Neuro NCLEX Questions & Answers Graded A++
1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
1. Reposition the client to avoid neck flexion
2. Admini...
1. An 18-year-old client is admitted with a closed head injury sustained in a
MVA. His intracranial pressure (ICP) shows an upward trend. Which
intervention should the nurse perform first?
1. Reposition the client to avoid neck flexion
2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilator’s respiratory rate to 20 breaths/minute
4. Administer 100 mg of pentobarbital IV as ordered.
2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading
dose of Dilantin IV. Which consideration is most important when administering
this dose?
1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2.
Rapid Dilantin administration can cause cardiac arrhythmias.
3. Dilantin should be mixed in dextrose in water before administration.
4. Dilantin should be administered through an IV catheter in the client’s
hand.
3. A client with head trauma develops a urine output of 300 ml/hr, dry skin,
and dry mucous membranes. Which of the following nursing interventions is
the most appropriate to perform initially?
1. Evaluate urine specific gravity
2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow down the IV fluids and notify the physician
,4. When evaluating an ABG from a client with a subdural hematoma, the
nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best
describes this result?
1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
2. Emergent; the client is poorly oxygenated.
3. Normal
4. Significant; the client has alveolar hypoventilation.
5. A client who had a transsphenoidal hypophysectomy should be watched
carefully for hemorrhage, which may be shown by which of the following signs?
1. Bloody drainage from the ears 2.
Frequent swallowing
3. Guaiac-positive stools
4. Hematuria
6. After a hypophysectomy, vasopressin is given IM for which of the following
reasons?
1. To treat growth failure
2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
3. To reduce cerebral edema and lower intracranial pressure
4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
7. A client comes into the ER after hitting his head in an MVA. He’s alert and
oriented. Which of the following nursing interventions should be done first?
,1. Assess full ROM to determine extent of injuries
2. Call for an immediate chest x-ray
3. Immobilize the client’s head and neck
4. Open the airway with the head-tilt-chin-lift maneuver
8. A client with a C6 spinal injury would most likely have which of the
following symptoms?
9. A 30-year-old was admitted to the progressive care unit with a C5
fracture from a motorcycle accident. Which of the following
assessments would take priority?
1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The client’s feelings about the injury
10. While in the ER, a client with C8 tetraplegia develops
a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the
following conditions?
, 11. A client is admitted with a spinal cord injury at the level of T12. He has
limited movement of his upper extremities. Which of the following medications
would be used to control edema of the spinal cord?
12. A 22-year-old client with quadriplegia is apprehensive and flushed, with a
blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following
nursing interventions should be done first?
1. Place the client flat in bed
2. Assess patency of the indwelling urinary catheter
3. Give one SL nitroglycerin tablet
4. Raise the head of the bed immediately to 90 degrees
13. A client with a cervical spine injury has Gardner-Wells tongs inserted for
which of the following reasons?
1. To hasten wound healing
2. To immobilize the cervical spine
3. To prevent autonomic dysreflexia
4. To hold bony fragments of the skull together
14. Which of the following interventions describes an appropriate bladder
program for a client in rehabilitation for spinal cord injury?
1. Insert an indwelling urinary catheter to straight drainage 2.
Schedule intermittent catheterization every 2 to 4 hours
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