NCLEX-PN
Neurological Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (
C). Eyes turning with head movement (
A) indicates intact reflexes, EEG waveforms (
B) suggest brain activity, and decorticate posturing (
D) indicates some brain function.
Question 2 of 5
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
Correct Answer: B,C
Rationale: Stool softeners (
B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (
C) ensures adequate oxygenation. High HOB elevation (
A) may reduce cerebral perfusion, deep suction (
D) risks increasing ICP, and sedatives (E) may mask neurological changes.
Question 3 of 5
The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
Correct Answer: B
Rationale: Cognitive deficits post-TBI may limit complex tasks. Focusing for 10 minutes (
B) is a realistic short-term goal to build cognitive endurance. Returning to work (
A) may be unrealistic within 6 months, dressing independently (
C) requires motor and cognitive skills, and bowel/bladder control (
D) may be affected by physical deficits.
Question 4 of 5
The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.
Correct Answer: A,C,D
Rationale: Cervical SCI risks respiratory compromise and autonomic dysreflexia. Monitoring pulse oximetry (
A) ensures oxygenation, coughing/deep breathing (
C) prevents pneumonia, and assessing for autonomic dysreflexia (
D) detects dangerous BP spikes. Pureed foods (
B) are unnecessary without dysphagia, and corticosteroids (E) are not standard for acute SCI management.
Question 5 of 5
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
Correct Answer: B
Rationale: Skin integrity under a halo device is critical. Instructing to report reddened or irritated skin (
B) prevents pressure ulcers. Removing pins (
A) is done by providers, the vest liner can be changed (
C), and prolonged recliner use (
D) risks immobility complications.