NSG 403 Adult health 2 WITH 100 Neuro NCLEX questions WITH ACCURATE ANSWERS, Exams of Nursing

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100 Neuro NCLEX questions

1. 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?

1. Reposition the client to avoid neck flexion
2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilator’s respiratory rate to 20 breaths/minute
4. Administer 100 mg of pentobarbital IV as ordered. 2. 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?
5. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
6. Rapid Dilantin administration can cause cardiac arrhythmias.
7. Dilantin should be mixed in dextrose in water before administration.
8. Dilantin should be administered through an IV catheter in the client’s hand. 3. 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?
9. Evaluate urine specific gravity
10. Anticipate treatment for renal failure
11. Provide emollients to the skin to prevent breakdown
12. Slow down the IV fluids and notify the physician

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4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?

1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
2. Emergent; the client is poorly oxygenated.
3. Normal
4. Significant; the client has alveolar hypoventilation. 5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs?
5. Bloody drainage from the ears
6. Frequent swallowing
7. Guaiac-positive stools
8. Hematuria 6. After a hypophysectomy, vasopressin is given IM for which of the following reasons?
9. To treat growth failure
10. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
11. To reduce cerebral edema and lower intracranial pressure
12. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. 7. 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?

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11. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?

1. Acetazolamide (Diamox)
2. Furosemide (Lasix)
3. Methylprednisolone (Solu-Medrol)
4. Sodium bicarbonate 12. 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?
5. Place the client flat in bed
6. Assess patency of the indwelling urinary catheter
7. Give one SL nitroglycerin tablet
8. Raise the head of the bed immediately to 90 degrees 13. A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
9. To hasten wound healing
10. To immobilize the cervical spine
11. To prevent autonomic dysreflexia
12. To hold bony fragments of the skull together 14. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?
13. Insert an indwelling urinary catheter to straight drainage
14. Schedule intermittent catheterization every 2 to 4 hours

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3. Perform a straight catheterization every 8 hours while awake
4. Perform Crede’s maneuver to the lower abdomen before the client voids. 15. 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?
5. Laceration of the middle meningeal artery
6. Rupture of the carotid artery
7. Thromboembolism from a carotid artery
8. Venous bleeding from the arachnoid space 16. 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?
9. Position the client flat in bed
10. Check the fluid for dextrose with a dipstick
11. Suction the nose to maintain airway patency
12. Insert nasal and ear packing with sterile gauze 17. When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval?
13. An interval when the client’s speech is garbled
14. An interval when the client is alert but can’t recall recent events
15. An interval when the client is oriented but then becomes somnolent
16. An interval when the client has a “warning” symptom, such as an odor or visual disturbance.

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3. Put the client in the Trendelenburg’s position
4. Put the client in the high-Fowler’s position 22. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?
5. Autonomic dysreflexia
6. Hypervolemia
7. Neurogenic shock
8. Sepsis 23. A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?
9. Absent corneal reflex
10. Decerebrate posturing
11. Movement of only the right or left half of the body
12. The need for mechanical ventilation 24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated?
13. Decreased urine output or oliguria
14. Hypertension and bradycardia
15. Respiratory depression
16. Symptoms of shock

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25. A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given?

1. “Clean the meatus from back to front.”
2. “Measure the quantity of urine.”
3. “Gently rotate the catheter during removal.”
4. “Clean the meatus with soap and water.” 26. 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?
5. “Watch him for keyhole pupil the next 24 hours.”
6. “Expect profuse vomiting for 24 hours after the injury.”
7. “Wake him every hour and assess his orientation to person, time, and place.”
8. “Notify the physician immediately if he has a headache.” 27. Which neurotransmitter is responsible for may of the functions of the frontal lobe?
9. Dopamine
10. GABA
11. Histamine
12. Norepinephrine 28. 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

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1. By inserting a nasopharyngeal airway
2. By inserting a oropharyngeal airway
3. By performing a jaw-thrust maneuver
4. By performing the head-tilt, chin-lift maneuver 32. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.
5. Elevate the HOB to 90 degrees
6. Loosen constrictive clothing
7. Use a fan to reduce diaphoresis
8. Assess for bladder distention and bowel impaction
9. Administer antihypertensive medication
10. Place the client in a supine position with legs elevated

1,2,4,

33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:

1. Desmopressin (DDAVP, Stimate)
2. Dexamethasone (Decadron)
3. Ethacrynic acid (Edecrin)
4. Mannitol (Osmitrol)

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34. 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 is compatible with:

1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma 35. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for:
5. A flattened abdomen
6. Hematest positive nasogastric tube drainage
7. Hyperactive bowel sounds
8. A history of diarrhea 36. 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?
9. Strict adherence to a bowel retraining program
10. Limiting bladder catheterization to once every 12 hours
11. Keeping the linen wrinkle-free under the client
12. Preventing unnecessary pressure on the lower limbs 37. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?

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4. Loosen tight clothing on the client
5. Administer an antihypertensive medication

2,4,1,3,

41. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

1. Unequal pupil size
2. Decreasing systolic blood pressure
3. Tachycardia
4. Decreasing body temperature 42. Which of the following respiratory patterns indicate increasing ICP in the brain stem?
5. Slow, irregular respirations
6. Rapid, shallow respirations
7. Asymmetric chest expansion
8. Nasal flaring 43. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
9. Give the client a warming blanket
10. Administer low-dose barbiturate
11. Encourage the client to hyperventilate
12. Restrict fluids 44. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition?

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1. Widening pulse pressure
2. Decrease in the pulse rate
3. Dilated, fixed pupil
4. Decrease in LOC 45. 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?
5. Place her in a jacket restraint
6. Wrap her hands in soft “mitten” restraints
7. Tuck her arms and hands under the draw sheet
8. Apply a wrist restraint to each arm 46. Which of the following describes decerebrate posturing?
9. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers
10. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet
11. Supination of arms, dorsiflexion of feet
12. Back arched; rigid extension of all four extremities. 47. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
13. Count the rate to be sure the ventilations are deep enough to be sufficient
14. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.

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4. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation. 51. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

A. Body temperature control. B. Balance and equilibrium. C. Visual acuity. D. Thinking and reasoning.

52. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (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) B. Mannitol (Osmitrol) C. Lidocaine (Xylocaine) D. Furosemide (Lasix)

53. 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. B. Place him on mechanical ventilation.

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C. Perform a lumbar puncture. D. Elevate the head of his bed.

54. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report:

A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision.

55. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury

56. 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. B. Help the client fill out his menu. C. Give the client privacy during meals. D. Fill out the menu for the client.

57. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?

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hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority?

A. Assessing the left leg B. Assessing the pupils C. Placing the client in Trendelenburg’s position D. Assessing level of consciousness

61. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers 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 the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:

A. Increasing the exudative reaction of ocular tissue. B. Decreasing leukocyte infiltration at the site of ocular inflammation. C. Inhibiting the action of carbonic anhydrase. D. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.

62. Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal?

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A. More back pain than the first postoperative day B. Paresthesia in the dermatomes near the wounds C. Urine retention or incontinence D. Temperature of 99.2° F (37.3° C)

63. After an eye examination, a male client is diagnosed with open- angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:

A. Instilling one drop of pilocarpine 0.25% into both eyes daily. B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. C. Instilling one drop of pilocarpine 0.25% into the right eye daily. D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.

64. 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. B. The client uses a mirror to inspect the skin. C. The client repositions only after being reminded to do so. D. The client hangs the left arm over the side of the wheelchair.

65. 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?