NCLEX-PN
NCLEX Questions on Neurological Disorders Quizlet Questions
Extract:
Question 1 of 5
The 80-year-old male client on an Alzheimer’s unit is agitated and asking the nurse to get his father to come and see tenor him. Which is the nurse’s best response?
Correct Answer: C
Rationale: In Alzheimer’s, agitation and confusion require validation. Talking about his father (
C) redirects and calms the client. Stating death (
A) may distress, calling (
B) reinforces delusion, and involving family (
D) is unnecessary.
Question 2 of 5
Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?
Correct Answer: B
Rationale: Purposeful movement (
B) indicates improved brain function compared to decorticate posturing. Flaccid paralysis (
A) or decerebrate posturing (
C) suggest worsening, and no movement (
D) is not an improvement.
Question 3 of 5
The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies.
Correct Answer: B
Rationale: A fever of 100.6°F (
B) in encephalitis may indicate worsening infection or inflammation, requiring immediate intervention. Decreased headache (
C) suggests improvement, and taste loss (
D) is less urgent. Facial palsies are noted but not an option.
Question 4 of 5
The nurse’s client with a T2 SCI is dysreflexic and has a BP of 170/90 mm Hg. Place the nurse’s interventions in the order that these should be performed.
Order the Items
Source Container
Correct Answer: C,A,B,G,F,E,D
Rationale: Elevate the HOB to 90 degrees. This initial quick action may help lower the client’s BP. Lower the end of the bed so feet are dependent. Placing the feet lower than the head will help decrease blood return and may help lower the BP. Remove elastic stocking and other constricting devices; assess below the level of injury. Anything constricting below the level of injury can be the stimulus that precipitates autonomic dysreflexia. The nurse can assess for other precipitating factors, such as a full bladder, while removing constricting devices. Retake the BP after being upright for 2 to 3 minutes. Elevating the HOB, lowering the feet, and removing constricting devices may have lowered the BP. If not, further interventions are needed. Administer a pm prescribed sublingual nifedipine for continued elevated BP. If the BP remains elevated, the prescribed antihypertensive medication, such as nifedipine (Procardia), should be given next to quickly lower the BP. Perform digital removal of impacted stool (last BM found to be 10 days ago). Digitally removing stool impaction may cause a further spike in BP, so that should be completed after the BP medication is administered. Inform the HCP of the incident, measures taken, and client response. This is last because a pro antihypertensive medication had already been prescribed. Care of the client is priority.
Question 5 of 5
The nurse is planning the care for a client diagnosed with Parkinson’s disease. Which would be a therapeutic goal of treatment for the disease process?
Correct Answer: D
Rationale: A therapeutic goal for Parkinson’s disease is to maximize functional ability, such as carrying out ADLs (
D). Akinesia (
A) is a symptom to minimize, medication adherence (
B) is a means to the goal, and family outings (
C) are less specific.