NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
If the drug is administered every 3 to 4 hours, which nursing action is most appropriate at this time in response to the client's statement?
Correct Answer: D
Rationale: Using a nondrug intervention like guided imagery is appropriate since it's too early for another dose, and it avoids escalating to opioids prematurely.
Question 2 of 5
After receiving report, the nurse working on the step-down neurological unit begins care for four clients. Prioritize the order in which the nurse should assess the four clients.
Order the Items
Source Container
Correct Answer: C,A,B,D
Rationale: The 24-year-old who had been unconscious at the scene of an MVA and is being admitted from the ED for observation. The nurse should assess the newly admitted client first to determine whether there are changes in level of consciousness and any early signs of increased ICP. The 78-year-old who underwent evacuation of a chronic subdural hematoma 24 hours earlier and is recovering. This client should be assessed next because the client is postoperative day 1, but stable. The 30-year-old who was diagnosed with viral meningitis 2 days earlier and wants to talk with the HCP. This client has a self-limiting condition and likely wants to be discharged; thus, he or she should be assessed third. The 40-year-old with Guillain-Barré who is currently receiving a third bedside plasmapheresis treatment being administered by another nurse. This client can be assessed last because another nurse is in the room with the client administering the plasmapheresis treatment.
Question 3 of 5
The nurse is teaching the client who is scheduled for an outpatient EEG. Which instruction should the nurse include?
Correct Answer: A
Rationale: In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Preparation includes clean hair without any objects in the hair to prevent inaccurate test results. The client should not be NPO since a usual glucose level is important for normal brain functioning. The scalp will not be shaved; the electrodes are applied with paste. There is no indication to have a serum glucose drawn before the test.
Question 4 of 5
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (
C). This is the first step to guide further action. Notifying the provider (
A) follows confirmation, antihistamines (
B) are irrelevant, and gauze (
D) is a secondary measure.
Question 5 of 5
Because the client with Parkinson's disease is prone to constipation, the nurse should encourage increased consumption of which food?
Correct Answer: A
Rationale: Fresh fruits are high in fiber, which helps alleviate constipation in clients with Parkinson's disease.