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NCLEX neuro practice questions

20 free NCLEX-style neurological questions: stroke windows, rising intracranial pressure, autonomic dysreflexia and the other emergencies the nurse must catch first, with the answer and rationale.

Tap an answer to check it, or open "Show the answer and rationale" under each question. Every client is fictional. For exam practice only, not medical advice.

Question 1 of 20

A client with advanced Parkinson disease was admitted with pneumonia 2 days ago, and the home carbidopa-levodopa was left off the admission medication list. The client now has a temperature of 104.4°F (40.2°C), severe muscle rigidity, confusion, a heart rate of 128 beats/min, and a creatine kinase of 4,800 units/L. Which action should the nurse anticipate?

  1. Holding the carbidopa-levodopa until the creatine kinase returns to normal
  2. Broadening the IV antibiotics to treat possible sepsis from pneumonia
  3. Restarting the carbidopa-levodopa promptly and cooling the client
  4. Giving IV haloperidol to control the confusion and agitation
Show the answer and rationale

Answer: C

Abruptly stopping levodopa can cause parkinsonism-hyperpyrexia syndrome, a reaction that resembles neuroleptic malignant syndrome, with high fever, severe rigidity, confusion, autonomic instability, and a rising creatine kinase that can progress to rhabdomyolysis and kidney injury. Treatment is restarting the dopaminergic drug promptly, through a feeding tube if the client cannot swallow, along with cooling, IV fluids, and close monitoring. Holding the carbidopa-levodopa sounds cautious because the picture looks like a drug reaction, but the crisis comes from the missing drug, so continuing to withhold it removes the treatment. Broader antibiotics may be considered for the pneumonia, but they do not replace the missing dopamine that is driving the fever and rigidity, and haloperidol blocks dopamine and would worsen the crisis.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 2 of 20

A 27-year-old client with a complete C6 spinal cord injury from 2 years ago is admitted with pneumonia. The client's usual BP is 92/56 mm Hg. Which finding requires immediate follow-up?

  1. BP 84/50 mm Hg on moving to the wheelchair, with dizziness that eases when reclined
  2. Temperature 96.8°F (36°C) after a bath in a cool room
  3. Heart rate 54 beats/min at rest, which is unchanged from the rate on admission
  4. BP 134/82 mm Hg with a new pounding headache and a stuffy nose
Show the answer and rationale

Answer: D

Clients with injuries above T6 often have a low baseline pressure, so a systolic rise of 20 to 40 mm Hg above baseline can signal autonomic dysreflexia even when the reading looks normal; 134/82 is 42 mm Hg above this client's usual systolic, and the headache and nasal stuffiness are classic. The nurse sits the client up, loosens clothing and checks the bladder. A slow heart rate is the runner-up because bradycardia can occur in dysreflexia, but this rate is the client's baseline. Orthostatic drops and a low body temperature are common after a cervical injury and are managed with gradual position changes and warming.

📚 Learn it: Tamponade, Tension Pneumothorax and Autonomic Dysreflexia

Question 3 of 20

A client with a traumatic brain injury has an intracranial pressure (ICP) monitor. Thirty minutes after receiving IV morphine for pain, the client's respirations are shallow at 8 breaths/min, and the ICP has risen from 14 to 26 mm Hg. The head of the bed is at 30 degrees with the head midline. Which finding best explains the rise in ICP?

  1. Serum sodium of 146 mEq/L
  2. PaO2 of 82 mm Hg
  3. PaCO2 of 58 mm Hg
  4. Temperature of 100.6°F (38.1°C)
Show the answer and rationale

Answer: C

Carbon dioxide is a powerful dilator of the brain's blood vessels, so when opioid-induced hypoventilation pushes the PaCO2 above the normal 35 to 45 mm Hg, cerebral blood volume and ICP climb; the nurse supports ventilation and reports at once. A fever is the runner-up, because it raises the brain's metabolic demand and can add to ICP, but a low-grade temperature does not explain a sudden jump that followed the slowed breathing. A slightly high sodium draws water out of brain tissue rather than into it, and a PaO2 of 82 mm Hg is adequate oxygenation.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 4 of 20

A nurse is teaching a client with a T3 spinal cord injury how to prevent autonomic dysreflexia at home. Which statement by the client indicates understanding?

  1. 'If I get a pounding headache, I'll lie down until it passes.'
  2. 'My pressure runs low, so 130/80 would not be a concern for me.'
  3. 'Once spinal shock is over, this won't be a risk for me.'
  4. 'I'll keep to my bladder schedule and a regular bowel program.'
Show the answer and rationale

Answer: D

Most episodes of autonomic dysreflexia are triggered by a full bladder or bowel, so a reliable bladder schedule and bowel program are the core of prevention, along with avoiding tight clothing and pressure on the skin. People with injuries at or above T6 often run low baseline pressures, which makes 130/80 sound harmless, but a rise of more than 20 mm Hg above the client's usual pressure can signal an episode. During an episode the client sits upright rather than lying down, because sitting up helps lower the pressure, and the risk does not end with spinal shock: it usually appears after spinal shock resolves and persists for life.

📚 Learn it: Tamponade, Tension Pneumothorax and Autonomic Dysreflexia

Question 5 of 20

A 59-year-old client's spouse says the client's speech became garbled and the right arm went weak at 1900 last evening; they hoped it would pass and arrived at the emergency department at 0900. The CT shows no hemorrhage and only a small area of early infarction, and the CT angiogram shows a blocked left middle cerebral artery. The spouse asks, 'Is it too late to do anything?' Which response by the nurse is accurate?

  1. 'The clot-dissolving drug can still be given, because the scan shows no bleeding.'
  2. 'Aspirin will be started right away to dissolve the clot.'
  3. 'Removing the clot with a catheter may still help, even this long after it started.'
  4. 'The window for treating the clot has closed, so care now focuses on preventing another stroke.'
Show the answer and rationale

Answer: C

For a large vessel occlusion such as this middle cerebral artery blockage, mechanical thrombectomy can be offered to selected clients up to 24 hours after onset when imaging shows brain tissue that can still be saved. IV thrombolysis is the runner-up, but 14 hours after a witnessed onset is past its window of 4.5 hours, or up to 9 hours in selected clients with advanced imaging, and a scan without bleeding does not extend it. Saying the window has closed overlooks thrombectomy, and aspirin helps prevent new clots but does not dissolve one.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 6 of 20

A client with a stab wound to the right chest had a bubbling, sucking chest wound, and the nurse covered it with an occlusive dressing taped on all four sides. Ten minutes later, the respiratory rate is 38 breaths/min, SpO2 83%, and BP 84/52 mm Hg. The neck veins are distended, breath sounds are absent on the right, and the trachea is shifted to the left. Which action should the nurse take first?

  1. Reinforce the dressing with another layer of tape
  2. Apply a non-rebreather mask with oxygen at 15 L/min
  3. Prepare the client for immediate insertion of a chest tube on the right side
  4. Lift one edge of the dressing to let the trapped air escape
Show the answer and rationale

Answer: D

A dressing sealed on all four sides lets air enter the pleural space through the injured lung but not leave, turning an open pneumothorax into a tension pneumothorax, as the tracheal shift, absent breath sounds, distended neck veins and hypotension show. Lifting or burping the dressing releases the trapped air within seconds and comes first, followed by a vented chest seal and a chest tube. High-flow oxygen is the runner-up, but it cannot reexpand a lung compressed by trapped air. A chest tube takes time to set up, and more tape seals the air in.

📚 Learn it: Tamponade, Tension Pneumothorax and Autonomic Dysreflexia

Question 7 of 20

A 64-year-old client arrives 70 minutes after the sudden onset of right arm weakness and trouble finding words. The client takes no anticoagulants and has no history of a bleeding disorder. The CT shows no hemorrhage, the blood pressure is 168/92 mm Hg, and the fingerstick glucose is 118 mg/dL. The stroke team prescribes IV tenecteplase, but the platelet count and INR have not resulted yet. Which action should the nurse take?

  1. Give the drug now, without waiting for the results
  2. Give aspirin 325 mg to start breaking up the clot
  3. Hold the drug until the platelet count and INR are back
  4. Lower the blood pressure below 140/90 mm Hg first
Show the answer and rationale

Answer: A

When nothing suggests anticoagulant use or a bleeding disorder, the platelet count and INR are not required before IV thrombolysis, because every minute of delay costs brain tissue, so the nurse gives the drug as prescribed and the team acts if a result comes back abnormal. Holding for the labs is the runner-up and sounds safe, but it is right only for a client who takes an anticoagulant or may have a coagulation problem. The pressure is already below the 185/110 mm Hg limit, so pushing it under 140/90 mm Hg only adds delay, and aspirin does not dissolve a clot and needs a swallow screen first.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 8 of 20

A 70-year-old client arrives 1 hour after the sudden onset of numbness in the left hand and a mild left facial droop. The client walks steadily, speaks normally, and can use the hand for all tasks; the NIH Stroke Scale score is 2. The CT shows no hemorrhage. Which treatment should the nurse anticipate?

  1. IV tenecteplase, because the client is within 4.5 hours
  2. A continuous IV heparin infusion to keep the clot from growing
  3. Emergency mechanical thrombectomy
  4. Aspirin and clopidogrel once a swallow screen is passed
Show the answer and rationale

Answer: D

IV thrombolysis is meant for disabling deficits, and for a mild, nondisabling stroke within 4.5 hours, current AHA/ASA guidance prefers dual antiplatelet therapy, such as aspirin with clopidogrel, over a thrombolytic, which adds bleeding risk without clear benefit for these clients. Tenecteplase is the runner-up because the timing fits, but timing alone does not make a client a candidate. A heparin infusion is not a standard early treatment for this stroke and raises bleeding risk, and thrombectomy is for a large vessel occlusion, usually with a stroke scale score of 6 or more.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 9 of 20

A client with infective endocarditis of the mitral valve is on day 4 of IV antibiotics. Which new finding requires the nurse's immediate action?

  1. Redness and tenderness at the PICC insertion site
  2. Trouble finding words and a drooping right side of the face
  3. A temperature of 100.6°F (38.1°C), lower than on admission
  4. Blood in the urine on this morning's urinalysis
Show the answer and rationale

Answer: B

Vegetations on a heart valve can break off and travel to the brain, so new word-finding trouble and facial droop signal an embolic stroke that needs immediate activation of the stroke team and imaging. Blood in the urine is the strongest distractor, because emboli or immune reactions can also injure the kidneys, but it is reported and monitored rather than treated within minutes, and it does not threaten brain function the way a stroke does. Redness at the PICC site needs assessment and a report, but a local site problem is less urgent, and a fever that is trending down suggests the antibiotics are working.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 10 of 20

A nurse assesses a client with a head injury after a fall. The client opens the eyes only when pressure is applied to a nail bed, moans without forming words, and pulls the hand away from the pressure. What Glasgow Coma Scale score should the nurse document?

  1. 10
  2. 8
  3. 7
  4. 9
Show the answer and rationale

Answer: B

Eye opening only to pressure scores 2, moaning without words scores 2 for the verbal response, and pulling away from the stimulus (normal flexion, or withdrawal) scores 4 for the motor response, for a total of 8. A score of 8 or less indicates a severe brain injury and a client who may not be able to protect the airway, so the nurse notifies the provider and anticipates intubation. A total of 9 is the common error of scoring the withdrawal as localizing, which earns 5 only when the hand reaches toward the stimulus to remove it. A total of 7 treats the withdrawal as abnormal flexion, the slow, stiff decorticate posture, and 10 would require 2 more points than the client earns, such as eyes opening to voice plus localizing, or obeying commands.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Practice 10 more Neuro & emergencies questions free →

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Question 11 of 20

A 66-year-old client with hypertension and atrial fibrillation is brought to the emergency department 50 minutes after the sudden onset of severe dizziness, vomiting, and double vision. The client cannot walk without veering to the left. The face is symmetric, both arms hold up without drifting, and the speech is clear. Which action should the nurse take first?

  1. Give the prescribed ondansetron and recheck in 30 minutes
  2. Score the NIH Stroke Scale and call if it is 4 or higher
  3. Keep the client still, because inner-ear vertigo is likely
  4. Activate the stroke alert
Show the answer and rationale

Answer: D

Sudden dizziness with double vision and an unsteady gait in a client with stroke risk factors is a posterior circulation stroke until proven otherwise; BE-FAST adds balance and eyes to the face, arm, and speech checks because these strokes often leave the face and arms normal, and this client is inside the treatment window. The antiemetic is the runner-up, since it eases real distress, but it can follow the stroke alert. The NIH Stroke Scale often scores posterior strokes low, so a low score does not rule one out, and calling it inner-ear vertigo is the classic way these strokes are missed.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 12 of 20

A client with relapsing-remitting multiple sclerosis says, 'After a long hot bath last night my vision blurred and my legs went weak, but this morning I'm back to normal.' Which response by the nurse is most appropriate?

  1. 'Heat briefly slows signals in damaged nerves; staying cool helps prevent it.'
  2. 'That was a new relapse, so you will need IV steroids started today.'
  3. 'Warm baths ease spastic muscles, so keep using them whenever your legs feel stiff.'
  4. 'An episode like this means your disease is progressing faster than we expected.'
Show the answer and rationale

Answer: A

A short-lived return of old symptoms with heat that clears once the body cools, known as Uhthoff's phenomenon, is a pseudo-relapse: heat slows conduction along demyelinated nerves without causing new damage, so the client is taught to avoid hot baths, saunas, and overheating. A true relapse brings new or worsening symptoms that last at least 24 hours without fever or overheating, and that is what IV corticosteroids treat. Heat is not recommended for spasticity in multiple sclerosis, and a heat-related episode says nothing about how fast the disease is progressing.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 13 of 20

Four hours after coronary artery bypass surgery, a client's mediastinal chest tube, which had been draining 150 to 200 mL/hr, has drained only 10 mL in the past hour. The blood pressure has fallen to 84/68 mm Hg, the heart rate is 132 beats/min, and the central venous pressure has risen from 8 to 18 mm Hg. Which action should the nurse take?

  1. Document that the bleeding has slowed and keep monitoring
  2. Give a fluid bolus and recheck the drainage in 1 hour
  3. Turn the client onto the left side to improve venous return
  4. Notify the surgeon immediately of possible cardiac tamponade
Show the answer and rationale

Answer: D

A sudden drop in chest tube output after heavy bleeding, together with falling blood pressure, a narrow pulse pressure, tachycardia, and a rising central venous pressure, suggests that clots are blocking the tube and blood is collecting around the heart and compressing it; tamponade after heart surgery usually needs an emergency return to the operating room. Reading the low output as a sign that bleeding has stopped ignores the worsening hemodynamics. Fluid may be given as prescribed to support filling, but it does not relieve the compression and must not delay notifying the surgeon, and repositioning does not help.

📚 Learn it: Tamponade, Tension Pneumothorax and Autonomic Dysreflexia

Question 14 of 20

A client admitted with an ischemic stroke this morning has a prescription for oral aspirin. The client has not had anything by mouth since arrival. Which action should the nurse take first?

  1. Perform a validated swallow screen at the bedside
  2. Check the gag reflex, then give the tablet with water
  3. Give the tablet with a sip of thickened liquid
  4. Crush the tablet and mix it into applesauce
Show the answer and rationale

Answer: A

Dysphagia is common after stroke, so a validated swallow screen is completed before the client receives any food, fluid, or oral medication; if the client fails it, the aspirin can be given by another route as prescribed. A gag reflex does not predict safe swallowing, because many clients with an intact gag still aspirate silently. Crushing the tablet or offering thickened liquid assumes the client can swallow safely before anyone has checked.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 15 of 20

A client received epinephrine 0.5 mg IM for anaphylaxis after IV contrast 10 minutes ago. The client still has wheezing and stridor, and the blood pressure is 78/44 mm Hg. Which action should the nurse anticipate next?

  1. Give IV diphenhydramine and recheck in 30 minutes
  2. Repeat the IM epinephrine dose in the outer thigh now
  3. Give IV methylprednisolone as the next rescue drug
  4. Wait for the first epinephrine dose to reach full effect
Show the answer and rationale

Answer: B

Epinephrine is the only first-line drug for anaphylaxis, and when symptoms persist the IM dose is repeated every 5 to 15 minutes while oxygen, IV fluids, and airway support continue. Antihistamines relieve hives and itching but do not reverse airway swelling or shock, and corticosteroids take hours to act. IM epinephrine acts within minutes, so persistent stridor and hypotension at 10 minutes mean another dose is needed now.

📚 Learn it: Tamponade, Tension Pneumothorax and Autonomic Dysreflexia

Question 16 of 20

The parent of an 18-month-old who had a simple febrile seizure lasting 1 minute asks how to prevent another one. Which response by the nurse is accurate?

  1. 'Put your child in a lukewarm bath during a seizure to lower the fever.'
  2. 'Give acetaminophen around the clock whenever your child has a fever.'
  3. 'Fever medicine eases discomfort, but it does not prevent these seizures.'
  4. 'Your child will need a daily antiseizure medicine until about age 6.'
Show the answer and rationale

Answer: C

Simple febrile seizures are brief, generalized, and usually harmless, and antipyretics ease discomfort but have not been shown to prevent them, so round-the-clock dosing only adds a risk of dosing errors. Daily antiseizure drugs are not recommended after simple febrile seizures, because their side effects outweigh the small benefit. During a seizure the parent places the child on the side on a safe surface, puts nothing in the mouth, times the seizure, and calls emergency services if it lasts longer than 5 minutes; a bath during a seizure risks drowning.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 17 of 20

A client receiving mechanical ventilation after chest trauma suddenly develops high peak airway pressures, absent breath sounds on the left, tracheal deviation to the right, and a blood pressure that falls from 118/72 to 82/50 mm Hg. Which intervention should the nurse prepare for first?

  1. Suctioning the endotracheal tube to clear secretions
  2. Increasing the PEEP to re-expand the collapsed lung
  3. A portable chest x-ray before any treatment begins
  4. Immediate needle decompression of the left chest
Show the answer and rationale

Answer: D

Absent breath sounds on one side, a trachea pushed toward the opposite side, rising airway pressures, and a falling blood pressure describe a tension pneumothorax, in which trapped air compresses the heart and great vessels; immediate needle decompression followed by a chest tube is lifesaving. Waiting for a chest x-ray delays a clinical diagnosis that needs treatment within minutes. Extra PEEP forces more air into the pleural space, and suctioning clears secretions, which would not shift the trachea or drop the blood pressure.

📚 Learn it: Tamponade, Tension Pneumothorax and Autonomic Dysreflexia

Question 18 of 20

A client with a subarachnoid hemorrhage has an external ventricular drain (EVD) prescribed open to drain at 15 cm H2O above the tragus. The nurse clamps the drain and then helps the client move up in bed, raising the head of the bed from 15 to 30 degrees. Which action should the nurse take next?

  1. Lower the drip chamber below the tragus to make up for the lost drainage
  2. Unclamp the drain and recheck its height at the next hourly check
  3. Flush the ventricular catheter with sterile saline before unclamping it
  4. Re-level the drain's zero point at the tragus, then unclamp it
Show the answer and rationale

Answer: D

The pressure level of an EVD is set relative to the tragus, which approximates the level of the foramen of Monro, so after any change in head position the zero point is re-leveled before the drain is reopened. A chamber left too low drains cerebrospinal fluid too fast and can collapse the ventricles or cause bleeding, and one left too high lets intracranial pressure climb, so reopening first and checking later leaves the client at risk. The nurse never flushes a ventricular catheter, because irrigation can raise intracranial pressure and introduce infection, and the drain height is changed only as prescribed.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 19 of 20

A client's generalized tonic-clonic seizure has continued for 6 minutes. The client is turned to the side with oxygen applied, and an IV line is in place. Which medication should the nurse prepare to administer first?

  1. Magnesium sulfate by IV infusion
  2. Fosphenytoin by IV infusion
  3. Levetiracetam by mouth
  4. Lorazepam by slow IV push
Show the answer and rationale

Answer: D

A seizure lasting 5 minutes or longer is status epilepticus, and a benzodiazepine such as IV lorazepam is the first-line drug because it stops seizures within minutes. Fosphenytoin is a second-line drug given after the benzodiazepine to prevent recurrence, and nothing is given by mouth to a client who is seizing. Magnesium sulfate prevents and treats eclamptic seizures in pregnancy, not status epilepticus.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 20 of 20

Forty minutes into an alteplase infusion for acute ischemic stroke, a client reports a sudden severe headache and begins vomiting. The blood pressure has risen to 196/112 mm Hg, and the client is harder to arouse. Which action should the nurse take first?

  1. Stop the alteplase infusion and call the provider
  2. Give the prescribed acetaminophen for the headache
  3. Slow the infusion rate and recheck in 15 minutes
  4. Lower the head of the bed flat to improve blood flow
Show the answer and rationale

Answer: A

A sudden severe headache, vomiting, a spike in blood pressure, and a falling level of consciousness during thrombolysis point to intracranial hemorrhage, so the infusion is stopped at once, the provider is notified, and an emergency head CT is anticipated. Treating the headache or merely slowing the rate lets more clot-dissolving drug reach a bleeding brain. Lying flat raises intracranial pressure and offers no benefit to a client who may be bleeding.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

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