ATI RN
Health Assessment Neurological System NCLEX Questions Questions
Question 1 of 5
An appropriate nursing intervention for this patient?
Correct Answer: B
Rationale: In this scenario, the correct nursing intervention for the patient is option B: Establish and consistently follow a daily schedule with the patient. This intervention is appropriate because patients with neurological system issues often benefit from structure and routine, which can help promote a sense of familiarity, security, and predictability. A daily schedule can also assist in managing symptoms, promoting independence, and facilitating optimal functioning for the patient. Option A, posting clocks and calendars in the patient's environment, while it may be helpful for some patients, does not address the need for a structured daily routine that option B provides. Option C, monitoring the patient's activities to maintain a safe environment, is important but does not specifically address the need for a daily schedule. Option D, stimulating thought processes by asking the patient questions, may be beneficial for cognitive function but does not address the overarching need for a structured routine. In an educational context, understanding the rationale behind selecting the appropriate nursing intervention is crucial for nursing students preparing for the NCLEX exam. By choosing option B, students demonstrate their understanding of the importance of structure and routine in caring for patients with neurological system issues. This rationale emphasizes the holistic approach to patient care, considering not only the physical but also the psychological and emotional needs of the patient.
Question 2 of 5
A patient complains of pain in the foot of a leg that was recently amputated. What should the nurse recognize about this pain?
Correct Answer: B
Rationale: The correct answer is B) It should be treated with ordered analgesics. In this scenario, the patient is experiencing phantom limb pain, a common phenomenon where individuals feel pain in a limb that has been amputated. This pain can be intense and debilitating for some patients. Using analgesics can help manage this pain effectively, providing relief and improving the patient's comfort. Option A is incorrect because while swelling at the incision site can cause pain, in this case, the pain is likely due to the phenomenon of phantom limb pain rather than incision-related issues. Option C is incorrect because the pain is not necessarily related to the use of a prosthesis. Phantom limb pain can occur regardless of whether a prosthesis is being used. Option D is incorrect because phantom limb pain is a real physiological phenomenon, not purely psychological. While psychological factors can contribute to pain perception, the pain experienced by the patient is not solely psychological and should be treated with appropriate pain management strategies. Educationally, it is essential for nurses to understand the complexities of pain management, especially in unique situations like phantom limb pain. By recognizing the nature of this pain and knowing appropriate interventions like analgesics, nurses can provide optimal care to patients experiencing such discomfort.
Question 3 of 5
Following 2 weeks of IV antibiotic therapy, a patient with acute osteomyelitis of the tibia is prepared for discharge from the hospital. The nurse determines that additional instruction is needed when the patient makes which statement?
Correct Answer: C
Rationale: In this scenario, option C is the incorrect statement that requires further clarification for the patient. Using a heating pad on the lower leg for comfort and to promote healing can be detrimental in osteomyelitis. Heat can increase blood flow to the affected area, potentially worsening the infection or spreading it further. Option A is correct because patients with acute osteomyelitis typically require 4 to 6 weeks of antibiotic therapy to ensure complete eradication of the infection. Option B is also correct as bearing weight on the affected leg can delay healing and may lead to complications. Option D is correct as increased pain may indicate worsening infection and should prompt immediate medical attention. From an educational perspective, it is crucial to emphasize the importance of patient education in preventing complications and promoting recovery. Patients need clear and accurate information to manage their condition effectively. Providing explanations for correct and incorrect statements helps reinforce understanding and ensures optimal outcomes for patients undergoing treatment for osteomyelitis.
Question 4 of 5
What is most likely to cause the pain experienced in the later stages of OA?
Correct Answer: D
Rationale: In osteoarthritis (OA), the pain experienced in later stages is mainly due to bone surfaces rubbing together (Option D). As OA progresses, the protective cartilage between bones wears down, leading to direct contact between bones during movement, causing pain. Option A, crepitation, refers to the grating, crackling, or popping sounds heard with joint movement in OA but is not the primary cause of pain. Options B and C, Bouchard's and Heberden's nodes respectively, are bony enlargements seen in OA but are not directly responsible for the pain. These nodes are a result of osteophyte formation at the joint margins, which can limit movement but do not directly cause the pain associated with bone-on-bone contact. Understanding the pathophysiology of OA is crucial for healthcare professionals, especially nurses, as they play a vital role in assessing and managing patients with this condition. Recognizing the primary source of pain in OA helps in providing appropriate interventions and education to improve patient outcomes and quality of life.
Question 5 of 5
After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when what is said by the patient?
Correct Answer: D
Rationale: The correct answer is D: "When my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain." This answer is correct because using a bag of frozen corn for a short duration can help reduce inflammation and pain in the joints, which is beneficial for someone with rheumatoid arthritis (RA). Cold therapy helps to numb the area, reduce blood flow, and decrease inflammation, providing relief for painful joints. Option A is incorrect because heat treatments can actually help relax muscles and reduce spasms, so they can be used even when muscle spasms are present. Option B is incorrect because cold applications should not be left on for more than 15 minutes at a time, as prolonged exposure to cold can cause tissue damage. Option C is incorrect because heat should not be used during an acute flare of RA as it can potentially exacerbate inflammation and pain. Educationally, it is essential for patients with RA to understand the proper use of heat and cold therapy to manage their symptoms effectively. Teaching patients the correct techniques and durations for these therapies can help them alleviate pain and inflammation associated with their condition. It is important for nurses to provide accurate and clear instructions to patients to ensure they can independently manage their symptoms at home.