ATI RN
Health Assessment Neurological System NCLEX Questions Questions
Question 1 of 5
During care of a patient in myasthenic crisis, maintenance of what is the nurse's first priority for the patient?
Correct Answer: C
Rationale: In a patient experiencing a myasthenic crisis, which is a life-threatening condition characterized by severe muscle weakness, the nurse's first priority should be to ensure adequate respiratory function. This is because the muscles responsible for breathing are significantly weakened during a myasthenic crisis, putting the patient at high risk for respiratory failure. Option A: Mobility is important for overall patient health but is not the priority in a myasthenic crisis where respiratory compromise can lead to immediate life-threatening consequences. Option B: Nutrition is essential for overall well-being, but in a myasthenic crisis, ensuring adequate ventilation takes precedence over nutritional concerns. Option D: Verbal communication is important for patient assessment and emotional support, but it is not the priority when the patient's respiratory function is compromised. Educationally, this question highlights the critical nature of prioritizing care in a life-threatening situation. Understanding the pathophysiology of myasthenic crisis and recognizing the potential for respiratory failure underscores the importance of quick and accurate decision-making in nursing practice. It also emphasizes the need for nurses to prioritize interventions based on the patient's condition to ensure optimal outcomes.
Question 2 of 5
A patient with a fractured tibia accompanied by extensive soft tissue damage initially has a splint applied and held in place with an elastic bandage. What early sign should alert the nurse that the patient is developing compartment syndrome?
Correct Answer: C
Rationale: Compartment syndrome is a serious condition that can occur following a traumatic injury, such as a fractured tibia with soft tissue damage. The correct answer, option C, "Distal pain unrelieved by opioid analgesics," is indicative of developing compartment syndrome. This is because in compartment syndrome, there is increased pressure within a muscle compartment, leading to impaired blood flow and tissue damage, resulting in severe pain that is not relieved by pain medication due to the compromised blood flow. Option A, "Paralysis of the toes," is incorrect as paralysis is a late sign of compartment syndrome. Option B, "Absence of peripheral pulses," is also a late sign and indicates severe compromise of blood flow. Option D, "Skin over the injury site is blanched when the bandage is removed," is not typically associated with compartment syndrome but may indicate other issues like poor circulation or pressure-related skin damage. Educationally, understanding the signs and symptoms of compartment syndrome is crucial for nurses caring for patients with traumatic injuries. Recognizing early signs like unrelieved pain is essential for prompt intervention to prevent further tissue damage and potential limb loss. Nurses must be vigilant in assessing patients with injuries at risk for compartment syndrome to provide timely and appropriate care.
Question 3 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 4 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 5 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.