NCLEX-RN
NCLEX RN Questions on Neurological Disorders Questions
Extract:
The following scenario applies to the next 1 items
The nurse in the clinic is caring for a 46-year-old female
Item 1 of 1
Nurses' Notes
0855: Client was brought to the clinic by her husband, who reports that she has been falling frequently, having difficulty remembering things, and numbness and tingling in the lower extremities. Onset was 2 weeks ago, with the falling and memory impairment worsening over the past week. The client was hospitalized 3 weeks ago because she ran out of medication, and her atrial fibrillation was giving her 'palpitations and shortness of breath.' Since refilling her medication, she has had no palpitations, chest discomfort, or dyspnea. The client's husband reports that he is worried about his wife's drinking because it has increased from three beers a day to five or six. She reports that her last drink was four days ago. On assessment, the client is alert and oriented to person, place, and time. Some speech latency was noted in her response. Her gait is unsteady, and had to be assisted to the examination room. Pupils are equal, round, and reactive to light with nystagmus. Skin is warm to touch and a normal color for ethnicity. Breathing is unlabored, and lung sounds are clear bilaterally. She reports occasional nonproductive cough. Bowel sounds present in all four quadrants. Peripheral pulses 2+ and irregular. Vital signs: T 97°F (36°C), P 72, RR 14, BP 136/78, pulse oximetry reading 97% on room air. Denies any pain, but reports tingling in her lower extremities.
Question 1 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress: Condition
| Start a peripheral vascular access device |
| Wernicke encephalopathy |
| Transient ischemic attack |
| Alcohol withdrawal |
| Obtain a prescription for thiamine |
| Lower extremity paresthesias |
| Gait |
Correct Answer: A,B,E,F,G
Rationale: Wernicke encephalopathy is likely due to memory impairment, ataxia, and nystagmus in the context of alcohol use. Thiamine is critical for Wernicke encephalopathy, and IV access facilitates its administration. Monitoring gait and level of consciousness assesses improvement in Wernicke encephalopathy.
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