NCLEX Neurological Disorders

Extract:

Question 1 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.

Question 2 of 5

The nurse observes a coworker acting erratically. The clients assigned to this coworker don’t seem to get relief when pain medications are administered. Which action should the nurse implement?

A. Try to help the coworker by confronting the coworker with the nurse’s suspicions. B. Tell the coworker that the nurse will give all narcotic medications from now on. C. Report the nurse’s suspicions to the nurse’s supervisor or the facility’s peer review. D. Do nothing until the nurse can prove the coworker has been using drugs.

Correct Answer: C

Rationale: Erratic behavior and ineffective pain relief suggest possible drug diversion. Reporting to the supervisor or peer review (
C) ensures proper investigation while protecting patients. Confronting (
A) may escalate, taking over medications (
B) doesn’t address the issue, and waiting for proof (
D) risks harm.

Question 3 of 5

Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.

A. Calling out the client's name B. Padding the client's body during the seizure activity C. Placing an emesis basin close to the client's mouth D. Rolling the client's body to the side E. Removing environmental hazards to protect the client F. Calling the respiratory therapy department

Correct Answer: D,E

Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.

Question 4 of 5

Which response by the nurse would be best to prevent distress when the client repeatedly asks, 'Where is my mother?'

A. Explain to the client, 'Your mother died several years ago.' B. Tell the client, 'Your mother will visit later.' C. State, 'You miss your mother. What was she like?' D. Ask the client, 'When did you last see your mother?'

Correct Answer: C

Rationale: Redirecting the conversation to memories of the mother validates the client's feelings without causing distress from confronting reality.

Question 5 of 5

The nurse stops at the scene of a motor-vehicle accident and provides emergency first aid at the scene. Which law protects the nurse as a first responder?

A. The First Aid Law. B. Ombudsman Act. C. Good Samaritan Act. D. First Responder Law.

Correct Answer: C

Rationale: The Good Samaritan Act (
C) protects nurses providing emergency care from liability. First Aid Law (
A) and First Responder Law (
D) are not standard, and Ombudsman Act (
B) is unrelated.

NCLEX Neurological Disorders | Nurselytic

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NCLEX-PN

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