Neurology NCLEX Questions
The nurse is assessing the motor function of an unconscious male client. The nurse
would plan to use which plan to use which of the following to test the client's peripheral
response to pain?
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle
Motor testing in the unconscious client can be done only by testing response to painful
stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain
are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
A female client admitted to the hospital with a neurological problem asks the nurse
whether magnetic resonance imaging may be done. The nurse interprets that the client
may be ineligible for this diagnostic procedure based on the client's history of:
a. Hypertension
b. Heart failure
c. Prosthetic valve replacement
d. Chronic obstructive pulmonary disorder
The client having a magnetic resonance imaging scan has all metallic objects removed
because of the magnetic field generated by the device. A careful history is obtained to
determine whether any metal objects are inside the client, such as orthopedic hardware,
pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may
heat up, become dislodged, or malfunction during this procedure. The client may be
ineligible if significant risk exists.
A male client is having a lumbar puncture performed. The nurse would plan to place the
client in which position?
a. Side-lying, with a pillow under the hip
b. Prone, with a pillow under the abdomen
c. Prone, in slight-Trendelenburg's position
d. Side-lying, with the legs pulled up and head bent down onto chest.
The client undergoing lumbar puncture is positioned lying on the side, with the legs
pulled up to the abdomen and the head bent down onto the chest. This position helps
open the spaces between the vertebrae.
The nurse is positioning the female client with increased intracranial pressure. Which of
the following positions would the nurse avoid?
a. Head mildline
, b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees
The head of the client with increased intracranial pressure should be positioned so the
head is in a neutral midline position. The nurse should avoid flexing or extending the
client's neck or turning the head side to side. The head of the bed should be raised to
30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium
to keep intracranial pressure down.
A female client has clear fluid leaking from the nose following a basilar skull fracture.
The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
skull fracture. CSF can be distinguished from other body fluids because the drainage
will separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose.
A male client with a spinal cord injury is prone to experiencing automatic dysreflexia.
The nurse would avoid which of the following measures to minimize the risk of
recurrence?
a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower limbs
d. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours, and foley catheters should be
checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are
other causes, so maintaining bowel regularity is important. Other causes include
stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers
care to minimize risk in these areas.
The nurse is caring for the male client who begins to experience seizure activity while in
bed. Which of the following actions by the nurse would be contraindicated?
a. Loosening restrictive clothing
b. Restraining the client's limbs
c. Removing the pillow and raising padded side rails
d. Positioning the client to side, if possible, with the head flexed forward
Nursing actions during a seizure include providing for privacy, loosening restrictive
clothing, removing the pillow and raising side rails in the bed, and placing the client on
The nurse is assessing the motor function of an unconscious male client. The nurse
would plan to use which plan to use which of the following to test the client's peripheral
response to pain?
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle
Motor testing in the unconscious client can be done only by testing response to painful
stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain
are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
A female client admitted to the hospital with a neurological problem asks the nurse
whether magnetic resonance imaging may be done. The nurse interprets that the client
may be ineligible for this diagnostic procedure based on the client's history of:
a. Hypertension
b. Heart failure
c. Prosthetic valve replacement
d. Chronic obstructive pulmonary disorder
The client having a magnetic resonance imaging scan has all metallic objects removed
because of the magnetic field generated by the device. A careful history is obtained to
determine whether any metal objects are inside the client, such as orthopedic hardware,
pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may
heat up, become dislodged, or malfunction during this procedure. The client may be
ineligible if significant risk exists.
A male client is having a lumbar puncture performed. The nurse would plan to place the
client in which position?
a. Side-lying, with a pillow under the hip
b. Prone, with a pillow under the abdomen
c. Prone, in slight-Trendelenburg's position
d. Side-lying, with the legs pulled up and head bent down onto chest.
The client undergoing lumbar puncture is positioned lying on the side, with the legs
pulled up to the abdomen and the head bent down onto the chest. This position helps
open the spaces between the vertebrae.
The nurse is positioning the female client with increased intracranial pressure. Which of
the following positions would the nurse avoid?
a. Head mildline
, b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees
The head of the client with increased intracranial pressure should be positioned so the
head is in a neutral midline position. The nurse should avoid flexing or extending the
client's neck or turning the head side to side. The head of the bed should be raised to
30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium
to keep intracranial pressure down.
A female client has clear fluid leaking from the nose following a basilar skull fracture.
The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
skull fracture. CSF can be distinguished from other body fluids because the drainage
will separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose.
A male client with a spinal cord injury is prone to experiencing automatic dysreflexia.
The nurse would avoid which of the following measures to minimize the risk of
recurrence?
a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower limbs
d. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours, and foley catheters should be
checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are
other causes, so maintaining bowel regularity is important. Other causes include
stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers
care to minimize risk in these areas.
The nurse is caring for the male client who begins to experience seizure activity while in
bed. Which of the following actions by the nurse would be contraindicated?
a. Loosening restrictive clothing
b. Restraining the client's limbs
c. Removing the pillow and raising padded side rails
d. Positioning the client to side, if possible, with the head flexed forward
Nursing actions during a seizure include providing for privacy, loosening restrictive
clothing, removing the pillow and raising side rails in the bed, and placing the client on
