Neurological Disorders NCLEX Questions

Question 1 of 5

Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?

A. Abnormal diaphoresis.B. A severe throbbing headache.C. Sudden loss of motor function.D. Spastic skeletal muscle movement.

Correct Answer: B

Rationale: Autonomic dysreflexia in SCI causes severe headache (
B) due to hypertensive crisis from a trigger like bladder distention. Diaphoresis (
A) is secondary, motor loss (
C) is expected, and spasticity (
D) is chronic.

Question 2 of 5

Which client should the nurse assess first after receiving the shift report?

A. The client diagnosed with a stroke who has right-sided paralysis.B. The client diagnosed with meningitis who complains of photosensitivity.C. The client with a brain tumor who has projectile vomiting.D. The client with epilepsy who complains of tender gums.

Correct Answer: C

Rationale: Projectile vomiting (
C) in a brain tumor suggests increased ICP, a life-threatening condition requiring immediate assessment. Paralysis (
A), photosensitivity (
B), and tender gums (
D) are less urgent.

Question 3 of 5

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?

A. When the client's head is turned to the right, the eyes turn to the right.B. The electroencephalogram (EEG) has identifiable waveforms.C. No eye activity is observed when the cold caloric test is performed.D. The client assumes decorticate posturing when painful stimuli are applied.

Correct Answer: C

Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (
C). Eyes turning with head movement (
A) indicates intact reflexes, EEG waveforms (
B) suggest brain activity, and decorticate posturing (
D) indicates some brain function.

Question 4 of 5

The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt-Jakob disease. Which intervention should the nurse implement prior to the procedure?

A. Determine if the client has claustrophobia.B. Obtain a signed informed consent form.C. Determine if the client is allergic to egg yolks.D. Start an intravenous line in both hands.

Correct Answer: A

Rationale: MRI involves a confined space, so assessing for claustrophobia (
A) ensures patient comfort and safety. Consent (
B) is required but secondary, egg yolk allergy (
C) is irrelevant, and bilateral IVs (
D) are unnecessary.

Question 5 of 5

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.

A. Position the client to prevent shoulder adduction.B. Turn and reposition the client every shift.C. Encourage the client to move the affected side.D. Perform quadriceps exercises three (3) times a day.E. Instruct the client to hold the fingers in a fist.

Correct Answer: A,C,D

Rationale: For a right-sided CVA, the left side is affected. Positioning to prevent shoulder adduction (
A) supports the weak left arm to prevent contractures. Encouraging movement of the affected side (
C) promotes neuroplasticity and recovery. Quadriceps exercises (
D) strengthen the affected leg. Turning every shift (
B) is too infrequent; every 2 hours is standard to prevent pressure ulcers. Instructing to hold fingers in a fist (E) risks contractures and is not therapeutic.

Neurological Disorders NCLEX Questions | Nurselytic

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