NCLEX Neurological Disorders

Extract:

Question 1 of 5

The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?

Correct Answer: 4 gtts/min

Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.

Question 2 of 5

Which nursing action is priority for a client with a stroke experiencing unilateral neglect?

A. Place objects on the unaffected side. B. Encourage bilateral arm exercises. C. Provide a mirror for self-awareness. D. Teach the client to scan the environment.

Correct Answer: D

Rationale: Teaching the client to scan the environment compensates for unilateral neglect, promoting safety and awareness.

Question 3 of 5

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?

A. Observe the client swallowing for possible aspiration. B. Position the client in a semi-Fowler's position when sleeping. C. Place a suction setup at the client's bedside during meals. D. Refer the client to an occupational therapist for evaluation.

Correct Answer: D

Rationale: Agnosia is the inability to recognize objects, people, or sounds, impacting functional abilities. Referring to an occupational therapist (
D) is appropriate to assess and develop strategies for managing agnosia. Swallowing issues (A,
C) are related to dysphagia, not agnosia, and semi-Fowler’s position (
B) is not specific to agnosia management.

Question 4 of 5

The client with PD has a new surgically implanted DBS. After the stimulator is operational, which criterion should the nurse use to evaluate that the DBS is effective?

A. The client has cogwheel rigidity when moving the upper extremities. B. The client has a decrease in the frequency and severity of tremors. C. The client has less facial pain and converses with more facial expression. D. The client no longer experiences auras or a severe frontal headache.

Correct Answer: B

Rationale: Cogwheel rigidity, a symptom of PD, is interrupted muscular movement and is not treated with the DBS. DBS is a treatment used for intractable tremors associated with PD. The electrical current interferes with the brain cells initiating the tremors. Severe facial pain is associated with trigeminal neuralgia, not PD rau. The DBS will not affect facial expression. Auras are unusual sensations experienced before a seizure occurs and are not associated with PD.

Question 5 of 5

The experienced nurse is instructing the new nurse on subarachnoid hemorrhage. The nurse evaluates that the new nurse understands the information when the new nurse makes which statements? Select all that apply.

A. “Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm.” B. “Subarachnoid hemorrhage occurs during sleep and is noticed when the client awakens.” C. “The client experiencing a subarachnoid hemorrhage may state having a severe headache.” D. “Tissue plasminogen activator (tPA) should be given to treat a subarachnoid hemorrhage.” E. “A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody.”

Correct Answer: A,C,E

Rationale: A subarachnoid hemorrhage is usually caused by rupture of a cerebral aneurysm. Ischemic stroke in older adults, not a subarachnoid hemorrhage, often occurs during sleep when circulation and BP decrease. Irritation of the meninges from bleeding into the subarachnoid spaces causes a severe headache. Thrombolytic therapy with tPA lyses clots and is contraindicated in subarachnoid hemorrhage. Bleeding into the subarachnoid space will cause the CSF to be bloody.

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN