NCLEX Neurological Disorders | Nurselytic

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NCLEX Neurological Disorders Questions

Question 1 of 5

For a client with Guillain-Barré syndrome, which complication should the nurse monitor most closely?

Correct Answer: B

Rationale: Deep vein thrombosis is a significant risk in Guillain-Barré syndrome due to immobility from muscle weakness.

Question 2 of 5

When the nurse alternates injection sites on the client's upper arms, how far apart should the injections be spaced?

Correct Answer: C

Rationale: Injections should be spaced 1'' apart to prevent tissue irritation and ensure proper drug absorption.

Question 3 of 5

Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?

Correct Answer: C

Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.

Question 4 of 5

The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?

Correct Answer: D

Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (
D) confirms the diagnosis via CSF analysis. CT (
A) may precede LP, blood cultures (
B) are supportive, and EMG (
C) is unrelated.

Question 5 of 5

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?

Correct Answer: D

Rationale: Airway maintenance (
D) is the highest priority in any critically ill patient, including those with head injuries, to ensure oxygenation. Neurological assessment (
A), vital signs (
B), and IV access (
C) follow after securing the airway.

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