Ten free neuro NCLEX practice questions with full rationales — stroke and tPA, increased intracranial pressure, seizures, autonomic dysreflexia, meningitis, Parkinson's, and myasthenia gravis. Answer each one, then reveal the correct answer and see why every option is right or wrong. No sign-up needed to practice here.
High-Yield Neuro Review
Neurological emergencies reward fast, correct prioritization. For suspected stroke, use FAST (Face droop, Arm drift, Speech, Time) and note the time of last-known-well. The single most important step before giving a thrombolytic (alteplase, or the increasingly used tenecteplase) is a non-contrast head CT to rule out hemorrhage, because thrombolytics given in a hemorrhagic stroke can be fatal. Alteplase is reserved for ischemic stroke within 4.5 hours of last-known-well when exclusion criteria (recent bleeding, uncontrolled BP, recent surgery/stroke, anticoagulation) are absent. Increased intracranial pressure (ICP) announces itself first with a decreasing level of consciousness and restlessness; Cushing's triad (bradycardia, widened pulse pressure/hypertension, irregular respirations) and fixed, dilated pupils are LATE, ominous signs. Manage ICP by elevating the head of bed to about 30 degrees, keeping the head midline/neutral, preventing Valsalva (stool softeners, no straining or prolonged suctioning), spacing care rather than clustering it, and giving osmotic therapy (mannitol or hypertonic saline).
During a seizure, protect the client: turn them side-lying, cushion the head, loosen clothing, remove hazards, time the event, and never restrain them or force anything into the mouth. Status epilepticus is treated with an IV benzodiazepine such as lorazepam; provide airway support and post-ictal reorientation afterward. Autonomic dysreflexia (spinal cord injury at or above T6) is a hypertensive emergency: sudden severe hypertension, pounding headache, bradycardia, and flushing/sweating above the lesion. Sit the client upright FIRST to drop blood pressure, THEN find and remove the trigger (distended bladder, kinked catheter, fecal impaction, tight clothing). Suspected bacterial meningitis requires droplet precautions plus recognition of nuchal rigidity, positive Kernig/Brudzinski signs, photophobia, fever, and severe headache. Parkinson disease shows resting tremor, rigidity, bradykinesia, and postural instability; levodopa-carbidopa teaching stresses slow position changes and fall/aspiration safety. In myasthenia gravis, distinguish a myasthenic crisis (under-medication) from a cholinergic crisis (over-medication with SLUDGE symptoms) – airway support is the priority for both.
Neuro NCLEX Practice Questions
Question 1 · Stroke – tPA and CT priority
A client arrives in the emergency department with sudden right-sided weakness and slurred speech that began 90 minutes ago. The provider is considering IV alteplase (tPA). Which intervention should the nurse anticipate FIRST?
- A Administer IV alteplase immediately to restore cerebral perfusion
- B Prepare the client for a non-contrast CT scan of the head
- C Begin a continuous heparin infusion
- D Give aspirin 325 mg by mouth
Show answer & rationale
Correct answer: B
A non-contrast head CT must be obtained and read BEFORE alteplase primarily to rule out intracranial hemorrhage; an early ischemic stroke is often not yet visible on the initial CT. Giving a thrombolytic to a client with a hemorrhagic stroke can cause catastrophic, often fatal bleeding, so administering alteplase immediately is unsafe until imaging clears the client. Aspirin is an antiplatelet that would worsen bleeding if the stroke is hemorrhagic, and it is withheld for at least 24 hours after tPA is given; it is not the first step. A heparin infusion is not indicated in the acute management of ischemic stroke and adds bleeding risk. Per AHA/ASA guidelines, alteplase may be given for eligible ischemic stroke within 4.5 hours of last-known-well when no exclusion criteria exist – and only after the CT confirms no hemorrhage. This client at 90 minutes is within the window, but imaging still comes first. (Tenecteplase is now an accepted alternative to alteplase for eligible ischemic strokes.) Clinical pearl: think 'CT before clot-buster.' Also track the 'last-known-well' time, not when symptoms were discovered, because that determines eligibility. FAST (Face droop, Arm drift, Speech difficulty, Time to call) helps you recognize stroke early and preserve the treatment window. The nurse should also establish IV access, draw labs including glucose and coagulation studies, and manage blood pressure per protocol while imaging is arranged.
Question 2 · Stroke – alteplase exclusion criteria
The nurse reviews the record of a client with acute ischemic stroke who is being considered for IV alteplase (tPA). Which findings would EXCLUDE the client from receiving thrombolytic therapy? Select all that apply.
- A Blood glucose 110 mg/dL
- B Symptom onset (last-known-well) 6 hours ago
- C History of a previous intracranial hemorrhage
- D Blood pressure 200/120 mmHg that remains elevated despite treatment
- E Current therapeutic anticoagulation with an elevated INR
- F Ischemic stroke within the past 3 months
Show answer & rationale
Correct answer: B, C, D, E, F
Alteplase is time-limited and bleeding-risk driven. An onset (last-known-well) of 6 hours falls outside the 4.5-hour window, so it excludes the client. Any prior intracranial hemorrhage is an absolute contraindication because thrombolysis dramatically raises rebleed risk. Blood pressure that stays above 185/110 mmHg (here 200/120) despite treatment is an exclusion, since uncontrolled hypertension increases hemorrhagic transformation. A recent ischemic stroke within about 3 months and current therapeutic anticoagulation with an elevated INR both raise bleeding danger and disqualify the client. The one finding that does NOT exclude therapy is a blood glucose of 110 mg/dL – that is a normal value; a very low glucose (below about 50 mg/dL) is the main concern, because hypoglycemia can mimic stroke and should be corrected or excluded first. Clinical pearl: alteplase exclusions cluster around 'anything that bleeds or has bled' plus 'out of the time window' plus 'BP too high to control.' Other common exclusions to remember include recent major surgery or serious trauma, active internal bleeding, recent GI/GU hemorrhage, platelet count below 100,000, and known bleeding disorders. Per AHA/ASA guidance, the nurse verifies eligibility carefully, keeps BP below 185/110 before and 180/105 after tPA, and monitors closely for signs of bleeding or neurologic deterioration during and after the infusion.
Question 3 · Increased ICP – earliest sign
A client with a traumatic brain injury is being monitored for increased intracranial pressure. Which assessment finding is the EARLIEST indicator that ICP is rising?
- A An irregular respiratory pattern with periods of apnea
- B Bradycardia with a steadily widening pulse pressure
- C Fixed and dilated pupils that do not react to light
- D Restlessness with a decreasing level of consciousness
Show answer & rationale
Correct answer: D
The earliest and most sensitive sign of increased ICP is a change in level of consciousness – restlessness, confusion, irritability, or subtle drowsiness – because the cerebral cortex is exquisitely sensitive to reduced perfusion and rising pressure. Recognizing this early allows intervention before herniation. Bradycardia with a widening pulse pressure is one component of Cushing's triad, which is a LATE and ominous sign reflecting brainstem compromise. An irregular respiratory pattern with periods of apnea is also part of Cushing's triad (the third component being hypertension/widening pulse pressure), again a late finding indicating the medulla is affected. Fixed and dilated pupils that do not react to light indicate compression of cranial nerve III and impending or ongoing herniation – the latest and most catastrophic finding. Clinical pearl: 'LOC is the first to go.' When you see a subtle mental-status change in an at-risk client, act – don't wait for the classic triad, because by then the client is decompensating. Cushing's triad is remembered as bradycardia, bounding/widened pulse pressure with hypertension, and irregular respirations. The nurse should notify the provider, elevate the head of bed to about 30 degrees, keep the head midline, minimize stimulation, and prepare for interventions such as osmotic diuretics. Early detection and prompt escalation are what preserve neurologic outcome.
Question 4 · Increased ICP – nursing interventions
A nurse is caring for a client at risk for increased intracranial pressure. Which interventions should the nurse include in the plan of care? Select all that apply.
- A Cluster all nursing care together to provide one long rest period
- B Elevate the head of the bed to approximately 30 degrees
- C Keep the client's head in a neutral, midline position
- D Suction the airway frequently and for prolonged periods
- E Administer stool softeners and instruct the client to avoid straining
- F Administer mannitol as prescribed
Show answer & rationale
Correct answer: B, C, E, F
Elevating the head of bed to about 30 degrees promotes venous drainage from the brain and helps lower ICP. Keeping the head neutral and midline (avoiding neck flexion, rotation, or extreme hip flexion) prevents jugular compression that would impede venous outflow and raise pressure. Preventing Valsalva is essential, so stool softeners and instructions to avoid straining, coughing, and breath-holding protect against transient ICP spikes. Mannitol, an osmotic diuretic, pulls fluid from brain tissue into the vasculature to reduce cerebral edema and ICP (hypertonic saline is an alternative). The two wrong choices are traps. Clustering care together should be AVOIDED – grouping multiple stimulating activities causes cumulative, sustained ICP elevation; instead, space activities and allow recovery between them. Frequent, prolonged suctioning should also be AVOIDED because suctioning triggers coughing and raises ICP; when suctioning is necessary, limit each pass to about 10 to 15 seconds and hyperoxygenate first. Clinical pearl: 'Straight, calm, and quiet' – keep the head straight/midline and elevated, keep the client calm and pain/anxiety controlled, and keep the environment quiet with minimal stimulation. Additional measures include maintaining normothermia, treating pain, preventing fever and seizures, and keeping oxygenation and normocapnia adequate, since hypoxia and hypercarbia both increase cerebral blood volume and ICP.
Question 5 · Seizure – actions during
A hospitalized client suddenly begins having a generalized tonic-clonic seizure. Which action should the nurse take?
- A Turn the client onto one side and protect the head
- B Restrain the client's extremities to stop the shaking
- C Insert a padded tongue blade between the client's teeth
- D Call a code and begin chest compressions immediately
Show answer & rationale
Correct answer: A
During an active seizure, the priorities are protecting the airway and preventing injury. Turning the client to a side-lying (lateral) position allows secretions to drain, reducing aspiration risk, while cushioning or protecting the head prevents trauma. The nurse should also loosen restrictive clothing, remove nearby hazards, stay with the client, and time the seizure. Never insert a tongue blade or any object into the mouth – this can break teeth, cause airway obstruction, or injure the nurse; the old teaching about preventing the client from 'swallowing the tongue' is a myth. Do NOT restrain the extremities, because forcibly holding a convulsing client can cause fractures, dislocations, or soft-tissue injury; instead, guide movements away from harm. Calling a code and starting chest compressions is not indicated during a seizure – the client has a pulse; CPR is only for cardiac arrest. Clinical pearl: 'Side, time, and protect – nothing in the mouth, no restraints.' If the seizure lasts longer than 5 minutes or seizures occur without recovery between them, this is status epilepticus, a neurologic emergency treated with an IV benzodiazepine such as lorazepam, along with airway and oxygen support. After the seizure (post-ictal phase), keep the client on their side, maintain the airway, assess for injury, reorient gently, allow rest, and document the onset, duration, movements, incontinence, and post-ictal state.
Question 6 · Autonomic dysreflexia – priority action
A client with a T4 spinal cord injury reports a sudden, pounding headache. The nurse notes a blood pressure of 210/110 mmHg, a heart rate of 48/min, and flushing and diaphoresis above the level of injury. What is the nurse's PRIORITY action?
- A Notify the provider and wait for further orders
- B Administer a prescribed antihypertensive medication
- C Sit the client upright by raising the head of the bed
- D Palpate the suprapubic area to check for bladder distention
Show answer & rationale
Correct answer: C
This client has autonomic dysreflexia, a life-threatening emergency seen in spinal cord injuries at or above T6. It causes sudden severe hypertension, a pounding headache, bradycardia, and flushing/sweating above the lesion. The FIRST action is to sit the client upright (raise the head of bed) to use orthostatic pooling to immediately lower blood pressure and reduce the risk of stroke or seizure from the hypertensive crisis. AFTER positioning, the nurse quickly identifies and removes the noxious trigger – most commonly a distended bladder (check for a kinked or blocked catheter, or catheterize), followed by fecal impaction, or tight clothing/restrictive devices. Simply notifying the provider and waiting delays a time-critical intervention the nurse can start now. Giving an antihypertensive may be needed if blood pressure stays dangerously high after positioning and trigger removal, but it is not the very first step and requires an order. Palpating the suprapubic area for bladder distention is part of finding the trigger, which comes AFTER sitting the client up. Clinical pearl: 'Sit them up, then hunt the trigger.' Remember the trigger order as bladder first (most common), then bowel, then skin/clothing. Blood pressure can rise to dangerous levels within minutes, so continuous monitoring is essential. Preventing autonomic dysreflexia centers on regular bladder and bowel management and avoiding skin irritation.
Question 7 · Meningitis – manifestations and precautions
A client is admitted with suspected bacterial meningitis. Which assessment findings should the nurse expect? Select all that apply.
- A Nuchal rigidity
- B Severe headache
- C Positive Kernig and Brudzinski signs
- D Bradycardia and hypothermia
- E Fever
- F Photophobia
Show answer & rationale
Correct answer: A, B, C, E, F
Bacterial meningitis produces meningeal irritation and infection, so expected findings include nuchal rigidity (a stiff, painful neck with resistance to flexion) and positive Kernig sign (pain/resistance when extending the knee with the hip flexed) and Brudzinski sign (involuntary hip/knee flexion when the neck is flexed). Photophobia (light sensitivity), severe headache, and fever are classic. The finding that does NOT fit is bradycardia and hypothermia – meningitis typically causes fever (hyperthermia) and often tachycardia from infection and inflammation; hypothermia and bradycardia are not expected features of the acute infectious presentation. Priority nursing care: place the client on DROPLET precautions immediately for suspected bacterial (especially meningococcal) meningitis and maintain them until the client has received at least 24 hours of effective antibiotics; give prescribed antibiotics promptly after cultures/lumbar puncture, since delay increases mortality. Monitor neurologic status closely because meningitis can raise ICP and cause seizures. Clinical pearl: 'Stiff neck, sensitive to light, spikes a fever' – and 'droplet plus antibiotics fast.' Provide a quiet, dimly lit environment for photophobia and headache, manage pain and fever, maintain hydration, and watch for complications such as increased ICP, altered LOC, and shock. Prophylaxis may be offered to close contacts of a client with meningococcal meningitis.
Question 8 · Parkinson disease – levodopa-carbidopa teaching
A client newly diagnosed with Parkinson disease is starting levodopa-carbidopa. Which statement by the client indicates correct understanding of the medication?
- A "I can stop taking it on my own once my tremors improve."
- B "I should take this medication with a high-protein meal."
- C "This medication will control my symptoms within the first day or two."
- D "I will change positions slowly because my blood pressure may drop."
Show answer & rationale
Correct answer: D
Levodopa-carbidopa commonly causes orthostatic (postural) hypotension, so teaching the client to change positions slowly – from lying to sitting to standing – prevents dizziness and falls, which is a critical safety concern in Parkinson disease. Taking the drug with a high-protein meal is incorrect: dietary protein (specifically its amino acids) competes with levodopa for absorption and can reduce the medication's effectiveness, so large protein loads should be spaced away from doses. Stopping the medication once tremors improve is unsafe; levodopa should never be discontinued abruptly, as this can trigger a severe worsening of symptoms and a neuroleptic malignant syndrome-like reaction. Expecting symptom control within a day or two is wrong – therapeutic benefit builds gradually over days to weeks, and the client must not assume the drug has failed early on. Clinical pearl: darkening of urine and sweat is a harmless, expected effect and not a reason to stop the drug. Parkinson cardinal signs are the TRAP mnemonic – Tremor (resting, 'pill-rolling'), Rigidity, Akinesia/bradykinesia, and Postural instability. Because of bradykinesia, rigidity, and postural instability, fall precautions are essential, and impaired swallowing raises aspiration risk, so aspiration precautions, careful feeding, and swallow evaluation matter. Encourage 'on' times for activity, allow extra time for movement, and monitor for wearing-off effects and dyskinesias as therapy continues.
Question 9 · Myasthenia gravis – myasthenic vs cholinergic crisis
A client with myasthenia gravis reports increasing muscle weakness and difficulty breathing and swallowing after taking extra doses of pyridostigmine. Which finding would indicate a CHOLINERGIC crisis rather than a myasthenic crisis?
- A Excessive salivation, lacrimation, diarrhea, and abdominal cramping
- B Ptosis and diplopia that improve with a period of rest
- C Hypertension and tachycardia with warm, dry skin
- D Improvement of muscle strength after administration of edrophonium (Tensilon)
Show answer & rationale
Correct answer: A
A cholinergic crisis results from OVER-medication with anticholinesterase drugs (like pyridostigmine), producing excess acetylcholine and muscarinic 'SLUDGE' symptoms: Salivation, Lacrimation, Urination, Diarrhea, GI cramping, and Emesis, along with miosis, bradycardia, and worsening weakness. The client's history of taking extra doses fits this picture, and the excessive secretions and GI symptoms point to cholinergic crisis. Improvement of strength after edrophonium indicates a MYASTHENIC crisis (under-medication) – giving more cholinesterase inhibitor helps; in a cholinergic crisis, edrophonium would make weakness WORSE, which is why the test was used cautiously with atropine and airway support available. (The edrophonium/Tensilon test is now largely historical in the US; the two crises are distinguished clinically and by response to treatment.) Ptosis and diplopia that improve with rest describe typical myasthenia gravis fatigable weakness, not a specific marker distinguishing cholinergic crisis. Hypertension, tachycardia, and warm dry skin reflect sympathetic/anticholinergic effects, the opposite of the cholinergic (parasympathetic) excess seen here. Clinical pearl: 'Cholinergic crisis = too much drug = SLUDGE; myasthenic crisis = too little drug = weakness that the edrophonium test improves.' Regardless of which crisis, the PRIORITY is always airway and respiratory support, because both can cause respiratory failure from weakened diaphragm and intercostal muscles – assess ventilation, keep suction and intubation equipment ready, and monitor swallowing to prevent aspiration. Distinguishing the two guides treatment: hold anticholinesterase drugs in a cholinergic crisis, whereas a myasthenic crisis needs adjusted dosing and may need plasmapheresis or IVIG.
Question 10 · Glasgow Coma Scale / LOC assessment
A nurse assessing a client with a head injury documents the following: opens eyes only to painful stimuli, makes incomprehensible sounds, and withdraws from painful stimuli. What is the client's Glasgow Coma Scale (GCS) score and its interpretation?
- A GCS 10; mild impairment requiring only routine monitoring
- B GCS 12; moderate impairment expected to resolve quickly
- C GCS 8; severe impairment warranting airway protection
- D GCS 6; the client meets criteria for brain death
Show answer & rationale
Correct answer: C
The Glasgow Coma Scale scores three areas: eye opening (1-4), verbal response (1-5), and best motor response (1-6). Here, opening eyes to pain scores 2, incomprehensible sounds score 2, and withdrawal from pain scores 4, for a total of 8. A GCS of 8 or less indicates severe impairment and a compromised ability to protect the airway, so this client warrants close monitoring and preparation for airway protection/intubation – remember the saying 'GCS 8, intubate.' A score of 6 is incorrect arithmetic, and a GCS score can never diagnose brain death (the lowest possible GCS is 3, in a living but deeply unresponsive client). A score of 10 is also incorrect math, and this presentation is not mild; mild injury is GCS 13 to 15. A score of 12 is likewise wrong and would represent moderate (GCS 9 to 12) rather than severe injury. Clinical pearl: memorize the bands – mild 13 to 15, moderate 9 to 12, severe 3 to 8. Always report the breakdown (E, V, M) as well as the total, because trends and individual components guide care; a declining GCS signals neurologic deterioration and possible rising ICP, prompting immediate provider notification. When documenting, note any factors that limit assessment, such as intubation (verbal cannot be scored normally) or sedation, since these affect interpretation of the score.
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Neuro NCLEX FAQ
Why does a stroke client need a CT scan before getting tPA (alteplase)?
A non-contrast head CT rules out a hemorrhagic stroke (a bleed); an early ischemic stroke often looks normal on the first CT. Alteplase dissolves clots, so giving it to someone who is actually bleeding in the brain can cause massive, potentially fatal hemorrhage. The rule is simple: CT before clot-buster. IV thrombolysis (alteplase or tenecteplase) is generally limited to eligible ischemic stroke within 4.5 hours of last-known-well with no exclusion criteria present.
What is the very first thing I do for autonomic dysreflexia?
Sit the client upright first – raise the head of the bed to lower the dangerously high blood pressure through gravity/orthostatic pooling. Then find and remove the trigger, checking the bladder first (distended bladder or kinked/blocked catheter), then bowel (fecal impaction), then skin (tight clothing or pressure). This condition occurs in spinal cord injuries at or above T6 and is a hypertensive emergency, so act immediately and keep monitoring blood pressure.
How do I tell a myasthenic crisis from a cholinergic crisis?
A myasthenic crisis is caused by UNDER-medication (not enough anticholinesterase drug), producing weakness that classically improves with the edrophonium (Tensilon) test, now largely historical in the US. A cholinergic crisis is caused by OVER-medication, producing SLUDGE symptoms (salivation, lacrimation, urination, diarrhea, GI cramping, emesis) plus worsening weakness, and edrophonium makes it worse. Either way, the priority is airway and breathing, because both can lead to respiratory failure.
What are the earliest versus latest signs of increased ICP?
The earliest sign is a change in level of consciousness – restlessness, confusion, or subtle drowsiness. Do not wait for the classic late signs. Cushing's triad (bradycardia, widened pulse pressure with hypertension, and irregular respirations) and fixed, dilated pupils are LATE, ominous findings that indicate brainstem compromise and possible herniation. Act on the earliest mental-status change: elevate the head of bed to about 30 degrees, keep the head midline, minimize stimulation, and notify the provider.