NCLEX Saunders -NEURO Exam
Questions & Answers (Grade A+)
A client with amyotrophic lateral sclerosis (ALS) tells the nurse,
"Sometimes I feel so frustrated. I can't do anything without help!"
This comment best supports which nursing diagnosis? -
correct answer ✅Powerlessness
When caring for a client with a head injury, the nurse must stay
alert for signs and symptoms of increased intracranial pressure
(ICP). Which cardiovascular findings are late indicators of increased
ICP? -
correct answer ✅Rising blood pressure and bradycardia
The nurse receives a physician's order to administer 1,000 ml of
normal saline solution I.V. over 8 hours to a client who recently had
a stroke. What should the drip rate be if the drop factor of the
tubing is 15 gtt/ml? -
correct answer ✅31
When caring for a client with head trauma, the nurse notes a small
amount of clear, watery fluid oozing from the client's nose. What
should the nurse do? -
correct answer ✅Test the nasal drainage for glucose.
,NCLEX Saunders -NEURO Exam
Questions & Answers (Grade A+)
The physician orders measurement of the serum acetaminophen
level of a client admitted with a suspected overdose of this drug. To
ensure an accurate result, the nurse should wait how long after
acetaminophen (Tylenol) ingestion before drawing the blood
sample? -
correct answer ✅4 hours
A home health nurse visits a client who's taking pilocarpine, a
miotic agent, to treat glaucoma. The nurse notes that the client's
pilocarpine solution is cloudy. What should the nurse do first? -
correct answer ✅Advise the client to discard the drug because it
may have undergone chemical changes or become contaminated.
Damage to which area of the brain results in receptive aphasia? -
correct answer ✅Temporal lobe
A client who sustained an L1 to L2 spinal cord injury in a
construction accident asks a nurse if he'll ever be able to walk
again. Which response by the nurse is appropriate? -
correct answer ✅"What has your physician told you about your
ability to walk again?"
,NCLEX Saunders -NEURO Exam
Questions & Answers (Grade A+)
A client is admitted to an acute care facility for treatment of a brain
tumor. When reviewing the chart, the nurse notes that the client's
extremity muscle strength is rated 1/5. What does this mean? -
correct answer ✅Muscle contraction is palpable and visible.
A client with a spinal cord injury and subsequent urine retention
receives intermittent catheterization every 4 hours. The average
catheterized urine volume has been 550 ml. The nurse should plan
to: -
correct answer ✅increase the frequency of the catheterizations.
(SELECT ALL THAT APPLY) The nurse is planning care for a client with
multiple sclerosis. Which problems should the nurse expect the
client to experience? -
correct answer ✅(1) Visual disturbances, (3) Balance problems,
(5) Mood disorders
A client undergoes cerebral angiography to evaluate for neurologic
deficits. 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? -
correct answer ✅Hemiplegia, seizures, and decreased level of
consciousness (LOC)
, NCLEX Saunders -NEURO Exam
Questions & Answers (Grade A+)
The nurse is administering neostigmine to a client with myasthenia
gravis. Which nursing intervention should the nurse implement? -
correct answer ✅Schedule the medication before meals.
A 78-year-old Alzheimer's client is being treated for malnutrition
and dehydration. The nurse decides to place him closer to the
nurses' station because of his tendency to: -
correct answer ✅wander.
During the course of a busy shift, a nurse fails to document that a
client's ventricular drain had an output of 150 ml. Assuming that
the drain was no longer draining cerebrospinal fluid, the physician
removes the drain. When the nurse arrives for work the next
morning, she learns that the client became agitated during the
night and his blood pressure became elevated. What action should
the nurse take? -
correct answer ✅Notify the physician of the documentation
omission.
How should the nurse position a client for a lumbar puncture? -
correct answer ✅Laterally, with knees drawn up to the abdomen
and chin touching the chest
Questions & Answers (Grade A+)
A client with amyotrophic lateral sclerosis (ALS) tells the nurse,
"Sometimes I feel so frustrated. I can't do anything without help!"
This comment best supports which nursing diagnosis? -
correct answer ✅Powerlessness
When caring for a client with a head injury, the nurse must stay
alert for signs and symptoms of increased intracranial pressure
(ICP). Which cardiovascular findings are late indicators of increased
ICP? -
correct answer ✅Rising blood pressure and bradycardia
The nurse receives a physician's order to administer 1,000 ml of
normal saline solution I.V. over 8 hours to a client who recently had
a stroke. What should the drip rate be if the drop factor of the
tubing is 15 gtt/ml? -
correct answer ✅31
When caring for a client with head trauma, the nurse notes a small
amount of clear, watery fluid oozing from the client's nose. What
should the nurse do? -
correct answer ✅Test the nasal drainage for glucose.
,NCLEX Saunders -NEURO Exam
Questions & Answers (Grade A+)
The physician orders measurement of the serum acetaminophen
level of a client admitted with a suspected overdose of this drug. To
ensure an accurate result, the nurse should wait how long after
acetaminophen (Tylenol) ingestion before drawing the blood
sample? -
correct answer ✅4 hours
A home health nurse visits a client who's taking pilocarpine, a
miotic agent, to treat glaucoma. The nurse notes that the client's
pilocarpine solution is cloudy. What should the nurse do first? -
correct answer ✅Advise the client to discard the drug because it
may have undergone chemical changes or become contaminated.
Damage to which area of the brain results in receptive aphasia? -
correct answer ✅Temporal lobe
A client who sustained an L1 to L2 spinal cord injury in a
construction accident asks a nurse if he'll ever be able to walk
again. Which response by the nurse is appropriate? -
correct answer ✅"What has your physician told you about your
ability to walk again?"
,NCLEX Saunders -NEURO Exam
Questions & Answers (Grade A+)
A client is admitted to an acute care facility for treatment of a brain
tumor. When reviewing the chart, the nurse notes that the client's
extremity muscle strength is rated 1/5. What does this mean? -
correct answer ✅Muscle contraction is palpable and visible.
A client with a spinal cord injury and subsequent urine retention
receives intermittent catheterization every 4 hours. The average
catheterized urine volume has been 550 ml. The nurse should plan
to: -
correct answer ✅increase the frequency of the catheterizations.
(SELECT ALL THAT APPLY) The nurse is planning care for a client with
multiple sclerosis. Which problems should the nurse expect the
client to experience? -
correct answer ✅(1) Visual disturbances, (3) Balance problems,
(5) Mood disorders
A client undergoes cerebral angiography to evaluate for neurologic
deficits. 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? -
correct answer ✅Hemiplegia, seizures, and decreased level of
consciousness (LOC)
, NCLEX Saunders -NEURO Exam
Questions & Answers (Grade A+)
The nurse is administering neostigmine to a client with myasthenia
gravis. Which nursing intervention should the nurse implement? -
correct answer ✅Schedule the medication before meals.
A 78-year-old Alzheimer's client is being treated for malnutrition
and dehydration. The nurse decides to place him closer to the
nurses' station because of his tendency to: -
correct answer ✅wander.
During the course of a busy shift, a nurse fails to document that a
client's ventricular drain had an output of 150 ml. Assuming that
the drain was no longer draining cerebrospinal fluid, the physician
removes the drain. When the nurse arrives for work the next
morning, she learns that the client became agitated during the
night and his blood pressure became elevated. What action should
the nurse take? -
correct answer ✅Notify the physician of the documentation
omission.
How should the nurse position a client for a lumbar puncture? -
correct answer ✅Laterally, with knees drawn up to the abdomen
and chin touching the chest
