NCLEX Questions - 1. An 18-year-old client is admitted with a clo...

NSG 403 Neuro NCLEX Questions & Answers 2023 1 / 4

NSG 403 Neuro NCLEX questions

• 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?

• Reposition the client to avoid neck flexion
• Administer 1 g Mannitol IV as ordered
• Increase the ventilator’s respiratory rate to 20 breaths/minute
• Administer 100 mg of pentobarbital IV as ordered.
• 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?

• Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
• Rapid Dilantin administration can cause cardiac arrhythmias.
• Dilantin should be mixed in dextrose in water before administration.
• Dilantin should be administered through an IV catheter in the client’s

hand.

• 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?

• Evaluate urine specific gravity
• Anticipate treatment for renal failure
• Provide emollients to the skin to prevent breakdown
• Slow down the IV fluids and notify the physician 2 / 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?

• Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure

(ICP).

• Emergent; the client is poorly oxygenated.
• Normal
• Significant; the client has alveolar hypoventilation.
• A client who had a transsphenoidal hypophysectomy should be

watched carefully for hemorrhage, which may be shown by which of the following signs?

• Bloody drainage from the ears
• Frequent swallowing
• Guaiac-positive stools
• Hematuria
• After a hypophysectomy, vasopressin is given IM for which of the

following reasons?

• To treat growth failure
• To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
• To reduce cerebral edema and lower intracranial pressure
• To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
• 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? 3 / 4

• Assess full ROM to determine extent of injuries
• Call for an immediate chest x-ray
• Immobilize the client’s head and neck
• Open the airway with the head-tilt-chin-lift maneuver
• A client with a C6 spinal injury would most likely have which of the

following symptoms?

• Aphasia
• Hemiparesis
• Paraplegia
• Tetraplegia
• 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?

• Bladder distension
• Neurological deficit
• Pulse ox readings
• The client’s feelings about the injury
• 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?

• Autonomic dysreflexia
• Hemorrhagic shock
• Neurogenic shock
• Pulmonary embolism
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