NCLEX-RN
NCLEX RN Neurological Questions Questions
Extract:
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 22-year-old female.
Item 1 of 1
History And Physical Orders
1114: A 22-year-old female client was with friends at a restaurant and reportedly started acting odd and then had uncontrollable and uncoordinated movements. This lasted three minutes. Once this terminated, EMS was called, and this occurred again and lasted four minutes. EMS administered lorazepam. The client does not have any medical history or take any medications. On exam, she did not recall the seizure, nor did she remember how she felt leading up to the seizure. She denied any drug use. She is drowsy following the administration of lorazepam but can sustain attention and is fully oriented. Glasgow Coma Scale 14. Will admit the client for observation.
Question 1 of 5
For each physician order, click to specify the appropriate nursing intervention: Magnetic Resonance Imaging (MRI) of the brain
| Ensure the client has a negative pregnancy test prior to the exam |
| Assess if the client has claustrophobia prior to the exam |
| Have the client nothing by mouth (NPO) eight hours prior to the exam |
| Monitor the client's lung sounds for pulmonary edema |
| Establish continuous cardiac monitoring during the infusion |
| Insert an indwelling urinary catheter to monitor intake and output |
| Position the client side-lying with their knees to their chest |
Correct Answer: A,B,E
Rationale: A negative pregnancy test is essential for female patients of childbearing age to avoid radiation risks to a fetus. Assessing for claustrophobia ensures patient comfort and safety during the MRI. Assessing for IV contrast dye allergy is necessary if contrast is used. Phenytoin can cause cardiac arrhythmias, so continuous cardiac monitoring is critical during infusion to detect and manage any adverse effects promptly. An EEG involves placing electrodes on the scalp, and instructing the client on how to remove adhesive post-test ensures proper care and comfort.
Extract:
Question 2 of 5
The nurse is caring for a client who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse?
Correct Answer: B,C,D
Rationale: Status epilepticus is a medical emergency requiring immediate action. Notifying the RRT ensures rapid intervention, obtaining a lorazepam prescription is critical to stop seizures, and loosening restrictive clothing prevents injury and ensures airway patency.
Question 3 of 5
The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad?
Correct Answer: B
Rationale: Cushing's triad, indicative of increased intracranial pressure, includes irregular respirations, bradycardia, and widening pulse pressure.
Question 4 of 5
The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching?
Correct Answer: B
Rationale: Planning activities helps manage fatigue, a common symptom in multiple sclerosis. Hot baths can worsen symptoms, and eye patches are used for one eye, not both.
Question 5 of 5
The nurse is caring for a client who is paraplegic secondary to a spinal cord injury. While planning this client's discharge, which would be most appropriate to include in the client's plan of care?
Correct Answer: B
Rationale: Early rehabilitation is critical for optimizing recovery and adaptation in spinal cord injury patients.