ATI RN
NCLEX Questions for Neurological System Questions
Question 1 of 5
Joe asks the nurse why he must be turned every 2 hours. The nurse explains that he is susceptible to developing decubitus ulcers primarily because
Correct Answer: D
Rationale: In this scenario, the correct answer is D) lack of muscle activity results in poor circulation. Turning a patient every 2 hours is a crucial preventive measure to avoid developing decubitus ulcers or pressure sores. When a patient is immobile or paralyzed, the lack of movement can lead to pressure on certain areas of the body, reducing circulation to those areas. This restricted blood flow can cause tissue damage, leading to the formation of ulcers. Option A is incorrect because while nutritional requirements may be increased in paralyzed patients, it is not the primary reason for developing decubitus ulcers. Option B is incorrect as muscle spasms causing flexion contractures may contribute to the risk of pressure sores, but it is not the primary reason for their development. Option C is also incorrect as retention of waste products causing metabolic acidosis is not directly linked to the formation of decubitus ulcers. Educationally, understanding the rationale behind turning immobile patients helps students grasp the importance of preventive nursing care. It reinforces the significance of maintaining proper circulation to prevent complications such as pressure ulcers, highlighting the holistic care approach needed for patients with limited mobility. This knowledge is vital for nurses to provide effective care and prevent potential complications in their patients.
Question 2 of 5
When planning range-of-motion exercises with Mrs. Iris, which exercises for the right leg would it be important for her to perform?
Correct Answer: C
Rationale: In the case of Mrs. Iris, who is likely experiencing some form of neurological impairment, it is crucial to focus on exercises that target specific muscle groups to maintain or improve her range of motion and prevent contractures. Option C, gluteal muscle-setting exercises, is the most important for her right leg because these exercises help to strengthen the gluteal muscles, which play a significant role in hip stability and mobility. Strengthening these muscles can aid Mrs. Iris in maintaining proper alignment and function of her right leg during daily activities. Options A and B, adduction of the leg and 45° knee flexion and extension exercises, while important for overall lower limb mobility, may not be as critical for Mrs. Iris at this stage. Adduction exercises involve moving the leg toward the midline of the body, which may not directly address her specific needs related to gluteal muscle weakness. Knee flexion and extension exercises are beneficial but do not target the gluteal muscles, which are particularly important for Mrs. Iris's stability and gait. Option D, dorsiflexion and plantar flexion of the foot, primarily target the muscles in the lower leg and foot, which are important for gait and balance. While these exercises are valuable, they do not directly address the weakness in Mrs. Iris's gluteal muscles, which are crucial for her right leg function. In an educational context, understanding the rationale behind selecting specific exercises for patients with neurological impairments is essential for nurses and healthcare professionals. By focusing on muscle-setting exercises that target specific muscle groups, like the gluteals in this case, healthcare providers can tailor rehabilitation programs to address individual patient needs effectively. This approach ensures that interventions are evidence-based and patient-centered, leading to better outcomes for patients like Mrs. Iris.
Question 3 of 5
As the community health nurse, you meet with Mrs. Rollo 1 week after discharge. She complains to you of increasing joint pain and stiffness despite adherence to the discharge plan for medication therapy and heat treatments. Which of the following aspects would you initially want to evaluate?
Correct Answer: B
Rationale: In this scenario, the correct initial aspect to evaluate is the balance between exercise and rest (Option B). This is because increasing joint pain and stiffness could be related to overexertion or inadequate rest periods, especially considering the patient's neurological condition. It is crucial to assess if Mrs. Rollo is engaging in appropriate levels of physical activity and allowing for sufficient rest to prevent exacerbation of her symptoms. Option A (Diet) may be important for overall health, but in this case, joint pain and stiffness are more likely related to physical activity and rest. Option C (Use of fad diet or appliances) is not directly relevant to the symptoms described. Option D (Feelings of self-worth and self-concept) is important in a holistic assessment but is not the priority when addressing physical symptoms like joint pain and stiffness in this context. From an educational perspective, this question highlights the importance of considering lifestyle factors in assessing and managing patient symptoms, especially in individuals with neurological conditions. It emphasizes the need for a comprehensive approach to care that takes into account the interconnectedness of physical and mental well-being. This rationale reinforces the significance of critical thinking and prioritization in nursing practice, particularly in community health settings where holistic care is essential.
Question 4 of 5
In discharge planning with Mrs. Post, it will be important to teach her to avoid exposure to the sun because
Correct Answer: C
Rationale: In the context of Mrs. Post's discharge planning, teaching her to avoid sun exposure due to the potential aggravation of rash and arthritis (Option C) is crucial. Sunlight can exacerbate skin conditions like rashes and inflammatory arthritis, leading to increased discomfort and potential flare-ups. Educating Mrs. Post on this aspect is essential for managing her symptoms effectively and maintaining her quality of life. Regarding the incorrect options: - Option A is incorrect because the concurrent use of steroids and sun exposure typically heightens the risk of skin damage, rather than lessening the drug's effectiveness. - Option B is incorrect as sunlight causing ulceration of skin lesions is not a primary concern in this scenario. - Option D is incorrect as the skin's increased sensitivity to burning, while a potential issue, is not the primary reason for advising Mrs. Post to avoid sun exposure in this case. By understanding the impact of sun exposure on specific conditions like rash and arthritis, Mrs. Post can take necessary precautions to manage her health effectively, demonstrating the importance of patient education in post-discharge care.
Question 5 of 5
Patients with a history of osteoporosis have an increased risk for
Correct Answer: D
Rationale: The correct answer is D) Fracture formation. Patients with a history of osteoporosis have an increased risk of fractures due to the weakened and porous nature of their bones. Osteoporosis is a condition characterized by low bone density and increased bone fragility, making individuals more susceptible to fractures, especially in weight-bearing bones like the hip, spine, and wrist. Option A) Infection in the bone is not directly related to osteoporosis. Osteomyelitis, or bone infection, is more commonly associated with factors such as trauma, surgery, or compromised immune function. Option B) Peripheral blood clot formation is not a typical risk associated with osteoporosis. Blood clot formation is more commonly linked to conditions like deep vein thrombosis or atherosclerosis. Option C) Painful joint inflammation is not a direct consequence of osteoporosis. Joint inflammation is more commonly seen in conditions like arthritis, which affect the synovial joints rather than the bone density itself. Educational Context: Understanding the complications associated with osteoporosis is crucial for healthcare professionals, especially those preparing for the NCLEX exam. Recognizing the increased risk of fractures in individuals with osteoporosis is essential for providing appropriate care and preventive measures to reduce the likelihood of bone injuries. This knowledge helps in promoting patient safety and quality of life for individuals with this condition.