NCLEX-PN
Neurological Disorder NCLEX Questions
Question 1 of 5
Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
Correct Answer: B
Rationale: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.
Question 2 of 5
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
Correct Answer: A
Rationale: A TIA in a client with atrial fibrillation is likely due to cardioembolic stroke risk. Oral anticoagulants (
A), such as warfarin or direct oral anticoagulants, are prescribed to prevent clot formation. Beta blockers (
B) control heart rate, anti-hyperuricemics (
C) treat gout, and thrombolytics (
D) are used acutely, not for discharge prevention.
Question 3 of 5
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
Correct Answer: D
Rationale: A severe headache in a stroke patient may indicate complications like hemorrhagic transformation or increased intracranial pressure. A neurological assessment (
D) is the first step to evaluate the cause and guide further actions. Analgesics (
A) may mask symptoms, MRI (
B) requires assessment first, and IV fluids (
C) are not urgent.
Question 4 of 5
The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?
Correct Answer: C
Rationale: A GCS score of 6 (
C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (
A) is standard for concussion, left-sided weakness (
B) is concerning but less acute, and expressive aphasia (
D) is stable.
Question 5 of 5
The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?
Correct Answer: A
Rationale: Purposeless movement (
A) indicates a higher level of brain function compared to decorticate posturing, suggesting improvement. Flaccid paralysis (
B) or decerebrate posturing (
C) indicates worsening, and nonreactive pupils (
D) suggest severe brain damage.