ATI RN
Health Assessment Neurological System NCLEX Questions Questions
Question 1 of 5
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?
Correct Answer: A
Rationale: The correct answer is A: Reflexes will be normal. In a patient with a head injury resulting from trauma and no other injuries, deep tendon reflexes are typically unaffected by the injury. The brain stem controls deep tendon reflexes, and since there are no other injuries, the reflexes should remain normal. Choices B, C, and D are incorrect because they do not align with the typical response of deep tendon reflexes in a head injury without other injuries. Choice B stating that reflexes cannot be elicited is incorrect as deep tendon reflexes are usually intact in this scenario. Choice C suggesting all reflexes will be diminished but present is incorrect as deep tendon reflexes are typically not affected by head injuries. Choice D stating that some reflexes will be present depending on the area of injury is incorrect because deep tendon reflexes are primarily controlled by the brain stem, which is not directly affected in this situation.
Question 2 of 5
A patient says, I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint?
Correct Answer: A
Rationale: Correct Answer: A. Depersonalization Rationale: 1. Depersonalization involves feeling detached from oneself or reality, as described by the patient. 2. The patient's description of feeling like they are looking through a cloudy window aligns with depersonalization symptoms. 3. Interference with work and study suggests significant distress, a common feature of depersonalization disorder. Summary of other choices: B. Hypochondriasis: Involves excessive worry about having a serious illness, which is not indicated in the patient's complaint. C. Dissociation: While depersonalization is a type of dissociative symptom, it specifically refers to feeling detached and unreal, not necessarily a broader dissociative disorder. D. Malingering: Involves feigning or exaggerating symptoms for secondary gain, which is not evident in the patient's genuine distress and impairment.
Question 3 of 5
You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
After receiving a change-of-shift report at 7:00 am, which of these patients will you assess first?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
Mr. Smith develops signs of increased intracranial pressure. Which of the following medications is likely to be ordered for Mr. Smith?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.