ATI RN
NCLEX Questions on Neurological System Questions
Question 1 of 5
A person who experiences an aura as part of his/her seizure pattern should be instructed to
Correct Answer: A
Rationale: The correct answer is A) lie down in a safe place. When a person experiences an aura before a seizure, it serves as a warning sign that a seizure is imminent. Instructing the person to lie down in a safe place helps prevent injury during the seizure. Option B) take additional anticonvulsant medication is incorrect because taking medication during a seizure is not safe or effective. Anticonvulsant medications are prescribed to prevent seizures, not to be taken as needed during a seizure. Option C) call an ambulance is not necessary for every seizure, especially if the person is aware of their seizure pattern and can manage it safely. Option D) exercise vigorously is unsafe during a seizure and can increase the risk of injury. It is important to promote a safe environment and positioning during a seizure to prevent harm. In an educational context, it is crucial for nurses to understand seizure management to provide safe and effective care to patients. Teaching individuals with epilepsy about seizure precautions and appropriate responses helps empower them to manage their condition effectively. Nurses play a key role in educating patients and caregivers on seizure first aid, including the importance of lying down in a safe place during an aura to prevent injury.
Question 2 of 5
A few weeks after the injury, the nurse notices that Joe seems to be pulling his legs away from her during the bath. Which of the following statements provides the best explanation of the patient's leg movement?
Correct Answer: B
Rationale: The correct answer is B) Muscle spasms are beginning to occur. Joe's leg movement of pulling away during the bath indicates the onset of muscle spasms, which is a common neurological response post-injury. This can be attributed to the hyperexcitability of nerves in the injured area, leading to involuntary muscle contractions. It is crucial for the nurse to recognize this sign as it may indicate the need for interventions to manage the muscle spasms and prevent further complications such as contractures. Option A) He is embarrassed about having to be bathed is incorrect because the behavior described is more indicative of a physiological response rather than an emotional one. Option C) Paralysis is diminishing due to reduction in edema is incorrect because a reduction in paralysis due to decreased edema would not manifest as muscle spasms but rather as improved voluntary muscle movement. Option D) He is adjusting negatively to his disability is incorrect because the behavior described is not a result of psychological adjustment but rather a physiological response related to the neurological injury. In an educational context, understanding the significance of changes in muscle tone and movement post-neurological injury is essential for nurses caring for patients with such conditions. Recognizing early signs of muscle spasms can help in implementing appropriate interventions to prevent complications and promote optimal recovery.
Question 3 of 5
Proper body alignment of the hemiplegic patient with the use of a footboard, trochanter rolls, and pillows will minimize the development of
Correct Answer: A
Rationale: Proper body alignment is crucial for hemiplegic patients to prevent complications like contractures. In this case, using a footboard helps maintain neutral ankle position, preventing plantar extension. Trochanter rolls aid in hip alignment, reducing internal hip rotation. Pillows support the affected side, preventing shoulder abduction. Choosing option A, plantar extension, as the correct answer is supported by the need to maintain proper foot alignment to prevent deformities. Plantar extension can lead to issues like foot drop and contractures, hence aligning the foot is essential. Option B, shoulder abduction, is incorrect as the question focuses on lower body alignment, not upper body positioning. Similarly, internal and external hip rotation (options C and D) are controlled by trochanter rolls, not footboard use. Educationally, understanding proper body alignment strategies for hemiplegic patients is vital for nursing practice. It promotes patient comfort, prevents complications, and supports overall rehabilitation efforts. Nurses must be knowledgeable about these interventions to provide holistic care and promote optimal patient outcomes.
Question 4 of 5
In helping Mr. Hall to maintain proper body alignment in bed to prevent dislocation of the prosthetic head and hip contracture, the nurse should assist the patient to lie
Correct Answer: A
Rationale: The correct answer is A) straight in bed alternating head position from flat to 30° elevation and left leg abducted. This position helps prevent dislocation of the prosthetic head and hip contracture by maintaining proper alignment of the body. Placing the head at a slight elevation reduces pressure on the hip joint. Abducting the left leg also helps prevent hip contracture by keeping the joint in a neutral position. Option B) diagonally toward the right side of the bed with legs together would not provide optimal alignment for preventing hip dislocation and contracture. Option C) flat on back in bed for first 48 hours with legs adducted may increase the risk of hip contracture due to prolonged adduction. Option D) on the right side only with the left leg in front of the right leg does not promote equal weight distribution and proper alignment. In an educational context, understanding proper body alignment in bed is crucial for preventing complications such as hip dislocation and contractures, especially in patients with prosthetic hips. Nurses must be knowledgeable about positioning techniques to promote patient comfort, prevent complications, and facilitate optimal recovery.
Question 5 of 5
In the initial nursing assessment of Mr. Singer it is important to remember that malignant rheumatoid arthritis
Correct Answer: B
Rationale: In the initial nursing assessment of Mr. Singer, understanding that malignant rheumatoid arthritis may also involve the heart, lungs, and other body systems is crucial. This is because rheumatoid arthritis is a systemic autoimmune disorder that can affect multiple organs besides the joints. The correct answer (B) is right because complications of rheumatoid arthritis can lead to cardiovascular issues, pulmonary complications, and systemic inflammation impacting various organs. Option A is incorrect because rheumatoid arthritis is not limited to synovial joints; it is a systemic disease. Option C is incorrect as rheumatoid arthritis is a chronic condition with periods of exacerbations and remissions, rather than purely episodic. Option D is incorrect as rheumatoid arthritis typically affects small joints, not just proximal joints. Educationally, this question highlights the importance of understanding the systemic nature of rheumatoid arthritis in a nursing assessment. Nurses need to assess not only joint symptoms but also be vigilant for potential complications in other body systems to provide holistic care for patients with rheumatoid arthritis.