NCLEX-PN
Neurological Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
Correct Answer: A,C,D
Rationale: For a right-sided CVA, the left side is affected. Positioning to prevent shoulder adduction (
A) supports the weak left arm to prevent contractures. Encouraging movement of the affected side (
C) promotes neuroplasticity and recovery. Quadriceps exercises (
D) strengthen the affected leg. Turning every shift (
B) is too infrequent; every 2 hours is standard to prevent pressure ulcers. Instructing to hold fingers in a fist (E) risks contractures and is not therapeutic.
Question 2 of 5
The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client?
Correct Answer: A
Rationale: The goal for encephalitis is to maximize neurological recovery (
A), as inflammation may cause deficits. No memory loss (
B) is unrealistic, renal function (
C) is unrelated, and hydrocortisone cream (
D) is not indicated.
Question 3 of 5
The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (
C) are appropriate. Aspiration precautions (
A) are unrelated, Reach to Recovery (
B) supports breast cancer recovery, and mastectomy care (
D) is not relevant to brain metastases.
Question 4 of 5
The nurse is monitoring clients for development of a brain abscess. Which client would be the nurse’s lowest priority for monitoring for a brain abscess?
Correct Answer: B
Rationale: The client with endocarditis has an infective process within the body’s circulation and is at risk for septic emboli, which could progress to a brain abscess. The client who has idiopathic epilepsy has the lowest risk of developing a brain abscess because epilepsy from an unknown cause does not have the risk factors of an active infectious process or an impaired immune system. The client with the liver transplant is at risk for brain abscess because immunosuppressant medications depress the immune system. The client with meningitis has an infective process in close proximity to the brain and should be monitored for a brain abscess.
Question 5 of 5
The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (
D) are the priority. Isolation (
A) is unnecessary, antibiotics (
B) are ineffective for viral causes, and supine position (
C) may increase ICP.