Test Part 1

Neurologic NCLEX Practice Test Part 1

1. If a male client experienced a cerebrovascular accident (CVA) that damaged the
hypothalamus, the nurse would anticipate that the client has problems with:
a. body temperature control.
b. balance and equilibrium.
c. visual acuity.
d. thinking and reasoning.
2. A female client admitted to an acute care facility after a car accident develops signs
and symptoms of increased intracranial pressure (ICP). The client is intubated and
placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP
caused by suctioning, the nurse anticipates administering which drug endotracheally
before suctioning?
a. phenytoin (Dilantin)
b. mannitol (Osmitrol)
c. lidocaine (Xylocaine)
d. furosemide (Lasix)
3. After striking his head on a tree while falling from a ladder, a young man age 18 is
admitted to the emergency department. He’s unconscious and his pupils are
nonreactive. Which intervention would be the most dangerous for the client?
a. Give him a barbiturate.
b. Place him on mechanical ventilation.
c. Perform a lumbar puncture.
d. Elevate the head of his bed.
4. When obtaining the health history from a male client with retinal detachment, the
nurse expects the client to report:
a. light flashes and floaters in front of the eye.
b. a recent driving accident while changing lanes.
c. headaches, nausea, and redness of the eyes.
d. frequent episodes of double vision.
5. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?
a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury
6. To encourage adequate nutritional intake for a female client with Alzheimer’s disease,
the nurse should:
a. stay with the client and encourage him to eat.
b. help the client fill out his menu.
c. give the client privacy during meals.
d. fill out the menu for the client.
7. The nurse is performing a mental status examination on a male client diagnosed with
subdural hematoma. This test assesses which of the following?
a. Cerebellar function
b. Intellectual function
c. Cerebral function
d. Sensory function
8. Shortly after admission to an acute care facility, a male client with a seizure disorder
develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat.
How soon can the nurse administer a second dose of diazepam, if needed and
prescribed?
a. In 30 to 45 seconds
b. In 10 to 15 minutes
c. In 30 to 45 minutes
d. In 1 to 2 hours
9. A female client complains of periorbital aching, tearing, blurred vision, and
photophobia in her right eye. Ophthalmologic examination reveals a small, irregular,
nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of
the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol),
two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which
drug classification?
a. Parasympathomimetic agent
b. Sympatholytic agent
c. Adrenergic blocker
d. Cholinergic blocker
10. Emergency medical technicians transport a 27-year-old iron worker to the
emergency department. They tell the nurse, “He fell from a two-story building. He has a
large contusion on his left chest and a hematoma in the left parietal area. He has a
compound fracture of his left femur and he’s comatose. We intubated him and he’s
maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-
resuscitation bag.” Which intervention by the nurse has the highest priority?
a. Assessing the left leg
b. Assessing the pupils
c. Placing the client in Trendelenburg’s position
d. Assessing level of consciousness
11. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers
irrigate his eyes with water for 20 minutes, and then take him to the emergency
department of a nearby hospital, where he receives emergency care for corneal injury.
The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops
of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every
hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in
the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic
effect by:
a. increasing the exudative reaction of ocular tissue.
b. decreasing leukocyte infiltration at the site of ocular inflammation.
c. inhibiting the action of carbonic anhydrase.
d. producing a miotic reaction by stimulating and contracting the sphincter muscles of
the iris.
12. Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago.
Which of the following findings should the nurse consider abnormal?
a. More back pain than the first postoperative day
b. Paresthesia in the dermatomes near the wounds
c. Urine retention or incontinence
d. Temperature of 99.2° F (37.3° C)
13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The
physician prescribes pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d.
Based on this prescription, the nurse should teach the client or a family member to
administer the drug by:
a. instilling one drop of pilocarpine 0.25% into both eyes daily.
b. instilling one drop of pilocarpine 0.25% into both eyes four times daily.
c. instilling one drop of pilocarpine 0.25% into the right eye daily.
d. instilling one drop of pilocarpine 0.25% into the left eye four times daily.
14. A female client who’s paralyzed on the left side has been receiving physical therapy
and attending teaching sessions about safety. Which behavior indicates that the client
accurately understands safety measures related to paralysis?
a. The client leaves the side rails down.
b. The client uses a mirror to inspect the skin.
c. The client repositions only after being reminded to do so.
d. The client hangs the left arm over the side of the wheelchair.
15. A male client in the emergency department has a suspected neurologic disorder. To
assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet
make a half circle. To document the client’s gait, the nurse should use which term?
a. Ataxic
b. Dystrophic
c. Helicopod
d. Steppage
16. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be
the best choice for this client?
a. A private room down the hall from the nurses’ station
b. An isolation room three doors from the nurses’ station
c. A semiprivate room with a 32-year-old client who has viral meningitis
d. A two-bed room with a client who previously had bacterial meningitis
17. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine
(Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase
agent, the nurse reviews the client’s history. Which preexisting condition would
contraindicate the use of pyridostigmine?
a. Ulcerative colitis
b. Blood dyscrasia
c. Intestinal obstruction
d. Spinal cord injury
18. A female client is admitted to the facility for investigation of balance and
coordination problems, including possible Ménière’s disease. When assessing this client,
the nurse expects to note:
a. vertigo, tinnitus, and hearing loss.
b. vertigo, vomiting, and nystagmus
c. vertigo, pain, and hearing impairment.
d. vertigo, blurred vision, and fever.
19. A male client with a conductive hearing disorder caused by ankylosis of the stapes in
the oval window undergoes a stapedectomy to remove the stapes and replace the
impaired bone with a prosthesis. After the stapedectomy, the nurse should provide
which client instruction?
a. “Lie in bed with your head elevated, and refrain from blowing your nose for 24
hours.”
b. “Try to ambulate independently after about 24 hours.”
c. “Shampoo your hair every day for 10 days to help prevent ear infection.”
d. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose
yourself to loud sounds for 30 days.”
20. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium).
Which adverse reaction is most common?
a. Excessive tearing
b. Urine retention
c. Muscle weakness
d. Slurred speech
21. The nurse is monitoring a male client for adverse reactions to atropine sulfate
(Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the
conjunctiva can cause which adverse reaction?
a. Tachycardia
b. Increased salivation
c. Hypotension
d. Apnea
22. A male client is admitted with a cervical spine injury sustained during a diving
accident. When planning this client’s care, the nurse should assign highest priority to
which nursing diagnosis?
a. Impaired physical mobility
b. Ineffective breathing pattern
c. Disturbed sensory perception (tactile)
d. Self-care deficient: Dressing/grooming
23. A male client has a history of painful, continuous muscle spasms. He has taken
several skeletal muscle relaxants without experiencing relief. His physician prescribes
diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful
muscle spasms, diazepam also is recommended for:
a. long-term treatment of epilepsy.
b. postoperative pain management of laminectomy clients.
c. postoperative pain management of diskectomy clients
d. treatment of spasticity associated with spinal cord lesions.
24. A female client who was found unconscious at home is brought to the hospital by a
rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic
(doll’s eye) response by:
a. introducing ice water into the external auditory canal.
b. touching the cornea with a wisp of cotton.
c. turning the client’s head suddenly while holding the eyelids open.
d. shining a bright light into the pupil.
25. While reviewing a client’s chart, the nurse notices that the female client has
myasthenia gravis. Which of the following statements about neuromuscular blocking
agents is true for a client with this condition?
a. The client may be less sensitive to the effects of a neuromuscular blocking agent.
b. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.
c. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.
d. Pancuronium and succinylcholine both require cautious administration.
26. A male client is color blind. The nurse understands that this client has a problem
with:
a. rods.
b. cones.
c. lens.
d. aqueous humor.
27. A female client who was trapped inside a car for hours after a head-on collision is
rushed to the emergency department with multiple injuries. During the neurologic
examination, the client responds to painful stimuli with decerebrate posturing. This
finding indicates damage to which part of the brain?
a. Diencephalon
b. Medulla
c. Midbrain
d. Cortex
28. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which
of the following symptoms would the nurse expect to find?
a. Vision changes
b. Absent deep tendon reflexes
c. Tremors at rest
d. Flaccid muscles
29. The nurse is caring for a male client diagnosed with a cerebral aneurysm who
reports a severe headache. Which action should the nurse perform?
a. Sit with the client for a few minutes.
b. Administer an analgesic.
c. Inform the nurse manager.
d. Call the physician immediately.
30. During recovery from a cerebrovascular accident (CVA), a female client is given
nothing by mouth, to help prevent aspiration. To determine when the client is ready for
a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This
assessment evaluates:
a. cranial nerves I and II.
b. cranial nerves III and V.
c. cranial nerves VI and VIII.
d. cranial nerves IX and X.

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Test Part 1 Answers and Rationale

Neurologic NCLEX Practice Test Part 1

Answers and Rationale
1. Answer A. The body’s thermostat is located in the hypothalamus; therefore, injury to
that area can cause problems of body temperature control. Balance and equilibrium
problems are related to cerebellar damage. Visual acuity problems would occur
following occipital or optic nerve injury. Thinking and reasoning problems are the result
of injury to the cerebrum.
2. Answer C. Administering lidocaine via an endotracheal tube may minimize elevations
in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce
ICP, they’re administered parenterally, not endotracheally. Phenytoin doesn’t reduce
ICP directly but may be used to abolish seizures, which can increase ICP. However,
phenytoin isn’t administered endotracheally.
3. Answer C. The client’s history and assessment suggest that he may have increased
intracranial pressure (ICP). If this is the case, lumbar puncture shouldn’t be done
because it can quickly decompress the central nervous system and, thereby, cause
additional damage. After a head injury, barbiturates may be given to prevent seizures;
mechanical ventilation may be required if breathing deteriorates; and elevating the
head of the bed may be used to reduce ICP.
4. Answer A. The sudden appearance of light flashes and floaters in front of the affected
eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane
suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache,
nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double
vision is common in clients with cataracts.
5. Answer B. In Parkinson’s crisis, dopamine-related symptoms are severely
exacerbated, virtually immobilizing the client. A client confined to bed during such a
crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk
of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective
airway clearance takes highest priority. Although the other options also are appropriate,
they aren’t immediately life-threatening.
6. Answer A. Staying with the client and encouraging him to feed himself will ensure
adequate food intake. A client with Alzheimer’s disease can forget how to eat. Allowing
privacy during meals, filling out the menu, or helping the client to complete the menu
doesn’t ensure adequate nutritional intake.
7. Answer C. The mental status examination assesses functions governed by the
cerebrum. Some of these are orientation, attention span, judgment, and abstract
reasoning. Intellectual functioning isn’t the only cerebral activity. Cerebellar function
testing assesses coordination, equilibrium, and fine motor movement. Sensory function
testing involves assessment of pain, light-touch sensation, and temperature
discrimination.
8. Answer B. When used to treat status epilepticus, diazepam may be given every 10 to
15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen
in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. The
nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose
can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been
administered completely by that time. Waiting longer than 15 minutes to repeat the
dose would increase the client’s risk of complications associated with status epilepticus.
9. Answer D. Atropine sulfate is a cholinergic blocker. It isn’t a parasympathomimetic
agent, a sympatholytic agent, or an adrenergic blocker.
10. Answer A. In the scenario, airway and breathing are established so the nurse’s next
priority should be circulation. With a compound fracture of the femur, there is a high
risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic
assessment is a secondary concern to airway, breathing, and circulation. The nurse
doesn’t have enough data to warrant putting the client in Trendelenburg’s position.
11. Answer B. Dexamethasone exerts its therapeutic effect by decreasing leukocyte
infiltration at the site of ocular inflammation. This reduces the exudative reaction of
diseased tissue, lessening edema, redness, and scarring. Dexamethasone and other anti-
inflammatory agents don’t inhibit the action of carbonic anhydrase or produce any type
of miotic reaction.
12. Answer C. Urine retention or incontinence may indicate cauda equina syndrome,
which requires immediate surgery. An increase in pain on the second postoperative day
is common because the long-acting local anesthetic, which may have been injected
during surgery, will wear off. While paresthesia is common after surgery, progressive
weakness or paralysis may indicate spinal nerve compression. A mild fever is also
common after surgery but is considered significant only if it reaches 101° F (38.3° C).
13. Answer B. The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for
the number 1, OU signifies both eyes, and "q.i.d." means four times a day. Therefore,
one drop of pilocarpine 0.25% should be instilled into both eyes four times daily.
14. Answer B. Using a mirror enables the client to inspect all areas of the skin for signs
of breakdown without the help of staff or family members. The client should keep the
side rails up to help with repositioning and to prevent falls. The paralyzed client should
take responsibility for repositioning or for reminding the staff to assist with it, if needed.
A client with left-side paralysis may not realize that the left arm is hanging over the side
of the wheelchair. However, the nurse should call this to the client’s attention because
the arm can get caught in the wheel spokes or develop impaired circulation from being
in a dependent position for too long.
15. Answer C. A helicopod gait is an abnormal gait in which the client’s feet make a half
circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the
client waddles with the legs far apart. In a steppage gait, the feet and toes raise high off
the floor and the heel comes down heavily with each step.
16. Answer B. A client with bacterial meningitis should be kept in isolation for at least 24
hours after admission and, during the initial acute phase, should be as close to the
nurses’ station as possible to allow maximal observation. Placing the client in a room
with a client who has viral meningitis may cause harm to both clients because the
organisms causing viral and bacterial meningitis differ; either client may contract the
other’s disease. Immunity to bacterial meningitis can’t be acquired; therefore, a client
who previously had bacterial meningitis shouldn’t be put at risk by rooming with a client
who has just been diagnosed with this disease.
17. Answer C. Anticholinesterase agents such as pyridostigmine are contraindicated in a
client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or
hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and
spinal cord injury don’t contraindicate use of the drug.
18. Answer A. Ménière’s disease, an inner ear disease, is characterized by the symptom
triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and
nystagmus suggests labyrinthitis. Ménière’s disease rarely causes pain, blurred vision, or
fever.
19. Answer D. For 30 days after a stapedectomy, the client should avoid air travel,
sudden movements that may cause trauma, and exposure to loud sounds and pressure
changes (such as from high altitudes). Immediately after surgery, the client should lie
flat with the surgical ear facing upward; nose blowing is permitted but should be done
gently and on one side at a time. The client’s first attempt at postoperative ambulation
should be supervised to prevent falls caused by vertigo and light-headedness. The client
must avoid shampooing and swimming to keep the dressing and the ear dry.
20. Answer C. The most common adverse reaction to dantrolene is muscle weakness.
The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle
weakness is rarely severe enough to cause slurring of speech, drooling, and enuresis.
Although excessive tearing and urine retention are adverse reactions associated with
dantrolene use, they aren’t as common as muscle weakness
21. Answer A. Systemic absorption of atropine sulfate can cause tachycardia,
palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption,
the client should apply digital pressure over the punctum at the inner canthus for 2 to 3
minutes after instilling the drops. The drug also may cause dry mouth. It isn’t known to
cause hypotension or apnea.
22. Answer B. Because a cervical spine injury can cause respiratory distress, the nurse
should take immediate action to maintain a patent airway and provide adequate
oxygenation. The other options may be appropriate for a client with a spinal cord injury
— particularly during the course of recovery — but don’t take precedence over a
diagnosis of Ineffective breathing pattern.
23. Answer D. In addition to relieving painful muscle spasms, diazepam also is
recommended for treatment of spasticity associated with spinal cord lesions.
Diazepam’s use is limited by its central nervous system effects and the tolerance that
develops with prolonged use. The parenteral form of diazepam can treat status
epilepticus, but the drug’s sedating properties make it an unsuitable choice for long-
term management of epilepsy. Diazepam isn’t an analgesic agent.
24. Answer C. To elicit the oculocephalic response, which detects cranial nerve
compression, the nurse turns the client’s head suddenly while holding the eyelids open.
Normally, the eyes move from side to side when the head is turned; in an abnormal
response, the eyes remain fixed. The nurse introduces ice water into the external
auditory canal when testing the oculovestibular response; normally, the client’s eyes
deviate to the side of ice water introduction. The nurse touches the client’s cornea with
a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function;
blinking is the normal response. Shining a bright light into the client’s pupil helps
evaluate brain stem and cranial nerve III functions; normally, the pupil responds by
constricting.
25. Answer D. The nurse must cautiously administer pancuronium, succinylcholine, and
any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client
isn’t less sensitive to the effects of a neuromuscular blocking agent. Either
succinylcholine or pancuronium can be administered in the usual adult dosage to a
client with myasthenia gravis.
26. Answer B. Cones provide daylight color vision, and their stimulation is interpreted as
color. If one or more types of cones are absent or defective, color blindness occurs. Rods
are sensitive to low levels of illumination but can’t discriminate color. The lens is
responsible for focusing images. Aqueous humor is a clear watery fluid and isn’t
involved with color perception.
27. Answer C. Decerebrate posturing, characterized by abnormal extension in response
to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon
or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is
applied. Damage to the medulla results in flaccidity.
28. Answer A. Vision changes, such as diplopia, nystagmus, and blurred vision, are
symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive
— not absent. Babinski’s sign may be positive. Tremors at rest aren’t characteristic of
multiple sclerosis; however, intentional tremors, or those occurring with purposeful
voluntary movement, are common in clients with multiple sclerosis. Affected muscles
are spastic, rather than flaccid.
29. Answer D. The headache may be an indication that the aneurysm is leaking. The
nurse should notify the physician immediately. Sitting with the client is appropriate but
only after the physician has been notified of the change in the client’s condition. The
physician will decide whether or not administration of an analgesic is indicated.
Informing the nurse manager isn’t necessary.
30. Answer D. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I,
II, and VIII don’t possess motor functions. The motor functions of cranial nerve III
include extraocular eye movement, eyelid elevation, and pupil constriction. The motor
function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

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/ Neurologic NCLEX Practice Test Part 2

Neurologic NCLEX Practice Test Part 2

1. A white female client is admitted to an acute care facility with a diagnosis of
cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous
obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?
a. Caucasian race
b. Female sex
c. Obesity
d. Bronchial asthma
2. The nurse is teaching a female client with multiple sclerosis. When teaching the client
how to reduce fatigue, the nurse should tell the client to:
a. take a hot bath.
b. rest in an air-conditioned room
c. increase the dose of muscle relaxants.
d. avoid naps during the day
3. A male client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed.
b. Restrain the client’s arms and legs.
c. Place a tongue blade in the client’s mouth.
d. Take measures to prevent injury.
4. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory
muscles and requires mechanical ventilation. When the client asks the nurse about the
paralysis, how should the nurse respond?
a. “You may have difficulty believing this, but the paralysis caused by this disease is
temporary.”
b. “You’ll have to accept the fact that you’re permanently paralyzed. However, you
won’t have any sensory loss.”
c. “It must be hard to accept the permanency of your paralysis.”
d. “You’ll first regain use of your legs and then your arms.”
5. The nurse is working on a surgical floor. The nurse must logroll a male client following
a:
a. laminectomy.
b. thoracotomy.
c. hemorrhoidectomy.
d. cystectomy.
6. A female client with a suspected brain tumor is scheduled for computed tomography
(CT). What should the nurse do when preparing the client for this test?
a. Immobilize the neck before the client is moved onto a stretcher.
b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
c. Place a cap over the client’s head.
d. Administer a sedative as ordered.
7. During a routine physical examination to assess a male client’s deep tendon reflexes,
the nurse should make sure to:
a. use the pointed end of the reflex hammer when striking the Achilles tendon.
b. support the joint where the tendon is being tested.
c. tap the tendon slowly and softly
d. hold the reflex hammer tightly.
8. A female client is admitted in a disoriented and restless state after sustaining a
concussion during a car accident. Which nursing diagnosis takes highest priority in this
client’s plan of care?
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury
9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I
feel so frustrated. I can’t do anything without help!” This comment best supports which
nursing diagnosis?
a. Anxiety
b. Powerlessness
c. Ineffective denial
d. Risk for disuse syndrome
10. For a male client with suspected increased intracranial pressure (ICP), a most
appropriate respiratory goal is to:
a. prevent respiratory alkalosis.
b. lower arterial pH.
c. promote carbon dioxide elimination.
d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
11. Nurse Maureen witnesses a neighbor’s husband sustain a fall from the roof of his
house. The nurse rushes to the victim and determines the need to opens the airway in
this victim by using which method?
a. Flexed position
b. Head tilt-chin lift
c. Jaw thrust maneuver
d. Modified head tilt-chin lift
12. The nurse is assessing the motor function of an unconscious male client. The nurse
would plan to use which plan to use which of the following to test the client’s peripheral
response to pain?
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle
13. A female client admitted to the hospital with a neurological problem asks the nurse
whether magnetic resonance imaging may be done. The nurse interprets that the client
may be ineligible for this diagnostic procedure based on the client’s history of:
a. Hypertension
b. Heart failure
c. Prosthetic valve replacement
d. Chronic obstructive pulmonary disorder
14. A male client is having a lumbar puncture performed. The nurse would plan to place
the client in which position?
a. Side-lying, with a pillow under the hip
b. Prone, with a pillow under the abdomen
c. Prone, in slight-Trendelenburg’s position
d. Side-lying, with the legs pulled up and head bent down onto chest.
15. The nurse is positioning the female client with increased intracranial pressure.
Which of the following positions would the nurse avoid?
a. Head mildline
b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees
16. A female client has clear fluid leaking from the nose following a basilar skull fracture.
The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
17. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia.
The nurse would avoid which of the following measures to minimize the risk of
recurrence?
a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower limbs
d. Limiting bladder catheterization to once every 12 hours
18. The nurse is caring for the male client who begins to experience seizure activity
while in bed. Which of the following actions by the nurse would be contraindicated?
a. Loosening restrictive clothing
b. Restraining the client’s limbs
c. Removing the pillow and raising padded side rails
d. Positioning the client to side, if possible, with the head flexed forward
19. The nurse is assigned to care for a female client with complete right-sided
hemiparesis. The nurse plans care knowing that this condition:
a. The client has complete bilateral paralysis of the arms and legs.
b. The client has weakness on the right side of the body, including the face and tongue.
c. The client has lost the ability to move the right arm but is able to walk independently.
d. The client has lost the ability to move the right arm but is able to walk independently.
20. The client with a brain attack (stroke) has residual dysphagia. When a diet order is
initiated, the nurse avoids doing which of the following?
a. Giving the client thin liquids
b. Thickening liquids to the consistency of oatmeal
c. Placing food on the unaffected side of the mouth
d. Allowing plenty of time for chewing and swallowing
21. The nurse is assessing the adaptation of the female client to changes in functional
status after a brain attack (stroke). The nurse assesses that the client is adapting most
successfully if the client:
a. Gets angry with family if they interrupt a task
b. Experiences bouts of depression and irritability
c. Has difficulty with using modified feeding utensils
d. Consistently uses adaptive equipment in dressing self
22. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and
aphasia. Which of the following actions by the nurse would be least helpful to the
client?
a. Speaking to the client at a slower rate
b. Allowing plenty of time for the client to respond
c. Completing the sentences that the client cannot finish
d. Looking directly at the client during attempts at speech
23. A female client has experienced an episode of myasthenic crisis. The nurse would
assess whether the client has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Increasing intake of fatty foods
24. The nurse is teaching the female client with myasthenia gravis about the prevention
of myasthenic and cholinergic crises. The nurse tells the client that this is most
effectively done by:
a. Eating large, well-balanced meals
b. Doing muscle-strengthening exercises
c. Doing all chores early in the day while less fatigued
d. Taking medications on time to maintain therapeutic blood levels
25. A male client with Bell’s palsy asks the nurse what has caused this problem. The
nurse’s response is based on an understanding that the cause is:
a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia
c. Primary genetic in origin, triggered by exposure to meningitis
d. Primarily genetic in origin, triggered by exposure to neurotoxins
26. The nurse has given the male client with Bell’s palsy instructions on preserving
muscle tone in the face and preventing denervation. The nurse determines that the
client needs additional information if the client states that he or she will:
a. Exposure to cold and drafts
b. Massage the face with a gentle upward motion
c. Perform facial exercises
d. Wrinkle the forehead, blow out the cheeks, and whistle
27. Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome.
The nurse inquires during the nursing admission interview if the client has history of:
a. Seizures or trauma to the brain
b. Meningitis during the last 5 years
c. Back injury or trauma to the spinal cord
d. Respiratory or gastrointestinal infection during the previous month.
28. A female client with Guillian-Barre syndrome has ascending paralysis and is
intubated and receiving mechanical ventilation. Which of the following strategies would
the nurse incorporate in the plan of care to help the client cope with this illness?
a. Giving client full control over care decisions and restricting visitors
b. Providing positive feedback and encouraging active range of motion
c. Providing information, giving positive feedback, and encouraging relaxation
d. Providing intravaneously administered sedatives, reducing distractions and limiting
visitors
29. A male client has an impairment of cranial nerve II. Specific to this impairment, the
nurse would plan to do which of the following to ensure client to ensure client safety?
a. Speak loudly to the client
b. Test the temperature of the shower water
c. Check the temperature of the food on the delivery tray.
d. Provide a clear path for ambulation without obstacles
30. A female client has a neurological deficit involving the limbic system. Specific to this
type of deficit, the nurse would document which of the following information related to
the client’s behavior.
a. Is disoriented to person, place, and time
b. Affect is flat, with periods of emotional lability
c. Cannot recall what was eaten for breakfast today
d. Demonstrate inability to add and subtract; does not know who is president

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Test Part 2 Answers and Rationale

Neurologic NCLEX Practice Test Part 2

Answers and Rationale
June 1, 2010 By admin 1 Comment
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1. Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of
ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the
cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral
contraceptive use, emotional stress, family history of CVA, and advancing age. The
client’s race, sex, and bronchial asthma aren’t risk factors for CVA.
2. Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering
the body temperature by resting in an air-conditioned room may relieve fatigue;
however, extreme cold should be avoided. A hot bath or shower can increase body
temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can
cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve
fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include
treating depression, using occupational therapy to learn energy conservation
techniques, and reducing spasticity.
3. Answer D. Protecting the client from injury is the immediate priority during a seizure.
Elevating the head of the bed would have no effect on the client’s condition or safety.
Restraining the client’s arms and legs could cause injury. Placing a tongue blade or other
object in the client’s mouth could damage the teeth.
4. Answer A. The nurse should inform the client that the paralysis that accompanies
Guillain-Barré syndrome is only temporary. Return of motor function begins proximally
and extends distally in the legs.
5. Answer A. The client who has had spinal surgery, such as laminectomy, must be
logrolled to keep the spinal column straight when turning. The client who has had a
thoracotomy or cystectomy may turn himself or may be assisted into a comfortable
position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure,
and the client may resume normal activities immediately after surgery.
6. Answer B. Because CT commonly involves use of a contrast agent, the nurse should
determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck
immobilization is necessary only if the client has a suspected spinal cord injury. Placing a
cap over the client’s head may lead to misinterpretation of test results; instead, the hair
should be combed smoothly. The physician orders a sedative only if the client can’t be
expected to remain still during the CT scan.
7. Answer B. To prevent the attached muscle from contracting, the nurse should support
the joint where the tendon is being tested. The nurse should use the flat, not pointed,
end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to
strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the
tendon slowly and softly wouldn’t provoke a deep tendon reflex response. The nurse
should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it
can swing in an arc.
8. Answer D. Because the client is disoriented and restless, the most important nursing
diagnosis is risk for injury. Although the other options may be appropriate, they’re
secondary because they don’t immediately affect the client’s health or safety.
9. Answer B. This comment best supports a nursing diagnosis of Powerlessness because
ALS may lead to locked-in syndrome, characterized by an active and functioning mind
locked in a body that can’t perform even simple daily tasks. Although Anxiety and Risk
for disuse syndrome may be diagnoses associated with ALS, the client’s comment
specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial
would be indicated if the client didn’t seem to perceive the personal relevance of
symptoms or danger.
10. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon
dioxide. That is because an acid environment in the brain causes cerebral vessels to
dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial
pH may bring about acidosis, an undesirable condition in this case. It isn’t necessary to
maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most
clients.
11. Answer C. If a neck injury is suspected, the jaw thrust maneuver is used to open the
airway. The head tilt–chin lift maneuver produces hyperextension of the neck and could
cause complications if a neck injury is present. A flexed position is an inappropriate
position for opening the airway.
12. Answer B. Motor testing in the unconscious client can be done only by testing
response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral
responses to pain are tested using sternal rub, placing upward pressure on the orbital
rim, or squeezing the clavicle or sternocleidomastoid muscle.
13. Answer C. The client having a magnetic resonance imaging scan has all metallic
objects removed because of the magnetic field generated by the device. A careful
history is obtained to determine whether any metal objects are inside the client, such as
orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine
devices. These may heat up, become dislodged, or malfunction during this procedure.
The client may be ineligible if significant risk exists.
14. Answer D. The client undergoing lumbar puncture is positioned lying on the side,
with the legs pulled up to the abdomen and the head bent down onto the chest. This
position helps open the spaces between the vertebrae.
15. Answer B. The head of the client with increased intracranial pressure should be
positioned so the head is in a neutral midline position. The nurse should avoid flexing or
extending the client’s 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 intracranial pressure down.
16. Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may
accompany basilar skull fracture. CSF can be distinguished from other body fluids
because the drainage will separate into bloody and yellow concentric rings on dressing
material, called a halo sign. The fluid also tests positive for glucose.
17. Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder.
Straight catheterization should be done every 4 to 6 hours, and foley catheters should
be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction
are other causes, so maintaining bowel regularity is important. Other causes include
stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers
care to minimize risk in these areas.
18. Answer B. Nursing actions during a seizure include providing for privacy, loosening
restrictive clothing, removing the pillow and raising side rails in the bed, and placing the
client on one side with the head flexed forward, if possible, to allow the tongue to fall
forward and facilitate drainage. The limbs are never restrained because the strong
muscle contractions could cause the client harm. If the client is not in bed when seizure
activity begins, the nurse lowers the client to the floor, if possible, protects the head
from injury, and moves furniture that may injure the client. Other aspects of care are as
described for the client who is in bed.
19. Answer B. Hemiparesis is a weakness of one side of the body that may occur after a
stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one
side. Complete bilateral paralysis does not occur in this condition. The client with right-
sided hemiparesis has weakness of the right arm and leg and needs assistance with
feeding, bathing, and ambulating.
20. Answer A. Before the client with dysphagia is started on a diet, the gag and swallow
reflexes must have returned. The client is assisted with meals as needed and is given
ample time to chew and swallow. Food is placed on the unaffected side of the mouth.
Liquids are thickened to avoid aspiration.
21. Answer D. Clients are evaluated as coping successfully with lifestyle changes after a
brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of
others, and have appropriate social interactions. Options A, B, and C are not adaptive
behaviors.
22. Answer C. Clients with aphasia after brain attack (stroke) often fatigue easily and
have a short attention span. General guidelines when trying to communicate with the
aphasic client include speaking more slowly and allowing adequate response time,
listening to and watching attempts to communicate, and trying to put the client at ease
with a caring and understanding manner. The nurse would avoid shouting (because the
client is not deaf), appearing rushed for a response, and letting family members provide
all the responses for the client.
23. Answer C. Myasthenic crisis often is caused by undermedication and responds to the
administration of cholinergic medications, such as neostigmine (Prostigmin) and
pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess
medication and responds to withholding of medications. Too little exercise and fatty
food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic
crisis.
24. Answer D. Clients with myasthenia gravis are taught to space out activities over the
day to conserve energy and restore muscle strength. Taking medications correctly to
maintain blood levels that are not too low or too high is important. Muscle-
strengthening exercises are not helpful and can fatigue the client. Overeating is a cause
of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and
emotional stress.
25. Answer A. Bell’s palsy is a one-sided facial paralysis from compression of the facial
nerve. The exact cause is unknown, but may include vascular ischemia, infection,
exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a
combination of these factors.
26. Answer A. Prevention of muscle atrophy with Bell’s palsy is accomplished with facial
massage, facial exercises, and electrical stimulation of the nerves. Exposure to cold or
drafts is avoided. Local application of heat to the face may improve blood flow and
provide comfort.
27. Answer D. Guillain-Barré syndrome is a clinical syndrome of unknown origin that
involves cranial and peripheral nerves. Many clients report a history of respiratory or
gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits.
Occasionally, the syndrome can be triggered by vaccination or surgery.
28. Answer C. The client with Guillain-Barré syndrome experiences fear and anxiety
from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate
these fears by providing accurate information about the client’s condition, giving expert
care and positive feedback to the client, and encouraging relaxation and distraction. The
family can become involved with selected care activities and provide diversion for the
client as well.
29. Answer D. Cranial nerve II is the optic nerve, which governs vision. The nurse can
provide safety for the visually impaired client by clearing the path of obstacles when
ambulating. Testing the shower water temperature would be useful if there were an
impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial
nerve VIII (vestibulocochlear). Cranial nerve VII (facial) and IX (glossopharyngeal) control
taste from the anterior two thirds and posterior third of the tongue, respectively.
30. Answer B. The limbic system is responsible for feelings (affect) and emotions.
Calculation ability and knowledge of current events relates to function of the frontal
lobe. The cerebral hemispheres, with specific regional functions, control orientation.
Recall of recent events is controlled by the hippocampus