Questions 75

NCLEX-RN

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NCLEX RN Neurological Questions Questions

Extract:

The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 22-year-old female.
Item 1 of 1
History And Physical Orders
1114: A 22-year-old female client was with friends at a restaurant and reportedly started acting odd and then had uncontrollable and uncoordinated movements. This lasted three minutes. Once this terminated, EMS was called, and this occurred again and lasted four minutes. EMS administered lorazepam. The client does not have any medical history or take any medications. On exam, she did not recall the seizure, nor did she remember how she felt leading up to the seizure. She denied any drug use. She is drowsy following the administration of lorazepam but can sustain attention and is fully oriented. Glasgow Coma Scale 14. Will admit the client for observation.


Question 1 of 5

For each physician order, click to specify the appropriate nursing intervention: Magnetic Resonance Imaging (MRI) of the brain

Ensure the client has a negative pregnancy test prior to the exam
Assess if the client has claustrophobia prior to the exam
Have the client nothing by mouth (NPO) eight hours prior to the exam
Monitor the client's lung sounds for pulmonary edema
Establish continuous cardiac monitoring during the infusion
Insert an indwelling urinary catheter to monitor intake and output
Position the client side-lying with their knees to their chest

Correct Answer: A,B,E

Rationale: A negative pregnancy test is essential for female patients of childbearing age to avoid radiation risks to a fetus. Assessing for claustrophobia ensures patient comfort and safety during the MRI. Assessing for IV contrast dye allergy is necessary if contrast is used. Phenytoin can cause cardiac arrhythmias, so continuous cardiac monitoring is critical during infusion to detect and manage any adverse effects promptly. An EEG involves placing electrodes on the scalp, and instructing the client on how to remove adhesive post-test ensures proper care and comfort.

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Question 2 of 5

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