NCLEX neurological practice questions
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- Physiological adaptation test-plan category
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- August 2026 last updated
Neuro questions hang on one idea: a falling level of consciousness is the earliest sign of rising intracranial pressure, and it outranks almost everything else in the stem. These ten cover stroke and thrombolytic windows, ICP and positioning, seizure precautions, spinal cord injury, and the myasthenic and cholinergic crises that are told apart by a single detail.
Written and reviewed by Dana Whitfield, RN, MSN · Updated August 2026
Physiological adaptation
The neurological set, all 10 free
Answer, check, and read why each of the four options wins or loses.
Neurological
Question 1 of 10
A client arrives 90 minutes after the sudden onset of right-sided weakness and expressive aphasia. Which finding in the history should the nurse report before thrombolytic therapy is considered?
Not quite — the answer is B
Why each option is right or wrong
A. Blood pressure of 158/88 mm Hg on arrival
A pressure of 158/88 is below the 185/110 threshold that must be treated before alteplase, so it does not disqualify this client.
B. A gastrointestinal bleed requiring transfusion three weeks ago
Active internal bleeding requiring transfusion within the past 21 days is an absolute contraindication to alteplase because of catastrophic hemorrhage risk.
C. A history of atrial fibrillation treated with rate control
Atrial fibrillation is a common source of embolic stroke rather than a contraindication; anticoagulant use, not rate control, would raise bleeding concern.
D. A blood glucose of 132 mg/dL
A glucose of 132 mg/dL is normal; only marked hypoglycemia or hyperglycemia would mimic stroke and change the thrombolytic decision.
Key takeaway
Recent active internal bleeding within the previous 21 days is an absolute contraindication to alteplase because thrombolysis could produce catastrophic hemorrhage, making this a critical safety report. A blood pressure of 158/88 is below the 185/110 threshold that would require treatment before thrombolysis, so it is not disqualifying.
A client with a traumatic brain injury has these serial vital signs: blood pressure rising from 124/76 to 178/62, heart rate falling from 88 to 48, and respirations becoming irregular. Which conclusion should the nurse draw?
Not quite — the answer is D
Why each option is right or wrong
A. The client is developing hypovolemic shock
Hypovolemic shock produces hypotension, tachycardia, and a narrowed pulse pressure, which is the opposite of the widening pressure and bradycardia seen here.
B. The client is responding appropriately to mannitol therapy
Effective mannitol therapy would lower intracranial pressure and stabilize vital signs, so this deteriorating pattern reflects failure rather than therapeutic response.
C. The client is experiencing an anxiety reaction to the ICU environment
Anxiety raises heart rate and blood pressure together; it does not cause bradycardia with irregular respirations in a client with brain injury.
D. The client is showing Cushing triad, indicating dangerously increased intracranial pressure
Widening pulse pressure, bradycardia, and irregular respirations form Cushing triad, a late sign of intracranial hypertension and impending herniation.
Key takeaway
Widening pulse pressure, bradycardia, and irregular respirations form Cushing triad, a late and ominous sign of increased intracranial pressure and impending herniation that requires immediate provider notification. Hypovolemic shock would instead produce hypotension with tachycardia and a narrowed pulse pressure, the opposite pattern.
The nurse enters a room and finds a client having a generalized tonic-clonic seizure in bed. Which action should the nurse take first?
Not quite — the answer is A
Why each option is right or wrong
A. Turn the client to the side and protect the head
Side-lying positioning keeps the airway patent and lets secretions drain, while protecting the head prevents trauma during the convulsive movements.
B. Insert a padded tongue blade between the teeth
Forcing anything between clenched teeth can fracture teeth, lacerate the mouth, or obstruct the airway, and is contraindicated during an active seizure.
C. Restrain the client's arms to prevent injury
Restraining the limbs during tonic-clonic activity can cause fractures and soft tissue injury; the nurse guides the client away from hazards instead.
D. Draw a stat serum phenytoin level
A phenytoin level helps assess dosing after the event, but drawing laboratory studies never takes precedence over protecting the airway during a seizure.
Key takeaway
Side-lying positioning maintains a patent airway and allows secretions to drain, addressing airway and breathing priorities while padding protects the head from trauma. Inserting anything into the mouth or restraining the limbs during a seizure can cause dental, oral, or musculoskeletal injury and is contraindicated.
A client with a T4 spinal cord injury suddenly reports a pounding headache; blood pressure is 210/112, and the nurse notes flushing above the level of injury and gooseflesh below it. After placing the client in high Fowler position, which action should the nurse take next?
Not quite — the answer is C
Why each option is right or wrong
A. Administer an as-needed dose of oral acetaminophen
Acetaminophen treats the headache symptom while the noxious trigger continues driving stroke-level hypertension, so the dysreflexic crisis would simply persist.
B. Apply oxygen at 4 L/min by nasal cannula
Oxygen may be added for comfort, but hypoxia is not the problem and the blood pressure will not fall until the stimulus is removed.
C. Assess for a kinked urinary catheter or bladder distention
Bladder distention or a kinked catheter is the most common trigger below the injury, and removing it resolves the hypertensive crisis.
D. Perform passive range-of-motion exercises to the lower extremities
Passive range of motion adds more stimulation below the level of injury and could intensify the sympathetic surge rather than relieve it.
Key takeaway
Autonomic dysreflexia is triggered by a noxious stimulus below the injury level, and bladder distention or an obstructed catheter is the most common cause, so removing the stimulus resolves the hypertensive crisis. Giving acetaminophen treats a symptom while leaving the trigger in place, allowing blood pressure to remain at stroke-level values.
A college student is admitted with suspected bacterial meningitis after presenting with fever, nuchal rigidity, and photophobia. Which nursing action is most important during the first 24 hours?
Not quite — the answer is D
Why each option is right or wrong
A. Position the client supine with the neck flexed for comfort
Neck flexion stretches inflamed meninges and increases pain, so the client is positioned with the head of the bed elevated and neck neutral.
B. Keep the room brightly lit for frequent neurologic assessment
Bright lighting aggravates photophobia and adds stimulation; a darkened, quiet room is preferred while neurologic checks are still performed as scheduled.
C. Encourage ambulation in the hallway every 4 hours
Hallway ambulation every four hours increases stimulation and energy demand during acute meningitis, when quiet rest with minimal stimuli is indicated.
D. Maintain droplet precautions until 24 hours of effective antibiotics have been given
Meningococcal meningitis spreads by respiratory droplets, so droplet precautions protect others until 24 hours of effective antibiotic therapy are complete.
Key takeaway
Neisseria meningitidis is transmitted by respiratory droplets, so droplet precautions protect other clients and staff until the client has received 24 hours of appropriate antibiotic therapy. Bright lighting worsens photophobia and increases discomfort and stimulation, so a darkened, quiet room is preferred.
A client with myasthenia gravis takes pyridostigmine. Which statement by the client indicates a need for further teaching?
Not quite — the answer is B
Why each option is right or wrong
A. I will schedule my most demanding activities for the morning
Scheduling demanding activities in the morning is correct, because muscle strength is greatest early and fatigue accumulates as the day progresses.
B. If I miss a dose it is fine to skip it and take the next one later in the day
Skipping or delaying anticholinesterase doses can precipitate myasthenic crisis with respiratory failure, so this statement reveals unsafe understanding needing correction.
C. I will take my medication about 30 minutes before meals
Taking pyridostigmine about 30 minutes before meals is accurate, since peak strength then improves chewing and swallowing and lowers aspiration risk.
D. I will call my provider if I develop new difficulty swallowing
Reporting new difficulty swallowing is appropriate, because bulbar weakness signals worsening disease and threatens the airway, so this reflects correct understanding.
Key takeaway
Anticholinesterase medication must be taken on an exact schedule because missed or delayed doses can precipitate myasthenic crisis with respiratory failure, so casually skipping a dose reflects unsafe understanding. Taking the drug 30 minutes before meals is correct because it maximizes chewing and swallowing strength and reduces aspiration risk.
The nurse is planning care for a client with Parkinson disease who has a shuffling gait, bradykinesia, and difficulty initiating movement. Which intervention should the nurse include?
Not quite — the answer is C
Why each option is right or wrong
A. Instruct the client to walk with the feet close together for balance
A narrow base of support reduces stability in a client with bradykinesia and festination, increasing rather than decreasing the risk of falls.
B. Discourage exercise to conserve limited energy
Exercise preserves range of motion, balance, and function in Parkinson disease, so discouraging it accelerates rigidity, contractures, and overall deconditioning.
C. Teach the client to consciously lift the toes and swing the arms while walking
Consciously lifting the toes and swinging the arms interrupts the shuffling festinating gait, lengthening stride and improving balance and safety.
D. Provide all meals as pureed textures regardless of swallowing ability
Pureed textures should follow a swallowing evaluation; applying them to everyone is unnecessarily restrictive and can reduce appetite and nutritional intake.
Key takeaway
Deliberately lifting the toes, using a wide base, and swinging the arms counteracts the festinating shuffling gait and reduces fall risk, supporting both mobility and safety. Narrowing the base of support would decrease stability and increase falls, and routine puree without a swallow evaluation is unnecessarily restrictive.
A client with relapsing-remitting multiple sclerosis asks how to reduce the risk of an exacerbation. Which response by the nurse is most accurate?
Not quite — the answer is A
Why each option is right or wrong
A. Avoid overheating, including hot baths and strenuous activity in hot weather
Elevated core temperature slows conduction in demyelinated fibers, so avoiding hot baths and heat exposure prevents transient worsening of symptoms.
B. Limit fluid intake to less than 1,000 mL per day
Fluid restriction has no role in multiple sclerosis and promotes constipation and urinary tract infection, both of which can aggravate symptoms.
C. Remain on strict bed rest whenever symptoms are present
Strict bed rest causes deconditioning, contractures, and pressure injury; balanced activity with planned rest periods is recommended even during exacerbations.
D. Take a hot bath before bed to loosen spastic muscles
A hot bath raises core temperature and typically intensifies weakness and fatigue, so it is specifically discouraged despite its appeal for spasticity.
Key takeaway
Elevated core temperature slows conduction in demyelinated fibers and commonly triggers a temporary worsening of symptoms, so heat avoidance is standard teaching. Hot baths are specifically discouraged for this reason, and prolonged bed rest promotes deconditioning, contractures, and pressure injury rather than protecting the client.
A client with a closed head injury opens the eyes to painful stimuli, makes incomprehensible sounds, and withdraws from pain. What Glasgow Coma Scale score should the nurse document?
Not quite — the answer is D
Why each option is right or wrong
A. 6
Six would require a lower motor score such as abnormal flexion, but withdrawal from pain scores four, making this total too low.
B. 12
Twelve overestimates this client, since eye opening to pain and incomprehensible sounds each earn only two points rather than higher responses.
C. 10
Ten is too high, because reaching that total would require confused or oriented speech instead of the incomprehensible sounds documented here.
D. 8
Eye opening to pain scores 2, incomprehensible sounds 2, and withdrawal 4, totaling 8, the threshold for considering intubation.
Key takeaway
Eye opening to pain scores 2, incomprehensible sounds score 2, and withdrawal from pain scores 4, for a total of 8, which is the threshold at which intubation for airway protection is generally considered. A score of 6 would underestimate the motor response, since withdrawal is scored higher than abnormal flexion or extension.
A client admitted after a fall has clear fluid draining from the right nostril that forms a yellow ring around a central blood stain on the linen. Which nursing action is appropriate?
Not quite — the answer is C
Why each option is right or wrong
A. Pack the nostril firmly with sterile gauze
Packing the nostril obstructs cerebrospinal fluid drainage and can force organisms upward through the fracture line, sharply raising the risk of meningitis.
B. Insert a small-bore nasogastric tube to decompress the stomach
A nasogastric tube can pass through the basilar skull fracture into the cranial vault, so oral placement is required if decompression is needed.
C. Allow the drainage to flow freely onto a sterile pad and notify the provider
The halo sign suggests cerebrospinal fluid rhinorrhea, so drainage flows freely onto a sterile pad and the provider is notified for meningitis risk.
D. Have the client blow the nose to clear the drainage
Blowing the nose raises intracranial and sinus pressure and can force bacteria into the cranial cavity, so it is specifically prohibited.
Key takeaway
A halo sign suggests cerebrospinal fluid rhinorrhea from a basilar skull fracture; drainage should be collected on a loose sterile dressing without obstruction, and the provider notified because of meningitis risk. Packing the nose or passing a nasogastric tube risks forcing organisms intracranially or passing the tube through the fracture into the brain.
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