Neurological NCLEX Questions and Answers with Complete Solution

Neurological NCLEX Questions and Answers with Complete Solution B. CN II and CN III - 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 D .CN IV and CN V D. Pupil changes can be caused by pressure on the ocular nerve. - 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. D. Touch his nose with his left index finger. - 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) - 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) C. "Checking this reflex assesses involuntary muscular contractions." - 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." D. Determine whether the patient is able to move his legs and arms - 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 B. "The procedure is safe and painless; you will hear a clicking noise as the CT machine rotates." - 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." C. "CT scanning is a new procedure, and since it involves the brain, I think the doctor can answer your questions better than I can." C. White blood cells (WBCs) 100/mm3 - 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. 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. - 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 C. Avoiding the use of recreational drugs E. Keeping serum cholesterol levels under control - The LPN/LVN discusses ways to prevent a stroke with a patient. Which measures should the nurse include in her teaching? (Select all that apply.) A. Proper treatment for hypertension B. Adequate treatment of atherosclerosis C. Avoiding the use of recreational drugs D. Encouraging the use of seat belts in vehicles E. Keeping serum cholesterol levels under control A. Polyuria - The nurse suspects that a 36-year-old patient recovering from a hypophysectomy (removal of the pituitary gland) has developed diabetes insipidus (DI). What sign or symptom is most indicative of DI? A. Polyuria B. Polyphagia C. Hypertension D. Hyperkalemia D. "I can take a four hour car ride, as long as I stay perfectly still. - The patient who had a laminectomy following a herniated lumbar disk is preparing to be discharged. Which statement by the patient indicates a need for additional discharge instructions? A. "I should try to maintain a normal weight." B. "It is best for me to do my back exercises twice a day." C. "I need to be sure not to twist or bend at the waist when lifting things." D. "I can take a four hour car ride, as long as I stay perfectly still. B. "I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours." - A 13-year-old female patient has been seen in a walk-in clinic following a blow to the head from a fall during basketball practice. Which statement by the parent indicates the need for further discharge teaching? A. "I need to wake her up every 2 or 3 hours for the first 24 hours." B. "I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours." C. "I need to check her pupils frequently with a flashlight to be sure her pupils constrict." D. "I need to watch for any changes in the level of consciousness or vomiting for 48 hours." A. The 76-year-old patient who is taking an anticoagulant - Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head? A. The 76-year-old patient who is taking an anticoagulant B. The 16-year-old football player who suffered a concussion C. The 36-year-old patient who has a history of migraine headaches D. The 56-year-old patient who is taking an antihypertensive medication C. Turn the patient slowly and as one unit to avoid twisting the spine. - The student nurse is assisting the nurse in turning a patient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? A. Flex the knees and hips before turning the patient. B. Support the patient's head with a pillow so that his neck is flexed. C. Turn the patient slowly and as one unit to avoid twisting the spine. D. Place the patient's back in traction so that the spine will be kept slightly flexed. A. Brain atrophy - Which of the following conditions can increase the risk for torn vessels and contusion on the brain if an accident that involves brain injury occurs? A. Brain atrophy B. Hydrocephalus C. Heterotopic ossification D. Increased intracranial pressure (ICP)