decorticate posturing
Decerebrate posturing, characterized by abnormal extension in response to painful stimuli,

indicates damage to the midbrain.
28. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the
following symptoms would the nurse expect to find?
a. Vision changes
b. Absent deep tendon reflexes
c. Tremors at rest - not a characteristic
d. Flaccid muscles
Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple
sclerosis.
29. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a
severe headache. Which action should the nurse perform?
a. Sit with the client for a few minutes
b. Administer an analgesic - doctor’s order is needed
c. Inform the nurse manager
d. Call the physician immediately
A headache may be an indication that an aneurysm is leaking. The nurse should notify the
physician immediately.
30. During recovery from a CVA, a female client is given nothing by mouth, to help prevent
aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s
swallowing ability once each shift. This assessment evaluates:
a. Cranial nerves I and II - olfactory and optic
b. Cranial nerves III and V - oculomotor & trigeminal
c. Cranial nerves VI and VIII - abducens &
d. Cranial nerves IX and X - glossopharyngeal &
Swallowing is a motor function of cranial nerves IX and X.
31. How should the nurse position a client for a lumbar puncture?
a. Laterally, with knees drawn up to the abdomen and chin touching the chest - fetal
position like is needed to expose the spine
b. Prone, with arms and legs straight and arms aligned next to the body
c. Laterally, with legs straight and arms folded across the chest
d. Sitting in a chair, with arms held out horizontally
Rationale: https://quizlet.com/235204105/msii-prep-u-ch-65-assessment-of-neurologic-
function-flash-cards/
To maximize the space between the vertebrae, the client is placed in a lateral recumbent
position with knees flexed toward the chin. The needle is inserted between L4 and L5. The
other positions wouldn't allow as much space between L4 and L5.
32. A 26-year old client is diagnosed with a brain tumor. As the nurse assists the client from the
bed to a chair, the client begins having generalized seizures. Which action should the nurse
take first?
a. Initiate the code team response - resuscitate patients
b. Put a padded tongue blade into the client’s mouth and restrain her extremities - restrain:
needs physician order
c. Record the type of seizure and the time that it occured - do it after
d. Assist the client to the floor, in a side lying position and protect her linens.
Rationale:
33. A client is transferred to the ICU after evacuation of a subdural hematoma. Which nursing
intervention would reduce the client’s risk of ICP?
a. Encouraging oral fluid intake - NPO status
b. Suctioning the client once each shift - not necessary; can increase ICP; do not suction if
not indicated
c. Elevating the HOB 90 degrees - can increase ICP, usually 30 to 45 degrees
d. Administering a stool softener as prescribed - will prevent Valsalva maneuver and
will not increase ICP further
Rationale:
34. A client injured in a train derailment is admitted to an acute care facility with a suspected
dysfunction of the lower brain stem. The nurse should monitor the client closely for:
a. Hypoxia - function of the lower brain stem is to regulate breathing
b. Fever
c. Visual disturbance
d. Gait alteration
Rationale: https://quizlet.com/71900088/neuro-flash-cards/
Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing,
and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature
control, vision, and gait aren't lower brain stem functions.
35. After a stroke,a 75-year old client is admitted to the facility. The client has left sided
weakness and an absent gag reflex. He is incontinent and has a tarry stool. His BP is
90/50 and his hemoglobin is 10g. Which of the following is a priority for this client?
a. Checking stools for occult blood blood
b. Performing ROM exercises to the left side
c. Keeping skin clean and dry
d. Elevating the HOB 30 degrees - this prevents aspiration (own saliva) for absent gag
reflex
Rationale:
36. A client with quadriplegia is in spinal shock. What should the nurse expect?
a. Absence of reflexes along with the flaccid extremities
b. Positive Babinski’s reflex along with spastic extremities
c. Hyperreflexia along with spastic extremities
d. Spasticity of all four extremities
Rationale:
37. A client who is receiving phenytoin (Dilantin) to control seizure is admitted to the health care
facility for observation. The physician orders measurement of the client’s serum phenytoin level.
Which serum phenytoin level is therapeutic?
a. A level below 5 mcg/mL
b. 10 to 20 mcg/mL
c. 25 to 35 mcg/mL
d. 40 to 50 mcg/mL
Rationale:
38. When caring for a client with a head injury, the nurse must stay for signs and symptoms of
ICP. Which cardiovascular findings are late indications of increased ICP?
a. Rising BP and bradycardia - widening pulse pressure
b. Hypotension and bradycardia
c. Hypotension and tachycardia
d. Hypertension and narrowing pulse pressure
Rationale:
39. If a client experienced a stroke that damaged the hypothalamus, the nurse would anticipate
the client has problems with:
a. Body temperature control
b. Balance and equilibrium
c. Visual acuity
d. Thinking and reasoning
The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause
problems of body temperature control.
40. When teaching a client about levodopa-carbidopa (Sinemet) therapy for Parkinson’s
disease, the nurse should include which instruction?
a. Report any eye spasms
b. Take this medication at bedtime - take before meals
c. Stop taking this drug when your symptoms disappear - this medication is for life
d. Be aware that your urine may appear darker than usual - expected finding
Rationale:
41. A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup.
Myasthenia gravis is confirmed by
a. A positive edrophonium (tensilon) test
b. Kernig’s sign - meningitis
c. Positive chloride test - Cystic fibrosis
d. Brudziński sign - meningitis
Rationale: https://quizlet.com/152896476/ch-69-autoimmune-disorders-neurologic-infections-
neuropathies-flash-cards/
A positive edrophonium test confirms the diagnosis of myasthenia gravis. After edrophonium
administration, most clients with myasthenia gravis show markedly improved muscle tone.
Kernig's sign and Brudzinski's sign indicate meningitis. The sweat chloride test is used to
confirm cystic fibrosis.
42. A client undergoes cerebral angiography for evaluation after an intracranial computed
tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently
for signs and symptoms of complications associated with this procedure. Which findings indicate
spasm or occlusion of a cerebral vessel by a clot?
a. Nausea, vomiting, and profuse sweating - allergic reaction
b. Hemiplegia, seizures, and decreased LOC - stroke
c. Difficulty breathing or swallowing - hematoma on the neck; late reaction to the contrast
media
d. Tachycardia, tachypnea, and hypotension - indicative of internal hemorrhage
Rationale: https://quizlet.com/87207896/ch-67-management-of-patients-with-cerebrovascular-
disorders-flash-cards/
Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar
to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and
increased focal symptoms.
43. The nurse is working on a surgical floor. The nurse must logroll a client following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy
Rationale: https://quizlet.com/71553774/neuro-nclex-questions-flash-cards/
The client who has had spinal surgery, such as laminectomy, must be logrolled to
keep the spinal column straight when turning. The client who has had a thoracotomy
or cystectomy may turn himself or may be assisted into a comfortable position. Under
normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client
may resume normal activities immediately after surgery.
44. The nurse is caring for a client with L1-L2 paraplegia (usually the bladder is affected) who
is undergoing rehabilitation. Which of the following goals is appropriate?
a. Establishing an intermittent catheterization routine every 4 hours - one cannot use
indwelling catheter because infection can occur
b. Managing spasticity with ROM exercises and medications
c. Establishing an ambulation program using short leg braces
d. Preventing autonomic dysreflexia by preventing bowel impaction
Rationale:
45. When providing discharge for a client with MS, the nurse should include which instruction?
a. Avoid taking daytime naps
b. Avoid hot baths and showers
c. Limit your fruit and vegetable intake
d. Restrict fluid intake to 1,500 mL/day
Rationale: https://quizlet.com/382757347/nclex-ppt-exam-4-flash-cards/
can exacerbate the disease
46. A client admitted with cerebral contusion is confused, disoriented and restless. Which
nursing diagnosis takes the highest priority?
a. Distubred sensory perception (visual) related to neurologic trauma
b. Feeding self-care deficit related to neurologic trauma
c. Impaired verbal communication related to confusion
d. Risk for injury related to neurologic deficit
Rationale: https://quizlet.com/425002962/chapter-68-neurologic-trauma-flash-cards/
Risk for injury related to neurologic deficit (Pg. 2036)

Characterized by loss of consciousness associated with stupor and confusion. effects of
injury, particularly hemorrhage and edema, peak after about 18 to 36 hours. these effects,
which can cause secondary effects resulting in increased ICP and possible herniation
syndromes, are most pronounced in temporal lobe contusions. patients are most often
managed medically with interventions directed toward prevention of additional insults.
Deep contusions are more often associated with hemorrhage and destruction of the
reticular activating fibers, altering arousal.
47. Family members would like to bring in birthday cake for a client with nerve damage. What
cranial nerve needs to be functioning so the client can chew?
a. II - optic
b. V - trigeminal
c. IX - glossopharyngeal
d. X - vagus
Rationale:
48. During recovery from a stroke, a client is given NPO to help prevent aspiration. To
determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing
ability once per shift. The assessment evaluates:
a. CN I and II
b. CN III and IV
c. CN VI and VIII
d. CN IX and X
Rationale:
49. For a client with head injury whose neck has been stabilized, the preferred bed position is:
a. Trendelenburg’s - can increase ICP
b. 30 degree head elevation
c. Flat
d. Side-lying
Rationale:
50. A client had an embolic stroke. Which of the following conditions places a client at risk for
thromboembolic stroke?
a. Atrial fibrillation
b. Bradycardia
c. DVT
d. History of MI
Rationale:
51. To maintain airway patency during a stroke in evolution, which of the following nursing
interventions is appropriate?
a. Thicken all dietary liquids - at first stage, client cannot take dietary liquids because
clients are at risk for aspiration
b. Restrict dietary and parenteral fluids
c. Place client in supine position - semi-fowlers (30 to 45 degrees)
d. Have tracheal suction available at all times - in the event the patient will have excess
drooling and developing aspiration, the client can
Rationale:
52. Which of the following diets would be least likely to lead to aspiration in a client who had a
stroke with residual dysphagia?
a. Clear liquid
b. Full liquid
c. Mechanical soft
d. Thickened liquid
Rationale: https://quizlet.com/74188008/nclex-pn-neuro-flash-cards/
Thickened liquids they are easiest to form into a bolus and swallow.
53. A 77-year old client had a thromboembolic right stroke; his left arm is swollen. Which of
the following conditions may cause swelling after a stroke?
a. Elbow contracture secondary to spasticity
b. Loss of muscle contraction decreasing venous return
c. DVT due to immobility of the ipsilateral side
d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus - protein loss is
not related to stroke
Rationale:
54. After a brain stem infarction, a nurse would observe for which of the following conditions?
a. Aphasia - during
b. Bradypnea - after
c. Contralateral hemiplegia - during
d. Numbness and tingling to the face or arm - during
55. Clear fluid is draining from the nose of a client who had a head trauma 3 hours ago. This
may indicate which of the following conditions?
a. Basilar skull fracture - CSF leak
b. Cerebral concussion
c. Cerebral Palsy
d. Sinus infection
Rationale:
56. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe
headache, nuchal rigidity and projectile vomiting. The nurse knows lumbar puncture would be
contraindicated in this client in which of the following circumstances?
a. Vomiting continues
b. ICP is increased
c. The client needs mechanical ventilation
d. Blood is anticipated in the CSF
Rationale:
57. A client with subdural hematoma becomes restless and confused, with dilation of the
ipsilateral pupil. The physician orders mannitol for which of the following reasons?
a. To reduce intraocular pressure
b. To prevent acute tubular necrosis
c. To promote osmotic diuresis to decrease ICP - measure urine output of patient
d. To draw water into the vascular system to increase BP
Rationale:
58. A client with lower back pain and a herniated nucleus pulposus should be taught that
strengthening which of the following muscles after laminectomy will prevent lower back pain?
a. Abdominal - can support the back and prevent lower back pain
b. Diaphragm
c. Gluteus
d. Rectus Femoris
Rationale:
59. Which of the following conditions is an early symptom commonly seen in myasthenia
gravis?
a. Dysphagia - late symptom
b. Fatigue improving at the end of the day - exacerbated by stress
c. Ptosis
d. Respiratory distress - late symptom
60. A client with suspected myasthenia gravis is to undergo a Tensilon test. Tensilon test is
used to diagnose - but not treat - myasthenia gravis. Why isn’t it used for treatment?
a. It isn’t available in oral form
b. With repeated use, immunosuppression may occur
c. Dry mouth and abdominal cramps may be intolerable side effects
d. The short half-life of tensilon makes it impractical for long term use
Rationale:
61. When assessing the trigeminal nerve function, the nurse should evaluate:
a. Corneal sensation
b. Smiling and frowning
c. Ocular muscle movement
d. Shrugging of shoulders
Rationale:
62. The nurse uses the Glasgow Coma Scale to assess a client with a head injury that resulted
from a vehicular accident. The nurse identifies that the client is in a coma when the GCS score
is
a. 6
b. 9
c. 12
d. 15 - highest score
Rationale:
63. During the immediate post-trauma period injury to the frontal lobe of the brain, the nurse
should place the client in the:
a. Supine position
b. Side-lying position
c. Low fowler’s position - 30 degrees
d. Trendelenburg position
Rationale:
64. When caring for an unconscious client with increasing intracranial pressure, the nursing
intervention that is contraindicated would be:
a. Lubricating the skin with baby oil (+)
b. Suctioning of the oropharynx routinely
c. Elevating the HOB 20 degrees
d. Cleansing the eyes every 4 hours with normal saline
Rationale:
65. A client has a history of progressive carotid and cerebral atherosclerosis and transient
ischemic attacks. The nurse understands that TIAs are:
a. Temporary episodes of neurologic dysfunction
b. Transient attacks caused by multiple small emboli - referred to stroke
c. Several periods of exacerbations alternating with remissions - MS
d. Ischemic attacks that result in progresive neurologic deterioration - no progressive or
permanent neurologic damage
Rationale:
66. During the first 24 hours after thrombolytic treatment for an ischemic CVA, the primary goal
is to control the client’s:
a. Pulse
b. Respirations
c. BP
d. Temperature
Rationale:
67. For the client who is experiencing expressive aphasia, which nursing interventions is most
helpful in promoting communication?
a. Speaking loudly
b. Using a picture board
c. Writing directions so client can read them
d. Speaking in short sentences
Rationale:
68. What is the expected outcome of a thrombolytic drug for CVA?
a. Increased vascular permeability
b. Vasoconstriction
c. DIssolved emboli
d. Prevention of hemorrhage
Rationale:
69. A new medication regimen is ordered to a client with Parkinson’s disease. At which time
would the nurse make certain that the medication is taken?
a. At bedtime
b. All at one time
c. Two hours before meal time
d. At the time scheduled
Rationale:
70. What is the intended outcome for the nursing intervention of performing passive ROM
exercises of an unconscious client?
a. Preservation of muscle mass - active ROM
b. Prevention of bone demineralization
c. Increase in muscle tone
d. Maintenance of joint mobility
Rationale:
71. When assessing a client with a suspected basilar skull fracture, the nurse most needs to
assess for which of the following identifying signs?
a. Scalp bleeding and headache in the area of forceful contact with the skull
b. Sleepiness and loss of consciousness if not continuously stimulated
c. Bruising over the mastoid process and periorbital ecchymosis - Battle’s sign
d. An opening between the outside environment and the brain
Rationale:
72. When assisting in the care of the client with increased intracranial pressure, the nurse will
carefully check the physician’s orders for intravenous solution against the type of solution the
client is receiving. Which of the following types of solutions are the only solutions that can be
given to maintain fluid and electrolyte balance and prevent hypotension in the client with
increased ICP?
a. D5W
b. .09 normal saline with 40 mg potassium
c. 0.9% normal saline or ringer’s lactated solution
d. 0.45% or half-strength normal saline
Rationale:
73. When caring for a client with acute neurological problems who has a diagnosis of Altered
Tissue Perfusion: Cerebral and is showing some signs of increased ICP, the nurse will notify the
physician and the supervising nurse and will continue or initiate which one of the following
interventions?
a. Keep lights on, and speak a little louder than usual
b. Position the client flat in bed or turned to one side - should be in low fowler’s
c. Remind the client to breathe and cough deeply every 2 hours - promotes valsalva
maneuver
d. Use a draw sheet, and turn the client very slowly
Rationale:
74. During the shift report you learn that one of your assigned clients with a diagnosis of
cerebrovascular CVA has neglect syndrome. You realize from preparatory research on CVA
that you can most expect the client to behave in which of the following ways because of neglect
syndrome?
a. Ignoring the affected side of the body by doing things like not dressing the
affected side
b. Isolating in his or her room and not contacting any family members or friends
c. Refusing to work with the speech therapist, the nutritionist, or any support staff
d. Refusing to carry out hygiene tasks, such as showering or letting anyone comb his or
her hair
Rationale:
75. Several days after a craniotomy, your assigned client tells you not to allow any family or
friends to visit, and you notice the client going into and out of your bathroom quickly. You
suggest brushing the teeth in front of the bathroom mirror, and the client says he will do it in
bed. Which of the following nursing diagnoses most fits this client’s behavior?
a. Defensive coping
b. Disturbed body image
c. Impaired social interaction
d. Dysfunctional grieving
Rationale:
76. The nurse is assisting with the care of a client who has experienced subarachnoid bleeding
from a cerebral aneurysm. The client is scheduled for surgery when stable; however, in the
meantime, the physician has ordered the following medications: aminocaproic acid, calcium
channel blocker, nimodipine, and a stool softener. The nurse realizes that these medications are
given mainly to accomplish which of the following goals?
a. Prevent slowing of the bowel and the complication of paralytic ileus
b. Prevent the clot from dislodging, prevent the rebleeding and prevent vasospasm
c. Slow the bleeding down to an amount that is not life-threatening
d. Prevent the client from going into shock and cardiac arrest
Rationale:
77. The client who is experiencing seizures is at risk for ineffective airway clearance. Which of
the following nursing interventions best maintains effective airway clearance when the client
begins to have a seizure?
a. Turn the client on the client’s side rather than leaving the client lying flat
b. Discontinue oxygen if client is on oxygen
c. Put a pillow under the client’s neck
d. Keep padded tongue blade at bedside and place it between the client’s teeth
Rationale:
78. While bathing a client, all of a sudden the client has a tonic-clonic seizure that follows a
typical pattern. Which of the following observations will the nurse most likely document about
this typical clonic-tonic seizure?
a. The client was responsive when the jerking movements stopped
b. The client denied having an aura
c. Following a loud cry, the client became rigid, with all arms and legs extended
d. The tonic phase involved jerking movements of the entire body
Rationale:
79. The nurse in a long-term care facility is caring for a client with a diagnosis of Alzheimer’s
disease who is on the anticholinesterase drug Tacrine Hydrochloride. The nurse needs to
review the client’s chart to see if this client has had which of the following tests or procedures
that are most important for monitoring clients on anticholinesterase drugs?
a. Liver function tests
b. Bone density measurements
c. Thyroid function tests
d. Long and short term memory tests
Rationale:
80. When working with clients who have been diagnosed with Alzheimer’s disease and a
nursing diagnosis of Thought Processes Altered, which of the following interventions would
usually be best?
a. A daily stimulating surprise activity
b. Music from the decay of the client's youth, such as 50s and rock and roll
c. Rearrangement of objects and furniture
d. Scheduled rest periods throughout the day
Rationale:
81. The physical therapist and/or the nurse working with an ambulatory client with a diagnosis
of multiple sclerosis (there should be balance) will most likely teach the client to do which of
the following things?
a. Omit any stretching exercises from the exercise routine
b. Use a cane as much as possible instead of a walker - case to case basis
c. Focus on improving posture when standing or walking
d. Stand with the feet wider apart than usual
Rationale:
82. When assessing clients with a diagnosis of Parkinson’s disease, over several days the
nurse would most likely find which of the following manifestations?
a. Paresthesias and weak peripheral pulses
b. Tremors during sleep and movement
c. Rigidity and bradykinesia - cardinal sign
d. Muscle weakness on one side
Rationale:
83. The nurse is assessing a client who has had a diagnosis of ALS. Which of the following
manifestations is the nurse most likely to find on assessment?
a. Muscle wasting on one side of the body only
b. Breathing difficulties - speech
c. muscle weakness and fasciculations
d. Confusion and loss of memory
Rationale:
84. A client with a spinal cord injury at or above T-6 is at risk for autonomic dysreflexia. Which of
the following actions must the nurse take if the client has manifestations of autonomic
dysreflexia?
a. Have the client perform the Valsalva maneuver
b. Start oxygen and CPR immediately and call a code
c. Elevate HOB 45 degrees, make certain the client has a patent catheter and remove
any impaction
d. Reposition the client to relieve pressure on the abdominal aorta and any nerves that
might be under positional pressure
Rationale:
85. A nursing student is reading information on the nervous system. The nursing student is
preparing to do a clinical rotation on a neuromedicine floor. Which of the following statements
demonstrates a good understanding of the content on the nervous system?
a. The nervous system is divided into two regions; the CNS and PNS
b. The neuroglia receives impulses and sends them on to other cells - neurons
c. The CNS consists of cranial nerves, spinal nerves, and the autonomic nervous system -
PNS
d. The peripheral nervous system of the brain and spinal cord - central nervous system
Rationale:
86. A nurse is working in the emergency department when a college student is admitted to the
status post a motor vehicle accident (MVA). the client manifests with flaccid paralysis, sensitivity
to pain, temperature, and crude touch. The client also tests positive for fine touch and vibration.
Which of the following reasons could contribute to the client’s symptoms?
a. The client has suffered damage to the posterior root of the spinal nerve pairs
b. The client has suffered damage to the anterior spinothalamic tracts
c. The client has suffered damage to the anterior root of the spinal nerve pain
d. The client has suffered damage to the posterior spinothalamic tracts
If the posterior root is affected, there will be no more sensation which makes options A and D
wrong. Damage to the anterior root will result in flaccid paralysis.
Rationale:
87. A nursing student is performing a neurological assessment on her lab partner during their
physical assessment course. The students complete the following assessments on each other;
instruct the other person to squeeze your hands, push their feet against the resistance of your
hands, observe the lab partner at rest, and have them reach for a glass of water. Which of the
following motor function assessments are the students attempting to complete?
a. Ataxia, spastic hemiparesis, and romberg’s
b. Cremasteric reflex, babinski, and clonus
c. Brudzinski, kernig and posturing
d. Tremors, muscle strength, and movement
Rationale:
88. A client is newly diagnosed with ALS. Which of the following statements if made by the client
demonstrates a correct understanding of ALS?
a. Although ALS is most often considered a disease of children, there is a chronic adult
form that causes neuronal dysfunction and psychosis.
b. ALS is neurologic disease that causes progressive degeneration of motor
neurons in the brain and spinal cord
c. ALS is on f the most common neurological diseases characterized by abnormal cell firing
in the brain that causes recurring seizures - epilepsy
d. ALS is the most common inherited neuropathy in the world characterized by a slowly
preogressive degeneration of the muscles of the foot, lower leg, hand and forearm.
Rationale:
89. The nurse is caring for a client who has been in a coma for 4 months. The physicians have
approached the client’s family about ceasing life support. Which of the following comments, if
said by the client’s family, demonstrates a correct understanding of the difference between a
persistent vegetative state and brain death?
a. The diagnosis of persistent vegetative state requires that conditions has continue for at
least six months - one month only
b. Brain death is the cessation and irreversibility of all brain functions, including
brainstem
c. Persistent vegetative state is a temporary condition of complete unawareness of self and
the environment and loss of all cognitive functions
d. Brain death has occured when there is little evidence of cerebral or brainstem function
for an extended period in any client
Rationale:
90. Which of the following facts is true in clients with increased ICP?
a. In pressure autoregulation, stretch receptors within small blood vessels of the brain
cause smooth muscle of the arterioles to dilate. - constricting
b. Autoregulatory mechanisms have a great ability to maintain cerebral blood flow - limiting
c. Interruption of the cerebral blood flow leads to ischemia and disruption of the
cerebral metabolism
d. The relationship between the volume of the intracranial components and ICP is known
as vasodilation - compliance
Rationale:
91. A 25-year old male client presents to the emergency room with complaints of an extremely
severe, unilateral, burning pain located behind the eyes. The client denies any nausea,
vomiting, aura or chills. Some alternative therapies used by the client to treat the pain include
vitamin D, elemental calcium, riboflavin (vitamin B), acupuncture, relaxation, massage, and
osteopathic manipulation. Which type of headache does this most closely resemble in this
particular client?
a. Tension headache - bilateral
b. Common headache
c. Cluster headache
d. Classic migraine - if with migraine headache, there should be headache
Rationale:
92. A client is admitted with a brain tumor that required surgery. The nurse is teaching her
nursing student about surgical options for clients with brain tumors. Which of the following
statements, if made by the nursing student, demonstrates the need for further teaching?
a. A burr hole is a hole made in the skull with a special drill. The hole may facilitate the
evacuation of an intracerebral clot, or a series of holes may be made in preparation for
craniotomy
b. A cranioplasty is a cadaverous bone transplant to repair the skull in which bone is
inserted to replace the cranial bone that was removed
c. A craniectomy is an excision of a portion of the skull and complete removal of the bone
flap
d. A craniotomy is a surgical opening into the cranial activity
Rationale:
93. A client who fell at home and hit his head was found on the floor of his apartment. It is
unknown how long the client had been injured, or had been lying on the kitchen floor. The nurse
knows that an untreated increased ICP can lead to brain herniation. Which of the following
statements is correct regarding brain herniation?
a. The client’s neurologic signs may deteriorate rapidly, with decreased LOC
progressing to coma
b. Herniation of the brainstem through the tentorium exerts pressure on the cerebellum,
with subsequent herniation through the foramen magnum
c. The client may demonstrate abnormal motor responses with bilateral decorticate
posturing - unilateral
d. The client’s neurologic signs may deteriorate rapidly, with pupils progressing from large
and reactive to midsize brain - small, reactive to midsize
Rationale:
94. A client on a medical-surgical unit has been in a coma for the past two months. When caring
for a client in a coma, which of the following nursing diagnoses should be most important?
a. Risk for impaired skin integrity
b. Impaired physical mobility
c. Risk for imbalanced nutrition: less than body requirements
d. Ineffective airway clearance
Rationale:
95. A nurse on a medical-surgical unit is caring for four different clients. Which of the following
clients in the nurse’s assignment is most at risk for developing a stroke?
a. A 23-year old Caucasian man admitted with hypertension
b. A 44-year old Hispanic woman admitted with osteoporosis - no relation with stroke
c. A 53-year old African American woman admitted with hypertension
d. An 80-year old Caucasian woman admitted with a hip fracture - no relation with stroke
Rationale:
96. The nurse is caring for a client admitted who has sustained a motor vehicle accident. Which
of the following symptoms would consist with a diagnosis of a cervical injury?
a. Paralysis, or weakness of extremities, a pulse rate of 45 beats per minute and
nasal flaring
b. Loss of sensation, absent bowel sounds, and BP of 80/40 - spinal shock
c. Bladder distension, a pulse rate of 75 beats per minute, and flaccid paralysis - shock
d. Absent bowel sounds, areflexia, and BP of 98/64 - spinal shock
Rationale:
97. The nurse is caring for a client who suffered a stroke just two days ago. The nurse is new to
the neurological unit and wants to review communication disorders with an experienced nurse.
Which of the following statements, if made by the nurse, indicates a good understanding of
communication disorders?
a. In Broca’s aphasia, speech may be fluent but inappropriate in content - Wernicke’s
aphasia
b. Dysarthria is any disturbance in muscular control of speech
c. Aphasia is any disturbance in muscular control of speech
d. Receptive aphasia is a motor speech problem in which one can understand what is
being said but can respond verbally only in short phrases - Expressive aphasia
Rationale:
98. The nurse is caring for a client who has been admitted to the neurological ICU to rule out
stroke. The client exhibits rapid and worsening symptoms. The client’s symptoms began with a
headache and vomiting, but rapidly progressed to seizures, hemiplegia, and LOC as reported by
the client’s family. Which of the following nursing interventions is most important for this
client?
a. Place client in a side lying position
b. Monitor mental health status - since there is established LOC
c. Assess for pain
d. Suction as necessary - to prevent aspiration and promote airway patency
Rationale:
99. A nursing student is studying for an examination on spinal cord tumors. Which of the
following statements, if made by the nursing student, would indicate the need for further
teaching?
a. Primary tumors arise from the epidural vessels, spinal meninges, or glial cells have an
unknown cause
b. Secondary tumors are metastatic in origin and are most commonly the result of
malignancies of the lung, breast, prostate, gastrointestinal tract, or uterus
c. Extramedullary tumors alter normal function through compression of the spinal cord, with
destruction of white matter and eventual filling of the space around the spinal cord
d. Intramedullary tumors both compress and invade. As the tumor grows within the
cord, the cord shrinks and thus distorts the gray matter - grows instead of shrink
and white matter instead of gray
Rationale:
100. A client is admitted to the ICU after suffering a ruptured intracranial aneurysm. The nurse
wants to ensure measures to prevent rebleeding as much as possible. Which of the following
nursing interventions should the nurse perform first?
a. Elevate the HOB to 30 to 45 degrees
b. Administer a soap suds enema - promote valsalva maneuver
c. Limit the number of visitors in the room - no visitors allowed
d. Keep the client in a semi private room
Rationale:

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1.

In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually

Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a

17. A physician diagnoses a client with myasthenia gravis prescribing pyridostigmine,

Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a

Decerebrate posturing, characterized by abnormal extension in response to painful stimuli,

Swallowing is a motor function of cranial nerves IX and X.

can exacerbate the disease

Risk for injury related to neurologic deficit (Pg. 2036)

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