NEURO NCLEX EXAM 2025 QUESTIONS AND
CORRECT ANSWERS
The nurse is assisting with caring for a client after a craniotomy. Which is the best position for
the client to be placed?
Semi-Fowler's position
Rationale:
After a craniotomy, the head of the bed is elevated 30 to 45 degrees (semi-Fowler's to Fowler's
position), and the client's head is maintained in a midline, neutral position to facilitate venous
drainage.
A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan
to implement for this client? Select all that apply.
1. Pad the bed's side rails.
2. Place an airway at the bedside.
3. Place oxygen equipment at the bedside.
4. Place suction equipment at the bedside.
,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.
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in
vital signs would occur if ICP is rising?
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital
signs would occur if ICP is rising?
Rationale:
A change in vital signs may be a late sign of increased ICP. Trends include increasing
temperature and BP and decreasing pulse and respirations. Respiratory irregularities may also
arise.
The nurse observes the unlicensed assistive personnel (UAP) positioning the client with
increased intracranial pressure (ICP). Which position would require intervention by the
nurse?
Head turned to the side
Rationale:
The head of the client with increased ICP should be positioned so that the head is in a neutral,
midline position. The nurse should avoid flexing or extending the 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 ICP down.
The client recovering from a head injury is arousable and participating in care. The nurse
determines that the client understands measures to prevent elevations in intracranial
pressure (ICP) if the nurse observes the client doing which activity?
Exhaling during repositioning
Rationale:
Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of
the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing,
sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in
bed opens the glottis, which prevents intrathoracic pressure from rising.
The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse
determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?
Separates into concentric rings and tests positive for glucose
Rationale:
Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be
distinguished from other body fluids because the drainage will separate into bloody and yellow
concentric rings on dressing material, which is known as the halo sign. It also tests positive for
glucose
, The client is admitted to the hospital for observation with a probable minor head injury after
an automobile crash. The nurse expects the cervical collar will remain in place until which
time?
he health care provider reviews the x-ray results.
Rationale:
There is a significant association between cervical spine injury and head injury. For this reason,
the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule
out fracture or other damage and the results have been reviewed by the health care provider
The client was seen and treated in the emergency department (ED) for a concussion. Before
discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse
determines that the family needs further teaching if they state they will return to the ED if
the client experiences which sign/symptom?
Minor headache
Rationale:
A concussion after head injury is a temporary loss of consciousness (from a few seconds to a
few minutes) without evidence of structural damage. After concussion, the family is taught to
monitor the client and call the health care provider or return the client to the emergency
department if certain signs and symptoms are noted. These include confusion, difficulty
awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is
expected.
CORRECT ANSWERS
The nurse is assisting with caring for a client after a craniotomy. Which is the best position for
the client to be placed?
Semi-Fowler's position
Rationale:
After a craniotomy, the head of the bed is elevated 30 to 45 degrees (semi-Fowler's to Fowler's
position), and the client's head is maintained in a midline, neutral position to facilitate venous
drainage.
A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan
to implement for this client? Select all that apply.
1. Pad the bed's side rails.
2. Place an airway at the bedside.
3. Place oxygen equipment at the bedside.
4. Place suction equipment at the bedside.
,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.
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in
vital signs would occur if ICP is rising?
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital
signs would occur if ICP is rising?
Rationale:
A change in vital signs may be a late sign of increased ICP. Trends include increasing
temperature and BP and decreasing pulse and respirations. Respiratory irregularities may also
arise.
The nurse observes the unlicensed assistive personnel (UAP) positioning the client with
increased intracranial pressure (ICP). Which position would require intervention by the
nurse?
Head turned to the side
Rationale:
The head of the client with increased ICP should be positioned so that the head is in a neutral,
midline position. The nurse should avoid flexing or extending the 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 ICP down.
The client recovering from a head injury is arousable and participating in care. The nurse
determines that the client understands measures to prevent elevations in intracranial
pressure (ICP) if the nurse observes the client doing which activity?
Exhaling during repositioning
Rationale:
Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of
the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing,
sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in
bed opens the glottis, which prevents intrathoracic pressure from rising.
The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse
determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?
Separates into concentric rings and tests positive for glucose
Rationale:
Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be
distinguished from other body fluids because the drainage will separate into bloody and yellow
concentric rings on dressing material, which is known as the halo sign. It also tests positive for
glucose
, The client is admitted to the hospital for observation with a probable minor head injury after
an automobile crash. The nurse expects the cervical collar will remain in place until which
time?
he health care provider reviews the x-ray results.
Rationale:
There is a significant association between cervical spine injury and head injury. For this reason,
the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule
out fracture or other damage and the results have been reviewed by the health care provider
The client was seen and treated in the emergency department (ED) for a concussion. Before
discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse
determines that the family needs further teaching if they state they will return to the ED if
the client experiences which sign/symptom?
Minor headache
Rationale:
A concussion after head injury is a temporary loss of consciousness (from a few seconds to a
few minutes) without evidence of structural damage. After concussion, the family is taught to
monitor the client and call the health care provider or return the client to the emergency
department if certain signs and symptoms are noted. These include confusion, difficulty
awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is
expected.
