Neurological System NCLEX Questions:

Neurological System NCLEX Questions:

Ch. 66 Already Passed

The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain?

• Sternal rub
• Nail Bed Pressure
• Pressure on orbital rim
• Squeezing of the sternocleidomastoid muscle ✔✔2. Nail Bed Pressure

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in VS if the intracranial pressure is rising?

• Increasing temperature, increasing pulse, increasing respirations, decreasing BP
• Increasing temperature, decreasing pulse, decreasing respirations, increasing BP
• Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP
• Decreasing temperature, increasing pulse, decreasing respirations, increasing BP ✔✔2.

Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing the activity?

• Blowing the nose
• Isometric exercises
• Coughing vigorously
• Exhaling during repositioning ✔✔4. Exhaling during repositioning

A client has clear liquid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

• Fluid is clear and tests negative for glucose.
• Fluid is grossly bloody in appearance and has a pH of 6.
• Fluid clumps together on the dressing and has a pH of 7.
• Fluid separates into concentric rings and tests positive for glucose. ✔✔4. Fluid separates into

concentric rings and tests positive for glucose.

A client with a spinal chord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence?

• Strict adherence to a bowel retraining program
• Keeping the linen wrinkle-free under the client
• Preventing unnecessary pressure on the lower limbs
• Limiting bladder catheterization to once ever 12 hours ✔✔4. Limiting bladder catheterization

to once ever 12 hours

The nurse is evaluating the neurological signs of a client in spinal shock following spinal chord injury. Which observation indicates that spinal shock persists?

• Hyperreflexia
• Positive reflexes
• Flaccid paralysis
• Reflex emptying of the bladder ✔✔3. Flaccid paralysis

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse is contraindicated?

• Loosening restrictive clothing
• Restraining the client's limbs
• Removing the pillow and raising padded side rails
• Positioning the client to the side, if possible, with the head flexed forward ✔✔2. Restraining

the client's limbs

The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply.

• The client is aphasic
• The client has weakness in the face and tongue
• The client has weakness on the right side of the body
• The client has complete bilateral paralysis of the arms and legs
• The client has lost the ability to move the right arm but is able to walk independently
• The client has lost the ability to ambulate independently but is able to feed and bathe himself

or herself without ✔✔1. The client is aphasic

• The client has weakness in the face and tongue
• The client has weakness on the right side of the body