Neuro NCLEX Q&A
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
1. The nurse is as- Semi-Fowler's position
sisting with caring
for a client after a
craniotomy. Which Rationale:
is the best position After a craniotomy, the head of the bed is elevated 30 to 45 degrees
for the client to be (semi-Fowler's to Fowler's position), and the client's head is maintained in a
placed? midline, neutral position to facilitate venous drainage.
2. A client with a 1. Pad the bed's side rails.
seizure disorder is
being admitted to 2. Place an airway at the bedside.
the hospital. Which
3. Place oxygen equipment at the bedside.
should the nurse
plan to implement
4. Place suction equipment at the bedside.
for this client? Se-
lect all that apply. Rationale:
The nurse should plan seizure precautions for a client with a seizure disorder.
The precautions include padded side rails and an airway, and oxygen and
suction equipment at the bedside. Attempts to force a padded tongue blade
between clenched teeth may result in injury to the teeth and mouth; therefore
a padded tongue blade is not placed at the bedside.
3. The nurse is car- The nurse is caring for a client with increased intracranial pressure (ICP). Which
ing for a client with change in vital signs would occur if ICP is rising?
increased intracra- Rationale:
nial pressure (ICP). A change in vital signs may be a late sign of increased ICP. Trends include
Which change in vi- increasing temperature and BP and decreasing pulse and respirations. Res-
tal signs would oc- piratory irregularities may also arise.
cur if ICP is rising?
4. The nurse ob- Head turned to the side
serves the un- Rationale:
actualstudy 1
, Neuro NCLEX Q&A
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
licensed assistive The head of the client with increased ICP should be positioned so that the head
personnel (UAP) po- is in a neutral, midline position. The nurse should avoid flexing or extending the
sitioning the client neck or turning the head side to side. The head of the bed should be raised to
with increased in- 30 to 45 degrees. Use of proper positions promotes venous drainage from the
tracranial pressure cranium to keep ICP down.
(ICP). Which posi-
tion would require
intervention by the
nurse?
5. The client recover- Exhaling during repositioning
ing from a head Rationale:
injury is arousable Activities that increase intrathoracic and intraabdominal pressures cause indi-
and participating in rect elevation of the ICP. Some of these activities include isometric exercises,
care. The nurse de- Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during
termines that the activities such as repositioning or pulling up in bed opens the glottis, which
client understands prevents intrathoracic pressure from rising.
measures to pre-
vent elevations in
intracranial pres-
sure (ICP) if the
nurse observes the
client doing which
activity?
6. The client has clear Separates into concentric rings and tests positive for glucose
fluid leaking from Rationale:
the nose after a Leakage of CSF from the ears or nose may accompany basilar skull fracture. It
basilar skull frac- can be distinguished from other body fluids because the drainage will separate
ture. The nurse de- into bloody and yellow concentric rings on dressing material, which is known
termines that this as the halo sign. It also tests positive for glucose
is cerebrospinal flu-
actualstudy 2
, Neuro NCLEX Q&A
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
id (CSF) if the fluid
meets which crite-
ria?
7. The client is admit- he health care provider reviews the x-ray results.
ted to the hospi- Rationale:
tal for observation There is a significant association between cervical spine injury and head injury.
with a probable mi- For this reason, the nurse leaves any form of spinal immobilization in place until
nor head injury af- lateral cervical spine x-rays rule out fracture or other damage and the results
ter an automobile have been reviewed by the health care provider
crash. The nurse ex-
pects the cervical
collar will remain
in place until which
time?
8. The client was Minor headache
seen and treated in Rationale:
the emergency de- A concussion after head injury is a temporary loss of consciousness (from a
partment (ED) for few seconds to a few minutes) without evidence of structural damage. After
a concussion. Be- concussion, the family is taught to monitor the client and call the health care
fore discharge, the provider or return the client to the emergency department if certain signs
nurse explains the and symptoms are noted. These include confusion, difficulty awakening or
signs/symptoms of speaking, one-sided weakness, vomiting, or severe headache. Minor headache
a worsening condi- is expected.
tion. The nurse de-
termines that the
family needs fur-
ther teaching if they
state they will re-
turn to the ED if the
client experiences
actualstudy 3
, Neuro NCLEX Q&A
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
which sign/symp-
tom?
9. The nurse is car- Head of bed elevated 30 to 45 degrees, head and neck midline.
ing for a client Rationale:
who has under- Following supratentorial surgery, the head of the bed is kept at a 30- to
gone craniotomy 45-degree angle. The head and neck should not be angled either anteriorly
with a supraten- or laterally, but rather should be kept in a neutral (midline) position. This will
torial incision. The promote venous return through the jugular veins, which will help prevent a rise
nurse should plan in intracranial pressure.
to place the client
in which position
postoperatively?
10. The client with a Comparing the amount of prescribed weights with the amount in use
cervical spine in- Rationale:
jury has Crutch- Crutchfield tongs are applied after drilling holes in the client's skull under local
field tongs applied anesthesia. Weights are attached to the tongs, which exert pulling pressure
in the emergency on the longitudinal axis of the cervical spine. The nurse ensures that weights
department. The hang freely and that the amount of weight matches the current prescription.
nurse should per- The client with Crutchfield tongs is placed on a Stryker frame or Roto-Rest bed.
form which essen- The nurse does not remove the weights to administer care or change the level
tial action when car- of tension or traction based on client comfort level.
ing for this client?
11. The nurse has pro- "I will drive only during the daytime."
vided discharge in- Rationale:
structions to a The client should not drive because the device impairs the range of vision. The
client with an appli- halo device alters balance and can cause fatigue because of its weight. The
cation of a halo de- client should cleanse the skin daily under the vest or the device to protect the
vice. The nurse de- skin from ulceration and should use powder or lotions sparingly or not at all.
termines that the The wool liner should be changed if odor becomes a problem. The client should
actualstudy 4
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
1. The nurse is as- Semi-Fowler's position
sisting with caring
for a client after a
craniotomy. Which Rationale:
is the best position After a craniotomy, the head of the bed is elevated 30 to 45 degrees
for the client to be (semi-Fowler's to Fowler's position), and the client's head is maintained in a
placed? midline, neutral position to facilitate venous drainage.
2. A client with a 1. Pad the bed's side rails.
seizure disorder is
being admitted to 2. Place an airway at the bedside.
the hospital. Which
3. Place oxygen equipment at the bedside.
should the nurse
plan to implement
4. Place suction equipment at the bedside.
for this client? Se-
lect all that apply. Rationale:
The nurse should plan seizure precautions for a client with a seizure disorder.
The precautions include padded side rails and an airway, and oxygen and
suction equipment at the bedside. Attempts to force a padded tongue blade
between clenched teeth may result in injury to the teeth and mouth; therefore
a padded tongue blade is not placed at the bedside.
3. The nurse is car- The nurse is caring for a client with increased intracranial pressure (ICP). Which
ing for a client with change in vital signs would occur if ICP is rising?
increased intracra- Rationale:
nial pressure (ICP). A change in vital signs may be a late sign of increased ICP. Trends include
Which change in vi- increasing temperature and BP and decreasing pulse and respirations. Res-
tal signs would oc- piratory irregularities may also arise.
cur if ICP is rising?
4. The nurse ob- Head turned to the side
serves the un- Rationale:
actualstudy 1
, Neuro NCLEX Q&A
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
licensed assistive The head of the client with increased ICP should be positioned so that the head
personnel (UAP) po- is in a neutral, midline position. The nurse should avoid flexing or extending the
sitioning the client neck or turning the head side to side. The head of the bed should be raised to
with increased in- 30 to 45 degrees. Use of proper positions promotes venous drainage from the
tracranial pressure cranium to keep ICP down.
(ICP). Which posi-
tion would require
intervention by the
nurse?
5. The client recover- Exhaling during repositioning
ing from a head Rationale:
injury is arousable Activities that increase intrathoracic and intraabdominal pressures cause indi-
and participating in rect elevation of the ICP. Some of these activities include isometric exercises,
care. The nurse de- Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during
termines that the activities such as repositioning or pulling up in bed opens the glottis, which
client understands prevents intrathoracic pressure from rising.
measures to pre-
vent elevations in
intracranial pres-
sure (ICP) if the
nurse observes the
client doing which
activity?
6. The client has clear Separates into concentric rings and tests positive for glucose
fluid leaking from Rationale:
the nose after a Leakage of CSF from the ears or nose may accompany basilar skull fracture. It
basilar skull frac- can be distinguished from other body fluids because the drainage will separate
ture. The nurse de- into bloody and yellow concentric rings on dressing material, which is known
termines that this as the halo sign. It also tests positive for glucose
is cerebrospinal flu-
actualstudy 2
, Neuro NCLEX Q&A
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
id (CSF) if the fluid
meets which crite-
ria?
7. The client is admit- he health care provider reviews the x-ray results.
ted to the hospi- Rationale:
tal for observation There is a significant association between cervical spine injury and head injury.
with a probable mi- For this reason, the nurse leaves any form of spinal immobilization in place until
nor head injury af- lateral cervical spine x-rays rule out fracture or other damage and the results
ter an automobile have been reviewed by the health care provider
crash. The nurse ex-
pects the cervical
collar will remain
in place until which
time?
8. The client was Minor headache
seen and treated in Rationale:
the emergency de- A concussion after head injury is a temporary loss of consciousness (from a
partment (ED) for few seconds to a few minutes) without evidence of structural damage. After
a concussion. Be- concussion, the family is taught to monitor the client and call the health care
fore discharge, the provider or return the client to the emergency department if certain signs
nurse explains the and symptoms are noted. These include confusion, difficulty awakening or
signs/symptoms of speaking, one-sided weakness, vomiting, or severe headache. Minor headache
a worsening condi- is expected.
tion. The nurse de-
termines that the
family needs fur-
ther teaching if they
state they will re-
turn to the ED if the
client experiences
actualstudy 3
, Neuro NCLEX Q&A
Neuro NCLEX
Study online at https://quizlet.com/_8kh256
which sign/symp-
tom?
9. The nurse is car- Head of bed elevated 30 to 45 degrees, head and neck midline.
ing for a client Rationale:
who has under- Following supratentorial surgery, the head of the bed is kept at a 30- to
gone craniotomy 45-degree angle. The head and neck should not be angled either anteriorly
with a supraten- or laterally, but rather should be kept in a neutral (midline) position. This will
torial incision. The promote venous return through the jugular veins, which will help prevent a rise
nurse should plan in intracranial pressure.
to place the client
in which position
postoperatively?
10. The client with a Comparing the amount of prescribed weights with the amount in use
cervical spine in- Rationale:
jury has Crutch- Crutchfield tongs are applied after drilling holes in the client's skull under local
field tongs applied anesthesia. Weights are attached to the tongs, which exert pulling pressure
in the emergency on the longitudinal axis of the cervical spine. The nurse ensures that weights
department. The hang freely and that the amount of weight matches the current prescription.
nurse should per- The client with Crutchfield tongs is placed on a Stryker frame or Roto-Rest bed.
form which essen- The nurse does not remove the weights to administer care or change the level
tial action when car- of tension or traction based on client comfort level.
ing for this client?
11. The nurse has pro- "I will drive only during the daytime."
vided discharge in- Rationale:
structions to a The client should not drive because the device impairs the range of vision. The
client with an appli- halo device alters balance and can cause fatigue because of its weight. The
cation of a halo de- client should cleanse the skin daily under the vest or the device to protect the
vice. The nurse de- skin from ulceration and should use powder or lotions sparingly or not at all.
termines that the The wool liner should be changed if odor becomes a problem. The client should
actualstudy 4
