NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
Correct Answer: C
Rationale: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.
Question 2 of 5
The wife of the client diagnosed with chronic alcoholism tells the nurse, 'I have to call his work just about every Monday to let them know he is ill or he will lose his job.' Which would be the nurse’s best response?
Correct Answer: A
Rationale: Reflecting and inviting discussion (
A) validates the wife’s feelings and encourages therapeutic communication. Assuming fear (
B) is less open-ended, questioning her actions (
C) may seem judgmental, and labeling enabling (
D) could alienate her.
Question 3 of 5
If the diagnosis is accurate, which assessment findings should the nurse document? Select all that apply.
Correct Answer: A,B,F
Rationale: Meningitis commonly presents with photophobia, stiff neck (nuchal rigidity), and fever due to inflammation of the meninges. Muscle weakness, diarrhea, and vertigo are not typically associated with meningitis.
Question 4 of 5
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
Correct Answer: B
Rationale: Expressive aphasia impairs the ability to communicate, leading to frustration and feelings of powerlessness (
B). Injury (
A) is physical, disturbed thought processes (
C) relate to cognition, and sexual dysfunction (
D) is not directly linked to aphasia.
Question 5 of 5
Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.