NCLEX Style Questions- NEURO
NCLEX Style Questions- NEURO
Study online at https://quizlet.com/_62mn1a
1. The nurse is assessing the C. Chart the client's level of consciousness as coma.
level of consciousness in a
client with a head injury who Rationale: The client has a score of 6 (eye opening to pain=2; ver-
has been unresponsive for bal response, incomprehensible sounds=2, best motor response,
the last 8 hours. Using the abnormal extension=2); a score >7 is indicative of coma. While
Glasgow Coma Scale, the the nurse should continue to speak to the client, at this time the
nurse notes that the client client will not be able to be aroused. The nurse should continue
opens the eyes only as a to provide skin care and appropriate alignment, but the client will
response to pain, responds continue to have a motor response of limb extension. It is not
with sounds that are not un- necessary to notify the HCP as this assessment does not represent
derstandable, and has ab- a significant change in neurological status.
normal extension of the ex-
tremities. What should the
nurse do?
A. Attempt to arouse the
client
B. Reposition the client with
the extremities in normal
alignment
C. Chart the client's level of
consciousness as coma.
D. Notify the healthcare
provider
2. A client is at risk for In- A. Unequal pupil size
creased intracranial pres-
sure (ICP). Which finding is Rationale: Increasing ICP causes unequal pupils as a result of
priority for the nurse to pressure on the third cranial nerve. Increasing ICP causes an in-
monitor? crease in systolic BP, which reflects the additional pressure need-
ed to perfuse the brain. It increases the pressure on the vagus
A. Unequal pupil size
1/9
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, NCLEX Style Questions- NEURO
NCLEX Style Questions- NEURO
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B. Decreasing systolic blood nerve, which produces bradycardia, and it causes an increase in
pressure body temperature from hypothalamic damage.
C. Tachycardia
D. Decreasing body temper-
ature
3. Which respiratory pattern in- A. Slow, irregular respirations
dicates increasing ICP in the
brain stem? Rationale: Neural control of respiration takes place in the brain
stem. Deterioration and pressure produce slow and irregular res-
A. Slow, irregular respira- pirations. Rapid and shallow respirations, asymmetric chest move-
tions ments, and nasal flaring are more characteristic of respiratory
B. Rapid, shallow respira- distress or hypoxia.
tions
C. Asymmetric chest excur-
sion
D. Nasal flaring
4. A client has an increased C. Encourage the client to take deep breaths to hyperventilate
ICP of 20mmHg. The nurse
should: Rationale: Normal ICP is 15mmHg or less for 15 to 30 seconds or
longer. Hyperventilation causes vasoconstriction, which reduces
A. Give the client a warming cerebrospinal fluid and blood volume, two important factors for
blanket reducing a sustained ICP of 20mmHg. A cooling blanket is used
B. Administer low-dose bar- to control the elevation of temperature because a fever increases
biturates the metabolic rate, which in turn increases ICP. High doses of bar-
C. Encourage the client to biturates may be used to reduce the increased cellular metabolic
take deep breaths to hyper- demands. Fluid volume and inotropic drugs are used to maintain
ventilate cerebral perfusion by supporting the cardiac output and keeping
D. Restrict fluids the cerebral perfusion pressure >80mmHg.
5. The nurse is assessing a D. Decrease in the level of consciousness (LOC)
client with increasing ICP.
2/9
actualstudy 2
NCLEX Style Questions- NEURO
Study online at https://quizlet.com/_62mn1a
1. The nurse is assessing the C. Chart the client's level of consciousness as coma.
level of consciousness in a
client with a head injury who Rationale: The client has a score of 6 (eye opening to pain=2; ver-
has been unresponsive for bal response, incomprehensible sounds=2, best motor response,
the last 8 hours. Using the abnormal extension=2); a score >7 is indicative of coma. While
Glasgow Coma Scale, the the nurse should continue to speak to the client, at this time the
nurse notes that the client client will not be able to be aroused. The nurse should continue
opens the eyes only as a to provide skin care and appropriate alignment, but the client will
response to pain, responds continue to have a motor response of limb extension. It is not
with sounds that are not un- necessary to notify the HCP as this assessment does not represent
derstandable, and has ab- a significant change in neurological status.
normal extension of the ex-
tremities. What should the
nurse do?
A. Attempt to arouse the
client
B. Reposition the client with
the extremities in normal
alignment
C. Chart the client's level of
consciousness as coma.
D. Notify the healthcare
provider
2. A client is at risk for In- A. Unequal pupil size
creased intracranial pres-
sure (ICP). Which finding is Rationale: Increasing ICP causes unequal pupils as a result of
priority for the nurse to pressure on the third cranial nerve. Increasing ICP causes an in-
monitor? crease in systolic BP, which reflects the additional pressure need-
ed to perfuse the brain. It increases the pressure on the vagus
A. Unequal pupil size
1/9
actualstudy 1
, NCLEX Style Questions- NEURO
NCLEX Style Questions- NEURO
Study online at https://quizlet.com/_62mn1a
B. Decreasing systolic blood nerve, which produces bradycardia, and it causes an increase in
pressure body temperature from hypothalamic damage.
C. Tachycardia
D. Decreasing body temper-
ature
3. Which respiratory pattern in- A. Slow, irregular respirations
dicates increasing ICP in the
brain stem? Rationale: Neural control of respiration takes place in the brain
stem. Deterioration and pressure produce slow and irregular res-
A. Slow, irregular respira- pirations. Rapid and shallow respirations, asymmetric chest move-
tions ments, and nasal flaring are more characteristic of respiratory
B. Rapid, shallow respira- distress or hypoxia.
tions
C. Asymmetric chest excur-
sion
D. Nasal flaring
4. A client has an increased C. Encourage the client to take deep breaths to hyperventilate
ICP of 20mmHg. The nurse
should: Rationale: Normal ICP is 15mmHg or less for 15 to 30 seconds or
longer. Hyperventilation causes vasoconstriction, which reduces
A. Give the client a warming cerebrospinal fluid and blood volume, two important factors for
blanket reducing a sustained ICP of 20mmHg. A cooling blanket is used
B. Administer low-dose bar- to control the elevation of temperature because a fever increases
biturates the metabolic rate, which in turn increases ICP. High doses of bar-
C. Encourage the client to biturates may be used to reduce the increased cellular metabolic
take deep breaths to hyper- demands. Fluid volume and inotropic drugs are used to maintain
ventilate cerebral perfusion by supporting the cardiac output and keeping
D. Restrict fluids the cerebral perfusion pressure >80mmHg.
5. The nurse is assessing a D. Decrease in the level of consciousness (LOC)
client with increasing ICP.
2/9
actualstudy 2
