Neurological NCLEX Questions with verified answer latest updated 2024., Exams of Nursing

Download Neurological NCLEX Questions with verified answer latest updated 2024. and more Exams Nursing in PDF only on Docsity! Neurological NCLEX Questions with verified answer latest updated 2024. 1. B. CN II and CN III - Correct answer The nurse is caring for a patient who suffered massive head trauma, and suspected increased intracranial pressure (ICP) from an automobile accident. Which cranial nerves are most appropriate to check at this time? A. CN I and CN II B. CN II and CN III C. CN III and CN IV 2. D .CN IV and CN V 3. D. Pupil changes can be caused by pressure on the ocular nerve. - Correct answer When increased ICP is suspected, the nurse performs a complete neurologic assessment. What does the pupillary response indicate? A. High pressure can cause blurred vision. B. Hemorrhage can cause visual impairment. C. Pupil dilation is the first sign of increased ICP. D. Pupil changes can be caused by pressure on the ocular nerve. E. Touch his nose with his left index finger. - Correct answer When rating a patient using the Glasgow Coma Scale, what would be appropriate for the LPN/LVN to ask the patient to do in order to test the patient's motor response? A. Roll his eyes in a circle. B. Take a deep breath and exhale. C. Describe the view from his window. D. Touch his nose with his left index finger. A. Decreasing level of consciousness (LOC) - Correct answer The nurse is assessing a patient who has a brain tumor. What assessment finding is most indicative of increased ICP in this patient? A. Decreasing level of consciousness (LOC) B. Elevated temperature C. Agitation and hostility D. Increasing blood pressure (BP) B. "Checking this reflex assesses involuntary muscular contractions." - Correct answer The nurse is assessing the patient's patellar reflex. The patient asks what the purpose of this exam is. Which response by the nurse is correct? A. "I am checking the conscious nerve response in your leg." B. "This assessment determines your hand-eye coordination." C. "Checking this reflex assesses involuntary muscular contractions." D. "The patellar reflex demonstrates large voluntary muscle coordination." E. Determine whether the patient is able to move his legs and arms - Correct answer The nurse is performing a "neuro check" on a patient who has demonstrated a decreased LOC. What is the best way to assess the patient's neuromuscular status? A. Measure the patient's vital signs. B. Test the reaction of the patient's pupils to light. C. Check the patient's response to the stimulus of pinching. D. Determine whether the patient is able to move his legs and arms C. "The procedure is safe and painless; you will hear a clicking noise as the CT machine rotates." - Correct answer A patient who is to have computed tomography (CT scan) of the brain voices concern about the procedure. The LPN/LVN can best allay the patient's fears by making which statement? A. "CT scans use only a small amount of radioactive material injected into your brain." B. "The procedure is safe and painless; you will hear a clicking noise as the CT machine rotates." C. "You will probably be given something to make you drowsy and deaden the pain during the CT scan." D. "CT scanning is a new procedure, and since it involves the brain, I think the doctor can answer your questions better than I can." D. White blood cells (WBCs) 100/mm3 - Correct answer The nurse is caring for a patient who has undergone a lumbar puncture in order to run tests on the cerebrospinal fluid (CSF). The nurse knows which laboratory value is abnormal? A. Glucose 60 mg/100 mL B. Clear, colorless appearance C. White blood cells (WBCs) 100/mm3 D. Total protein 40 mg/100 mL A. CSF circulates within the subarachnoid space. B. CSF cushions and protects the brain and spinal cord. C. CSF is reabsorbed by the arachnoid villi at the same rate at which it is formed. D. CSF is formed continuously within the ventricles of the brain as a filtrate from the blood. - Correct answer The nurse is measuring the pressure of the CSF. Which statement accurately describes CSF? (Select all that apply.) A. CSF circulates within the subarachnoid space. B. CSF cushions and protects the brain and spinal cord. C. CSF normal pressure is 90 to 150 cm water pressure (cm H2O). D. CSF is reabsorbed by the arachnoid villi at the same rate at which it is formed. E. CSF is formed continuously within the ventricles of the brain as a filtrate from the blood. A. Proper treatment for hypertension B. Adequate treatment of atherosclerosis 5. Confused 6. Lethargy 7. Obtunded 8. Stuporous 9. Comatose - Correct answer All the following are LOCs. Starting with the optimal LOC, place these in order of a decreasing LOC. 10.Alert 11.Lethargic 12.Confused 13.Obtunded 14.Comatose 15.Stuporous D. "Drinking very cold or hot liquids is frequently a trigger, so you should avoid both." - Correct answer The patient with trigeminal neuralgia asks the nurse if there is anything she can do to prevent future episodes of the disorder. Which response by the nurse is correct? A. "It is best if you speak with your physician about this condition." B. "Unfortunately, there is little you can do to prevent future episodes of pain." C. "Drinking very cold or hot liquids is frequently a trigger, so you should avoid both." D. "Surgery is the only form of treatment that will prevent this condition from recurring." B. The patient tilts his head back when trying to swallow solid foods. - Correct answer A patient is admitted to a rehabilitation facility following a brain injury that has resulted in dysphagia. While observing the patient and his wife, the nurse determines further instruction is necessary if which activity is performed? A. The patient sips from a cup rather than using a straw. B. The patient sits in his chair for 45 minutes after each meal. C. The patient tilts his head back when trying to swallow solid foods. D. The patient's wife places a teaspoon of food in the patient's mouth at a time. E. "This helps to strengthen and retrain muscles " - Correct answer The nurse who is caring for a patient following a stroke performs passive range-of-motion exercises on the patient. The patient asks why these exercises are so important. Which response by the nurse is accurate? A. "This helps the patient believe she is making some progress." B. "This helps overcome mood swings and crying spells." C. "This helps prevent fatigue from worsening." D. "This helps to strengthen and retrain muscles." C. At the time of menstruation - Correct answer The nurse is providing patient teaching to a 23-year-old female who has recently been diagnosed with epilepsy. The nurse should educate the patient that seizures are most likely to occur at which time in the patient's menstrual cycle? A. At the time of ovulation B. 1 week after menstruation C. At the time of menstruation D. 1 week before menstruation A. The patient should have periodic drug levels drawn. - Correct answer A patient who has epilepsy is to take phenytoin (Dilantin). What is an important teaching point that the LPN/LVN should include regarding this medication? A. The patient should have periodic drug levels drawn. B. The patient should regulate the dosage according to need. C. The patient should take the medication with juice containing vitamin C. D. The patient should take an extra dose of the medication before exercising. B. Aphasia - Correct answer A patient has had a left-sided cerebrovascular accident (CVA). Which condition does the nurse expect the patient to have as a result of the CVA? A. Ataxia B. Aphasia C. Dyslexia D. Quadriplegia E. Severe headache that wakes patient and visual problems - Correct answer A patient has been diagnosed with a cerebral neoplasm. What are the symptoms of a cerebral neoplasm? A. Long-term memory loss and paralysis B. Loss of muscle strength and paresthesia C. Grand mal seizure activity and facial paralysis D. Severe headache that wakes patient and visual problems C. Epistaxis - Correct answer The nurse obtaining an admission history for a patient recovering from a CVA finds a medication history including aspirin (Ecotrin). What should alert the nurse to a possible adverse effect of this drug? A. Nausea B. Epistaxis C. Hyperactivity D. Abdominal distention B. What the patient was doing prior to the seizure. C. What time the seizure began and how long it lasted. D. Whether body movements are unilateral and symmetrical. E. Which direction the patient's eyes turned during the seizure. - Correct answer The LPN/LVN is talking with a patient, who has epilepsy, when he begins having a tonic-clonic (grand mal) seizure. Which assessment(s) should the LPN/LVN make? (Select all that apply.) A. What the patient had eaten prior to the seizure. B. What the patient was doing prior to the seizure. C. What time the seizure began and how long it lasted. D. Whether body movements are unilateral and symmetrical. E. Which direction the patient's eyes turned during the seizure. A. Cerebral thrombosis B. Cerebral hemorrhage F. Atherosclerosis of the arteries in the head and neck - Correct answer The nurse is providing teaching to a group of patients regarding CVA (stroke). The patients demonstrate an understanding of the teaching when listing which factors as being the possible cause of a stroke? (Select all that apply.) A. Cerebral thrombosis B. Cerebral encephalitis C. Cerebral hemorrhage D. Meningococcal meningitis E. Atherosclerosis of the arteries in the head and neck A. Hospice Services - Correct answer During the advanced stages of amyotrophic lateral sclerosis (ALS), which service would be most beneficial to the family and patient? A. Hospice services B. In-home physical therapy C. Pulmonary rehabilitation program D. Nursing visits from a home health care agency B. "It is a good idea for me to take a hot shower in the morning to relax my muscles." - Correct answer When teaching the patient with multiple sclerosis (MS) about how to best manage his disease, the nurse determines the patient requires further instruction when making which statement? A. "It is important that I attend all of my physical therapy sessions." B. "I should eat adequate fiber to prevent constipation." C. "It is a good idea for me to take a hot shower in the morning to relax my muscles." D. "The injections of interferon beta-1b (Betaseron) will help manage my symptoms." C. Weakness of the limbs - Correct answer A patient has recently been diagnosed with MS. The family asks the nurse about the common manifestations of the disease. The nurse is correct by identifying which as the most common clinical manifestation of the disease? A. Urinary incontinence B. Weakness of the limbs C. A loss of the sense of smell D. Decreased intellectual function C. decreasing temperature, increasing pulse, decreasing respirations, increasing BP D. increasing temperature, decreasing pulse, decreasing respirations, increasing BP B. Head turned to the side - Correct answer The nurse observes the unlicensed assistive personnel positioning the client with increased intracranial pressure. Which position would require intervention by the nurse? A. Head midline B. Head turned to the side C. neck in neutral position D. head of bed elevated to 30 to 45 degrees E. exhaling during respostioning - Correct answer The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following? A. Blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning E. separates into concentric rings and tests positive for glucose - Correct answer The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that is is cerebrospinal fluid ( CSF) if the fluid meets which criteria? A. Is grossly bloody in appearance and has a pH of 6 B. Clumps together on the dressing and has a pH of 7 C. Is clear in appearance and tests negative for glucose D. separates into concentric rings and tests positive for glucose E. The health care provider reviews the x-rays - Correct answer The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? A. The client is taken for spinal x-rays B. The family comes to visit after surgery C. The nurse needs to provide physical care D. The health care provider reviews the x-rays C. Minor headache - Correct answer The client was seen and treated in the ER for a concussion. Before discharge, the nurse explains the signs and symptoms of worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign and symptom? A. Vomiting B. Minor headache C. Difficulty speaking D. Difficulty awakening D. Head of bed elevated 30 to 45 degrees head and neck midline - Correct answer The nurse is caring for a client who has undergone craniotomy with a supratentoral incision. The nurse should plan to place the client in which position post-op? A. Head of bed flat, head and neck midline B. Head of bed flat, head turned to the nonoperative side C. Head of bed elevated 30 to 45 degrees head and neck midline D. Head of bed elevated 30 to 45 degrees, head turned to the operative side E. Comparing the amount of prescribed weights with the amount in use - Correct answer The client with a cervical spine injury has Crutchfield tongs applied in the ER. The nurse should preform which essential action when caring for this client? A. Providing a standard bed frame B. Removing a standard bed frame C. Removing the weights if the client is uncomfortable D. Comparing the amount of prescribed weights with the amount in use C. " I will drive only during the daytime" - Correct answer The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? A. " I will use a straw for drinking" B. " I will drive only during the daytime" C. " I will use caution because the device alters balance" D. " I will wash the skin daily under the lambs wool liner of the vest" D. Severe, throbbing headache - Correct answer The nurse is caring for the client who has suffered a spinal cord injury. The nurse further monitors the client for signs and symptoms of autonomic dysreflexia and suspects this complication if which sign and symptoms is noted? A. sudden tachycardia B. Pallor of face and neck C. Severe, throbbing headache D. Severe and sudden hypotension E. Limiting bladder catherization to once every 12 hours - Correct answer The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? A. Strictly adhering to a bowel retraining program B. Keeping the linen wrinkle-free under the client C. Avoiding unnecessary pressure on the lower limbs D. Limiting bladder catherization to once every 12 hours A. raise the head of bed and removed the noxious stimulus - Correct answer The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the vital signs, which immediate action should the nurse take? A. raise the head of bed and removed the noxious stimulus B. lower the head of bed and remove the noxious stimulus C. lower the head of bed and administer an antihypertensive agent D. remove the noxious stimulus and administer an antihypertensive agent E. Side- laying with legs pulled up and chin to the chest - Correct answer The client is having a lumbar puncture preformed. The nurse should place the client in which position for the procedure? A. Supine, in semi-fowlers B. Prone, in slight Trendelenburg C. Prone, with a pillow under the abdomen D. Side- laying with legs pulled up and chin to the chest