Grade A+ NCLEX Style Questions- NEURO and answers 2025
The nurse is assessing the level of consciousness in a client with C. Chart the client's level of consciousness as coma.
a head injury who has been unresponsive for the last 8 hours.
Using the Glasgow Coma Scale, the nurse notes that the client Rationale: The client has a score of 6 (eye opening to pain=2; ver-
opens the eyes only as a response to pain, responds with sounds bal response, incomprehensible sounds=2, best motor response,
that are not understandable, and has abnormal extension of the abnormal extension=2); a score >7 is indicative of coma. While
extremities. What should the nurse do? the nurse should continue to speak to the client, at this time the
client will not be able to be aroused. The nurse should continue
A. Attempt to arouse the client to provide skin care and appropriate alignment, but the client
B. Reposition the client with the extremities in normal alignment will continue to have a motor response of limb extension. It is
C. Chart the client's level of consciousness as coma. not necessary to notify the HCP as this assessment does not
D. Notify the healthcare provider represent a significant change in neurological status.
A. Unequal pupil size
A client is at risk for Increased intracranial pressure (ICP). Which
finding is priority for the nurse to monitor?
Rationale: Increasing ICP causes unequal pupils as a result of
pressure on the third cranial nerve. Increasing ICP causes an
A. Unequal pupil size
increase in systolic BP, which reflects the additional pressure
B. Decreasing systolic blood pressure
needed to perfuse the brain. It increases the pressure on the vagus
C. Tachycardia
nerve, which produces bradycardia, and it causes an increase in
D. Decreasing body temperature
body temperature from hypothalamic damage.
Which respiratory pattern indicates increasing ICP in the brain A. Slow, irregular respirations
stem?
Rationale: Neural control of respiration takes place in the brain
A. Slow, irregular respirations stem. Deterioration and pressure produce slow and irregular
B. Rapid, shallow respirations respirations. Rapid and shallow respirations, asymmetric chest
C. Asymmetric chest excursion movements, and nasal flaring are more characteristic of respira-
D. Nasal flaring tory distress or hypoxia.
C. Encourage the client to take deep breaths to hyperventilate
Rationale: Normal ICP is 15mmHg or less for 15 to 30 seconds or
A client has an increased ICP of 20mmHg. The nurse should: longer. Hyperventilation causes vasoconstriction, which reduces
cerebrospinal fluid and blood volume, two important factors for
A. Give the client a warming blanket reducing a sustained ICP of 20mmHg. A cooling blanket is used
B. Administer low-dose barbiturates to control the elevation of temperature because a fever increases
C. Encourage the client to take deep breaths to hyperventilate the metabolic rate, which in turn increases ICP. High doses of bar-
D. Restrict fluids biturates may be used to reduce the increased cellular metabolic
demands. Fluid volume and inotropic drugs are used to maintain
cerebral perfusion by supporting the cardiac output and keeping
the cerebral perfusion pressure >80mmHg.
The nurse is assessing a client with increasing ICP. The nurse D. Decrease in the level of consciousness (LOC)
should notify the healthcare provider about which early change in
the client's condition?
Rationale: A decrease in the client's LOC is an early indicator of
deterioration of the client's neurological status. Changes in LOC,
A. Widening pulse pressure
such as restlessness and irritability, may be subtle. Widening of
B. Decrease in the pulse rate
the pulse pressure, decrease in the pulse rate, and dilated, fixed
C. Dilated, fixed pupils
pupils occur later if the increased ICP is not treated.
D. Decrease in the level of consciousness (LOC)
Which activity should the nurse encourage the client to avoid when
C. Coughing
there is a risk for increased ICP?
Rationale: Coughing is contraindicated for a client at risk for in-
A. Deep breathing
creased ICP because coughing increases ICP. Deep breathing
B. Turning
can be continued. Turning and passive ROM exercises can be
C. Coughing
continued with care not to extend or flex the neck.
D. Passive range of motion exercises
The nurse is assessing a client for decerebrate posturing. The D. Back arched and rigid extension of all four extremities
nurse should assess the client for:
Rationale: Decerebrate posturing occurs in clients with damage
A. Internal rotation and adduction of the arms with flexion of the to the upper brain stem, midbrain, or pons and is demonstrated
elbows, wrists, and fingers clinically by arching of the back, rigid extension of the extremities,
B. Back hunched over and rigid flexion of all four extremities with pronation of the arms, and plantar flexion of the feet. Internal
supination of the arms and plantar flexion of the feet rotation and adduction of arms with flexion of elbows, wrists, and
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The nurse is assessing the level of consciousness in a client with C. Chart the client's level of consciousness as coma.
a head injury who has been unresponsive for the last 8 hours.
Using the Glasgow Coma Scale, the nurse notes that the client Rationale: The client has a score of 6 (eye opening to pain=2; ver-
opens the eyes only as a response to pain, responds with sounds bal response, incomprehensible sounds=2, best motor response,
that are not understandable, and has abnormal extension of the abnormal extension=2); a score >7 is indicative of coma. While
extremities. What should the nurse do? the nurse should continue to speak to the client, at this time the
client will not be able to be aroused. The nurse should continue
A. Attempt to arouse the client to provide skin care and appropriate alignment, but the client
B. Reposition the client with the extremities in normal alignment will continue to have a motor response of limb extension. It is
C. Chart the client's level of consciousness as coma. not necessary to notify the HCP as this assessment does not
D. Notify the healthcare provider represent a significant change in neurological status.
A. Unequal pupil size
A client is at risk for Increased intracranial pressure (ICP). Which
finding is priority for the nurse to monitor?
Rationale: Increasing ICP causes unequal pupils as a result of
pressure on the third cranial nerve. Increasing ICP causes an
A. Unequal pupil size
increase in systolic BP, which reflects the additional pressure
B. Decreasing systolic blood pressure
needed to perfuse the brain. It increases the pressure on the vagus
C. Tachycardia
nerve, which produces bradycardia, and it causes an increase in
D. Decreasing body temperature
body temperature from hypothalamic damage.
Which respiratory pattern indicates increasing ICP in the brain A. Slow, irregular respirations
stem?
Rationale: Neural control of respiration takes place in the brain
A. Slow, irregular respirations stem. Deterioration and pressure produce slow and irregular
B. Rapid, shallow respirations respirations. Rapid and shallow respirations, asymmetric chest
C. Asymmetric chest excursion movements, and nasal flaring are more characteristic of respira-
D. Nasal flaring tory distress or hypoxia.
C. Encourage the client to take deep breaths to hyperventilate
Rationale: Normal ICP is 15mmHg or less for 15 to 30 seconds or
A client has an increased ICP of 20mmHg. The nurse should: longer. Hyperventilation causes vasoconstriction, which reduces
cerebrospinal fluid and blood volume, two important factors for
A. Give the client a warming blanket reducing a sustained ICP of 20mmHg. A cooling blanket is used
B. Administer low-dose barbiturates to control the elevation of temperature because a fever increases
C. Encourage the client to take deep breaths to hyperventilate the metabolic rate, which in turn increases ICP. High doses of bar-
D. Restrict fluids biturates may be used to reduce the increased cellular metabolic
demands. Fluid volume and inotropic drugs are used to maintain
cerebral perfusion by supporting the cardiac output and keeping
the cerebral perfusion pressure >80mmHg.
The nurse is assessing a client with increasing ICP. The nurse D. Decrease in the level of consciousness (LOC)
should notify the healthcare provider about which early change in
the client's condition?
Rationale: A decrease in the client's LOC is an early indicator of
deterioration of the client's neurological status. Changes in LOC,
A. Widening pulse pressure
such as restlessness and irritability, may be subtle. Widening of
B. Decrease in the pulse rate
the pulse pressure, decrease in the pulse rate, and dilated, fixed
C. Dilated, fixed pupils
pupils occur later if the increased ICP is not treated.
D. Decrease in the level of consciousness (LOC)
Which activity should the nurse encourage the client to avoid when
C. Coughing
there is a risk for increased ICP?
Rationale: Coughing is contraindicated for a client at risk for in-
A. Deep breathing
creased ICP because coughing increases ICP. Deep breathing
B. Turning
can be continued. Turning and passive ROM exercises can be
C. Coughing
continued with care not to extend or flex the neck.
D. Passive range of motion exercises
The nurse is assessing a client for decerebrate posturing. The D. Back arched and rigid extension of all four extremities
nurse should assess the client for:
Rationale: Decerebrate posturing occurs in clients with damage
A. Internal rotation and adduction of the arms with flexion of the to the upper brain stem, midbrain, or pons and is demonstrated
elbows, wrists, and fingers clinically by arching of the back, rigid extension of the extremities,
B. Back hunched over and rigid flexion of all four extremities with pronation of the arms, and plantar flexion of the feet. Internal
supination of the arms and plantar flexion of the feet rotation and adduction of arms with flexion of elbows, wrists, and
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