ATI RN
Health Assessment Neurological System NCLEX Questions Questions
Question 1 of 5
Which type of seizure is most likely to cause death for the patient?
Correct Answer: D
Rationale: The correct answer is D) Tonic-clonic status epilepticus, which is the type of seizure most likely to cause death for the patient. Tonic-clonic status epilepticus is a prolonged seizure lasting more than five minutes or consecutive seizures without the person regaining consciousness. This condition can lead to hypoxia, brain damage, and even death if not promptly treated with antiepileptic medications. Option A) Subclinical seizures are not typically life-threatening as they do not present with visible motor symptoms and often go unnoticed without an EEG. Option B) Myoclonic seizures involve sudden, brief muscle jerks and are not usually associated with a high risk of mortality. Option C) Psychogenic seizures are seizures that are psychologically based and not due to abnormal electrical activity in the brain. While they can be distressing for the individual, they are not typically life-threatening. In an educational context, understanding the different types of seizures and their potential risks is crucial for healthcare professionals, especially nurses, who may encounter patients experiencing seizures in various clinical settings. Recognizing the signs and symptoms of tonic-clonic status epilepticus and knowing how to intervene promptly can be life-saving for patients with epilepsy. It is essential to have this knowledge to provide safe and effective care for individuals with seizure disorders.
Question 2 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 3 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 4 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 5 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.