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Physiological Adaptation

NCLEX Neurological Practice Questions

Quick answer

Neurological questions test whether you can spot a brain or spinal cord problem early and act before the client loses function. They fall under Physiological Adaptation, which is about 11 to 17 percent of the exam, and neuro scenarios show up often because so many of them have a "do this first" answer.

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Neuro is the part of the exam where minutes matter and the question writers know it. A stroke client arrives at 9:10 and the last time anyone saw him normal was 7:30. A head injury client has a pupil that stopped reacting. A spinal cord client suddenly has a pounding headache and a blood pressure of 210. The trap students fall into on this topic is answering with the thing the doctor will eventually do (CT scan, mannitol, nifedipine) instead of the thing the nurse does in the next 30 seconds (check glucose, raise the head, sit the client up). Read each stem and ask yourself what the nurse can do alone, right now, with her own hands. That answer is usually the one they want. The 10 questions below cover the neuro scenarios that get tested most.

Practice questions

1

A client arrives in the emergency department with sudden right sided facial droop, right arm weakness, and slurred speech. The family says he was fine at breakfast at 7:30 AM and they found him this way at 9:15 AM. It is now 9:40 AM. Which action should the nurse take first?

  1. ACheck a fingerstick blood glucose
  2. BPrepare the client for IV alteplase
  3. CGive aspirin 325 mg by mouth
  4. DObtain a 12 lead ECG
Show answer

Answer: A

Hypoglycemia can look exactly like a stroke, and a glucose check takes seconds. It is the first thing done for any client with sudden focal deficits, before any stroke treatment is considered.

Why the others are wrong

Alteplase (B) cannot be given until a CT scan rules out bleeding, and the last known well time of 7:30 AM keeps the client inside the window only if the workup moves quickly, so guessing at the drug before the scan is unsafe. Aspirin by mouth (C) is wrong for two reasons: the client has slurred speech and may not be able to swallow, and no antiplatelet is given before a bleed is excluded. The ECG (D) is part of the workup but does not change the first action.

2

A client with a closed head injury has the following findings over the past four hours: blood pressure changed from 128/80 to 172/60 mm Hg, pulse dropped from 88 to 52 beats per minute, and respirations have become irregular. Which conclusion should the nurse draw?

  1. AThe client is developing early signs of increased intracranial pressure
  2. BThe client is showing Cushing's triad, a late sign of brain herniation
  3. CThe client is dehydrated and needs a fluid bolus
  4. DThe client is in pain and needs an opioid
Show answer

Answer: B

Widening pulse pressure (systolic up, diastolic down), bradycardia and irregular respirations together are Cushing's triad. This is a late finding that means the brainstem is being compressed, and the provider is called immediately.

Why the others are wrong

The early signs of rising intracranial pressure are a change in level of consciousness, restlessness, headache and nausea, not these vital signs (A). Dehydration causes a fast pulse and low pressure, the opposite pattern (C). Pain raises both pulse and pressure, and an opioid would mask neuro checks and depress breathing (D).

3

A client with a subdural hematoma has an intracranial pressure monitor reading 22 mm Hg. Which nursing action is most appropriate?

  1. APlace the client flat with the head turned to the left
  2. BKeep the head of the bed at 30 degrees with the head in midline
  3. CCluster all care activities together to allow long rest periods
  4. DEncourage the client to cough and deep breathe every hour
Show answer

Answer: B

Normal intracranial pressure is 0 to 15 mm Hg, so 22 is high. Raising the head 30 degrees and keeping the neck straight lets venous blood drain from the brain, which lowers pressure without a single medication.

Why the others are wrong

Lying flat with the head turned (A) kinks the jugular veins and traps blood in the skull. Clustering care (C) sounds restful but stacking suctioning, turning and bathing back to back causes pressure spikes; activities are spaced out instead. Coughing (D) is a Valsalva maneuver and raises intracranial pressure.

4

A nurse is walking past a client's room and sees the client fall to the floor with full body jerking movements. Which action should the nurse take first?

  1. AInsert a padded tongue blade between the teeth
  2. BHold the client's arms and legs still to prevent injury
  3. CMove furniture away and place something soft under the head
  4. DLeave to get the emergency medication from the medication room
Show answer

Answer: C

During a tonic clonic seizure the nurse protects the client from injury: clear the area, cushion the head, loosen tight clothing, and note the time it started. Nothing goes in the mouth and nothing is restrained.

Why the others are wrong

Forcing anything between the teeth (A) can break teeth, cause vomiting or injure the nurse. Holding the limbs (B) can tear muscles and dislocate joints. The nurse never leaves a seizing client (D); she calls for help from the bedside.

5

A client admitted after a fall with a basilar skull fracture has clear fluid dripping from the right nostril. The nurse places a drop on a gauze pad and sees a clear ring spread around a central spot of blood. Which action should the nurse take?

  1. APack the nostril with sterile gauze to stop the drainage
  2. BInsert a nasogastric tube to decompress the stomach
  3. CPlace a loose sterile pad under the nose and notify the provider
  4. DAsk the client to blow the nose gently to clear the passage
Show answer

Answer: C

A halo ring on gauze means the fluid is cerebrospinal fluid leaking through a fracture in the skull base. The nurse lets it drain freely onto a loose dressing, keeps the head of the bed raised, and reports it, because the open path into the brain is an infection risk.

Why the others are wrong

Packing the nose (A) blocks drainage and pushes bacteria toward the meninges. A nasogastric tube (B) can pass through the fractured bone into the brain, so nothing goes through the nose in this client, including suction catheters. Blowing the nose (D) forces air and organisms into the skull.

6

A client with a T4 spinal cord injury suddenly reports a severe pounding headache. The nurse finds the blood pressure is 214/118 mm Hg, pulse 48 beats per minute, and the face is flushed with sweating above the chest. Which action should the nurse take first?

  1. AGive the prescribed nifedipine
  2. BRaise the head of the bed to 90 degrees and lower the legs
  3. CApply a cool cloth to the forehead for the headache
  4. DLay the client flat and start continuous blood pressure monitoring
Show answer

Answer: B

This is autonomic dysreflexia, a hypertensive emergency triggered by a noxious stimulus below the injury, most often a full bladder. Sitting the client bolt upright drops the blood pressure through gravity in seconds while the nurse looks for the cause (check the catheter, check the bowel, loosen clothing).

Why the others are wrong

Medication (A) is given only if the pressure stays high after the cause is removed, and it takes time to work. A cool cloth (C) treats the symptom while the client remains at risk of stroke. Lying flat (D) is the one position that will make the blood pressure climb higher.

7

A client admitted after a motorcycle crash opens his eyes only when the nurse squeezes the trapezius muscle, says words that do not make sense, and pulls his arm away from the painful stimulus. Which Glasgow Coma Scale score should the nurse document?

  1. A15
  2. B11
  3. C9
  4. D6
Show answer

Answer: C

Eye opening to pain scores 2 out of 4. Inappropriate words score 3 out of 5. Withdrawal from pain scores 4 out of 6. Added together, 2 + 3 + 4 = 9, which is a moderate brain injury.

Why the others are wrong

15 (A) is a fully alert client who opens eyes spontaneously, is oriented and follows commands. 11 (B) would need better eye opening or better speech than this client shows. 6 (D) would mean no eye opening, no sounds and only abnormal flexion, which is far worse than this picture.

8

A college student is admitted with a fever of 103.2 F, severe headache, and a stiff neck. The nurse notes the client flexes the hips and knees when the neck is flexed forward. Which action should the nurse take?

  1. APlace the client on contact precautions and dim the lights
  2. BPlace the client on droplet precautions in a private room
  3. CPlace the client on airborne precautions with a negative pressure room
  4. DNo isolation is needed until the lumbar puncture results return
Show answer

Answer: B

Fever, headache, nuchal rigidity and a positive Brudzinski sign point to bacterial meningitis. Until the organism is known it is treated as meningococcal, which spreads by respiratory droplets, so the client goes into a private room on droplet precautions and staff wear a mask within 3 feet.

Why the others are wrong

Contact precautions (A) do not stop droplet spread, though dimming the lights for photophobia is a good comfort measure. Airborne precautions (C) are for tuberculosis, measles and varicella, not meningitis. Waiting for results (D) exposes roommates, visitors and staff for hours.

9

A client with myasthenia gravis who takes pyridostigmine is admitted with increasing weakness, difficulty swallowing and shallow breathing. The provider gives a dose of IV edrophonium and the client's muscle strength improves within one minute. Which conclusion should the nurse draw?

  1. AThe client is in cholinergic crisis from too much medication
  2. BThe client is in myasthenic crisis from too little medication
  3. CThe client has had an allergic reaction to pyridostigmine
  4. DThe client's weakness is from anxiety and needs reassurance
Show answer

Answer: B

Edrophonium is a short acting anticholinesterase. If the client gets stronger after it, the problem was not enough acetylcholine at the muscle, which is myasthenic crisis. The treatment is more anticholinesterase medication, and the nurse watches the airway closely.

Why the others are wrong

In cholinergic crisis (A) the client has too much drug, so edrophonium makes the weakness worse and adds drooling, cramping and small pupils; atropine is kept at the bedside for that reason. Allergic reactions (C) do not improve with edrophonium. Anxiety (D) does not cause measurable muscle strength changes that reverse with a drug.

10

A client with Parkinson's disease who takes carbidopa-levodopa is being discharged. Which statement by the client shows that the teaching was effective?

  1. A"I will take my pills with a big glass of milk and a protein shake at breakfast."
  2. B"I will take my pills at the same times every day and get up slowly from my chair."
  3. C"I can skip a dose if I feel steady that morning."
  4. D"I will stop the medication if my movements get jerky."
Show answer

Answer: B

Carbidopa-levodopa works only while it is in the blood, so doses are kept on a strict schedule to prevent "off" periods where the client freezes. The drug also causes orthostatic hypotension, so rising slowly is a safety rule.

Why the others are wrong

High protein meals compete with levodopa for absorption, so the dose is taken away from protein, not with a protein shake (A). Skipping doses (C) brings on rigidity and freezing and can lead to falls. Jerky movements (dyskinesia) are reported to the provider for a dose adjustment, but stopping the drug suddenly (D) can cause a dangerous rebound of symptoms.

Quick tips

  • Last known well time starts the stroke clock, not arrival time. IV alteplase has a 3 to 4.5 hour window measured from the moment the client was last seen normal, and glucose plus CT scan come before any clot drug.
  • The earliest sign of rising intracranial pressure is a change in level of consciousness. By the time you see Cushing's triad (wide pulse pressure, slow pulse, irregular breathing) the client is herniating. Head up 30 degrees, neck midline, no coughing, no hip flexion.
  • After a seizure ends, turn the client onto the side, check breathing, and let them sleep. Do not give food or fluids until fully awake, and document how long it lasted and what the body did, because that record guides the provider's treatment.
  • Autonomic dysreflexia: sit the client up first, then find the trigger (bladder, bowel, tight clothing, skin). Drugs come last. Think "up, unplug, then pills."
  • Guillain-Barre weakness climbs from the feet upward and can reach the diaphragm. The nurse checks vital capacity and negative inspiratory force every 2 to 4 hours, and a vital capacity falling below about 15 mL/kg means intubation is close.
  • Clear fluid dripping from the nose or ear after a head injury is cerebrospinal fluid until proven otherwise. Test it with a glucose strip or watch for a halo ring on gauze. Never pack the nose, never suction through the nose, never put a nasogastric tube in that client.

Related topics

FAQ

how many neuro questions are on the NCLEX

There is no fixed number. Neuro content is spread across Physiological Adaptation, Reduction of Risk Potential and Pharmacology, so an 85 question exam might show you 5 to 10 neuro stems. Expect at least one stroke, one increased intracranial pressure and one seizure question.

what is the difference between early and late signs of increased ICP

Early signs are subtle: restlessness, confusion, drowsiness, headache, nausea and a slight change in pupil reaction. Late signs are Cushing's triad (widening pulse pressure, bradycardia, irregular respirations), fixed and dilated pupils and posturing. The exam loves to ask which group a finding belongs to.

what do I do if a client has a seizure on the NCLEX

Protect, do not restrain. Clear the area, cushion the head, turn the client to the side once the jerking stops, time the seizure, and stay with the client. Anything that involves the mouth, holding limbs down, or leaving the room is a wrong answer.

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