NCLEX Neurological Emergencies questions
The PrepScore bank has 86 Neurological Emergencies questions, each with a rationale and two tags: the Client Needs category from the test plan and the clinical judgment step it tests. In this topic the items lean on Recognize cues and Take action, which is worth knowing before you practise it. Three worked samples are below, answers behind a reveal.
Stroke recognition, increased ICP, seizure status, GBS, meningitis, head and spinal cord injuries — the windows are minutes.
Three worked questions
Q1. A 68-year-old male presents to the ED with sudden right-sided weakness and slurred speech that started 90 minutes ago per family. Vitals: BP 168/92, HR 88, glucose 124, SpO2 96%. He has no recent bleeding or anticoagulation. Which initial action is the PRIORITY?
- A. Activate the stroke protocol, obtain STAT non-contrast CT head, assess for tPA eligibility within the 4.5-hour window
- B. Document the symptoms and observe over the next 4 hours before initiating any specific neurologic intervention
- C. Administer aspirin 325 mg PO immediately as the first treatment for the suspected ischemic stroke today
- D. Wait for symptoms to fully develop and stabilize before initiating any specific stroke protocol or workup
Show answer and rationale
Answer: Activate the stroke protocol, obtain STAT non-contrast CT head, assess for tPA eligibility within the 4.5-hour window
Acute stroke symptoms within 4.5 hours of onset require immediate stroke protocol activation: STAT non-contrast CT head (rules out hemorrhage), tPA eligibility assessment, door-to-needle target ≤ 60 min. Documentation/observation, aspirin-first, and waiting all miss the time-critical reperfusion window.
Q2. A 45-year-old male is in the medical ICU on day 2 after severe TBI. The bedside nurse is evaluating for signs of increased ICP. Which findings SUPPORT increased ICP? Select all that apply.
- A. Worsening level of consciousness (declining GCS)
- B. Cushing's triad: hypertension + bradycardia + irregular respirations (late sign)
- C. Unequal pupils with sluggish or absent response to light
- D. Vomiting (especially projectile in pediatrics)
- E. New severe headache with photophobia and neck stiffness
- F. Symmetric ankle reflexes within normal limits at the bedside
Show answer and rationale
Answer: Worsening level of consciousness (declining GCS)Cushing's triad: hypertension + bradycardia + irregular respirations (late sign)Unequal pupils with sluggish or absent response to lightVomiting (especially projectile in pediatrics)New severe headache with photophobia and neck stiffness
Increased ICP signs: declining LOC + Cushing's triad (HTN + bradycardia + irregular respirations — late) + unequal sluggish pupils (uncal herniation) + vomiting + severe headache. Symmetric normal ankle reflexes are routine neuro exam findings, not specific for raised ICP.
Q3. A 35-year-old female has a generalized tonic-clonic seizure during her admission to the medical floor. The nurse witnesses the seizure starting. Which initial action is the PRIORITY during the seizure?
- A. Protect from injury (clear surroundings, padding), position side-lying when possible, time the seizure, do not restrain or insert anything in mouth
- B. Insert an oral airway between her teeth to prevent her from biting her tongue during the active seizure phase
- C. Physically restrain her arms and legs to prevent injury from thrashing during the seizure activity
- D. Administer immediate IV diazepam as the first action without securing airway or protecting from injury during the seizure
Show answer and rationale
Answer: Protect from injury (clear surroundings, padding), position side-lying when possible, time the seizure, do not restrain or insert anything in mouth
Seizure first aid: protect from injury (clear surroundings, padding), side-lying position (when possible) to protect airway from aspiration, time the seizure (status if > 5 min), do NOT restrain (causes injury), do NOT insert anything in mouth (broken teeth, jaw injury). Pharmacologic intervention is for status (> 5 min) or repeated seizures.
The rules that decide these questions
From the pack's rule cards — the reasoning shortcuts a wrong answer usually means you were missing.
tPA eligibility uses LKW — the last time the patient was confirmed neurologically normal — NOT when symptoms were found. Hypoglycemia is the major mimic; check glucose. Imaging (non-contrast CT) is first to differentiate ischemic from hemorrhagic. Aggressively dropping BP in ischemic stroke can worsen ischemia; allow permissive HTN up to 220/120 unless tPA is planned (then < 185/110).
Sustained ICP > 22 mmHg, falling GCS, anisocoria, and pupil changes all precede the classic Cushing's triad (HTN + bradycardia + irregular respirations). HOB 30°, midline neck, avoid hypotonic fluids, cluster care, limit suctioning to ≤ 10 sec. First-line acute therapy: osmotherapy (mannitol or 3% saline). Brief hyperventilation only as a bridge.
Convulsive status epilepticus = seizure > 5 minutes (or recurrent without recovery). Step ladder: airway/oxygen → IV access → IV benzo → 2nd-line load (levetiracetam / fosphenytoin / valproate) → general anesthesia. Don't keep giving benzos without escalating; don't insert bite blocks.
Spinal cord injury can cause loss of sympathetic tone — hypotension PLUS bradycardia with warm, dry, flushed skin BELOW the level. Don't flood with crystalloid — use moderate fluid + vasopressors to maintain MAP ≥ 85 for cord perfusion. Watch the diaphragm (level-dependent), decompress the bladder, prevent skin breakdown.
A 'normal' initial post-trauma exam followed by a decline (vomiting, repetitive questioning, GCS drop, anisocoria) is classic for epidural hematoma — especially after a temporal blow (middle meningeal artery). CT head, neurosurgery, no sedation that masks the neuro exam. Never discharge a head-injured patient whose exam is worsening, no matter how the family wants to go home.
Don't wait for the LP. Blood cultures + droplet precautions + IV empiric antibiotics (ceftriaxone + vancomycin ± ampicillin) + dexamethasone within the first hour. CT before LP if altered mental status, focal deficits, or papilledema. Treat close contacts with chemoprophylaxis if meningococcal. Petechiae = think meningococcal until proven otherwise.
Practise the whole pack, tagged and explained
Every item carries its Client Needs category and clinical judgment step, so a wrong answer names the step that failed.
Frequently asked questions
How many Neurological Emergencies questions does the bank have?
86 multiple-choice items, plus 10 unfolding cases in the Neurological Emergencies pack, each with a rationale.
Are the samples real bank items?
Yes — the three questions above are drawn from the live bank, with their real rationales and tags.
Which clinical judgment steps does this topic train?
Most items in this topic test Recognize cues and Take action, though every step appears.
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