NCLEX REVIEW: NEURO EXAM 2025
QUESTIONS AND ANSWERS
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should
do which of the following in priority order? 1. Maintain patent airway 2.record the seizure
activity observed 3.ease the client to the floor 4. Obtain vital signs - ANS 3,1,4,2
Which of the following is contraindicated for a client with seizure precautions? 1. Encouraging
him to perform his own personal hygiene. 2. Allowing him to wear his own clothing. 3.
Assessing oral temperature with a glass thermometer. 4. Encouraging him to be out of bed. -
ANS 3. Temperatures are not assessed orally with a glass thermometer because the
thermometer could break and cause injury if a seizure occurred. The client can perform
personal hygiene. There is no clinical reason to discourage the client from wearing his own
clothes. As long as there are no other limitations, the client should be encouraged to be out of
bed.
Which of the following will the nurse observe in the client in the ictal phase of a generalized
tonic-clonic seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas. 2.
Vacant staring and abruptly ceasing all activity. 3. Facial grimaces, patting motions, and lip
smacking. 4. Loss of consciousness, body stiffening, and violent muscle contractions. - ANS 4.
A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic
phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction,
which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The
seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts
in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity
spreading to other areas of the body). An absence seizure usually occurs in children and
involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex
partial seizure involves facial grimacing with patting and smacking.
It is the night before a client is to have a computed tomography (CT) scan of the head without
contrast. The nurse should tell the client? 1. "You must shampoo your hair tonight to remove all
oil and dirt." 2. "You may drink fluids until midnight, but after that drink nothing until the scan
is completed." 3. "You will have some hair shaved to attach the small electrode to your scalp."
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, 4. "You will need to hold your head very still during the examination." - ANS 4. The client will
be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes.
In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a
contrast medium is used because the radiopaque substance sometimes causes nausea. There is
no special preparation for a CT scan, so a shampoo the night before is not required. The client
may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT
scan, nor is the head shaved.
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is
served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of
the following should the nurse do? 1. Remove all the food. 2. Remove the coffee. 3. Remove
the toast, butter, and marmalade only. 4. Substitute vegetable juice for the orange juice. -
ANS 2. Beverages containing caffeine, such as coffee, tea, and cola drinks, are withheld
before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal
should not be omitted before an EEG because low blood sugar could alter brain wave patterns;
the client can have the entire meal except for the coffee.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon
awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've
never had one before." Which cause should the nurse include in the response as a primary
cause of tonic-clonic seizures in adults older than age 20? 1. Head trauma. 2. Electrolyte
imbalance. 3. Congenital defect. 4. Epilepsy. - ANS 1. Trauma is one of the primary causes of
brain damage and seizure activity in adults. Other common causes of seizure activity in adults
include neoplasms, withdrawal from drugs and alcohol, and vascular disease. Given the history
of head injury, electrolyte imbalance is not the cause of the seizure. There is no information to
indicate that the seizure is related to a congenital defect. Epilepsy is usually diagnosed in
younger clients.
Which of the following should the nurse include in the teaching plan for a client with seizures
who is going home with a prescription for gabapentin (Neurontin)? 1. Take all the medication
until it is gone. 2. Notify the physician if vision changes occur. 3. Store gabapentin in the
refrigerator. 4. Take gabapentin with an antacid to protect against ulcers. - ANS 2.
Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination
should be reported to the physician. Gabapentin should not be stopped abruptly because of the
potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to
be stored at room temperature and out of direct light. It should not be taken with antacids.
What is the priority nursing intervention in the postictal phase of a seizure? 1. Reorient the
client to time, person, and place. 2. Determine the client's level of sleepiness. 3. Assess the
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QUESTIONS AND ANSWERS
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should
do which of the following in priority order? 1. Maintain patent airway 2.record the seizure
activity observed 3.ease the client to the floor 4. Obtain vital signs - ANS 3,1,4,2
Which of the following is contraindicated for a client with seizure precautions? 1. Encouraging
him to perform his own personal hygiene. 2. Allowing him to wear his own clothing. 3.
Assessing oral temperature with a glass thermometer. 4. Encouraging him to be out of bed. -
ANS 3. Temperatures are not assessed orally with a glass thermometer because the
thermometer could break and cause injury if a seizure occurred. The client can perform
personal hygiene. There is no clinical reason to discourage the client from wearing his own
clothes. As long as there are no other limitations, the client should be encouraged to be out of
bed.
Which of the following will the nurse observe in the client in the ictal phase of a generalized
tonic-clonic seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas. 2.
Vacant staring and abruptly ceasing all activity. 3. Facial grimaces, patting motions, and lip
smacking. 4. Loss of consciousness, body stiffening, and violent muscle contractions. - ANS 4.
A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic
phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction,
which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The
seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts
in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity
spreading to other areas of the body). An absence seizure usually occurs in children and
involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex
partial seizure involves facial grimacing with patting and smacking.
It is the night before a client is to have a computed tomography (CT) scan of the head without
contrast. The nurse should tell the client? 1. "You must shampoo your hair tonight to remove all
oil and dirt." 2. "You may drink fluids until midnight, but after that drink nothing until the scan
is completed." 3. "You will have some hair shaved to attach the small electrode to your scalp."
1 Copyright ©2025 BRAINBARTER ALL RIGHTS RESERVED
, 4. "You will need to hold your head very still during the examination." - ANS 4. The client will
be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes.
In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a
contrast medium is used because the radiopaque substance sometimes causes nausea. There is
no special preparation for a CT scan, so a shampoo the night before is not required. The client
may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT
scan, nor is the head shaved.
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is
served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of
the following should the nurse do? 1. Remove all the food. 2. Remove the coffee. 3. Remove
the toast, butter, and marmalade only. 4. Substitute vegetable juice for the orange juice. -
ANS 2. Beverages containing caffeine, such as coffee, tea, and cola drinks, are withheld
before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal
should not be omitted before an EEG because low blood sugar could alter brain wave patterns;
the client can have the entire meal except for the coffee.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon
awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've
never had one before." Which cause should the nurse include in the response as a primary
cause of tonic-clonic seizures in adults older than age 20? 1. Head trauma. 2. Electrolyte
imbalance. 3. Congenital defect. 4. Epilepsy. - ANS 1. Trauma is one of the primary causes of
brain damage and seizure activity in adults. Other common causes of seizure activity in adults
include neoplasms, withdrawal from drugs and alcohol, and vascular disease. Given the history
of head injury, electrolyte imbalance is not the cause of the seizure. There is no information to
indicate that the seizure is related to a congenital defect. Epilepsy is usually diagnosed in
younger clients.
Which of the following should the nurse include in the teaching plan for a client with seizures
who is going home with a prescription for gabapentin (Neurontin)? 1. Take all the medication
until it is gone. 2. Notify the physician if vision changes occur. 3. Store gabapentin in the
refrigerator. 4. Take gabapentin with an antacid to protect against ulcers. - ANS 2.
Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination
should be reported to the physician. Gabapentin should not be stopped abruptly because of the
potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to
be stored at room temperature and out of direct light. It should not be taken with antacids.
What is the priority nursing intervention in the postictal phase of a seizure? 1. Reorient the
client to time, person, and place. 2. Determine the client's level of sleepiness. 3. Assess the
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