NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
The client is brought to the emergency department by the police for public disorderliness. The client reports feeling no pain and is unconcerned that the police have arrested him. The nurse notes the client has epistaxis and nasal congestion. Which substance should the nurse suspect the client has abused?
Correct Answer: D
Rationale: Cocaine (
D) causes epistaxis, nasal congestion, and euphoria with pain insensitivity. Marijuana (
A), heroin (
B), and ecstasy (
C) do not typically cause these nasal symptoms.
Question 2 of 5
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (
D) prevents injury from falling. Clearing furniture (
A) follows, placing on the side (
B) is done after the client is safe, and vital signs (
C) are assessed post-seizure.
Question 3 of 5
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
Correct Answer: D
Rationale: Light-headedness and low BP (84/40) in T1 SCI suggest orthostatic hypotension or neurogenic shock. Lowering the HOB (
D) restores cerebral perfusion. Notifying the provider (
A) or increasing IV rate (
C) follows, and talking therapeutically (
B) does not address the urgent issue.
Question 4 of 5
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (
C). This is the first step to guide further action. Notifying the provider (
A) follows confirmation, antihistamines (
B) are irrelevant, and gauze (
D) is a secondary measure.
Question 5 of 5
For a client with Guillain-Barré syndrome, which complication should the nurse monitor most closely?
Correct Answer: B
Rationale: Deep vein thrombosis is a significant risk in Guillain-Barré syndrome due to immobility from muscle weakness.