NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.
Question 2 of 5
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
Correct Answer: A
Rationale: Reflecting the client’s feelings (
A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (
B), challenge the client inappropriately (
C), or assume solutions (
D).
Question 3 of 5
When planning for the client's discharge after the diskectomy and spinal fusion, the nurse should include which instructions? Select all that apply.
Correct Answer: A,C,F
Rationale: Avoiding twisting, prolonged sitting, and monitoring for neurological changes (e.g., color changes) promote recovery and prevent complications.
Question 4 of 5
The home health nurse evaluates the foot care of the dark-skinned African client who has peripheral neuropathy. Which client actions in providing foot care are appropriate? Select all that apply.
Correct Answer: A,B,D
Rationale: Using a mirror allows for visual inspection of the bottom of the feet and between the toes for areas of skin breakdown. Keeping the skin adequately lubricated with lotion prevents drying and cracking. Lotion should not be applied between the toes because it increases moisture and the risk for infection. Clients should avoid going barefoot because this increases the risk for foot injury. Wearing appropriate clothing protects the skin from injury because sensation is diminished with peripheral neuropathy.
Toenails should be trimmed straight across to avoid damaging the tissue, which is slow to heal in the presence of peripheral neuropathy. In a dark-skinned client, areas of inflammation may appear purplish-blue or violet rather than appearing reddened (erythematous).
Question 5 of 5
The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply.
Correct Answer: A,D,E
Rationale: Stabilizing the cervical spine (
A) prevents spinal injury, Glasgow Coma Scale (
D) assesses neurological status, and IV access (E) prepares for interventions. Organ procurement (
B) is premature, high HOB (
C) risks perfusion, and checking for blood acceptance (F) is secondary.