Neurological Disorder NCLEX

Extract:

Question 1 of 5

The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.

Correct Answer: A,C

Rationale: Referring to the Huntington’s Disease Society (
A) provides support and resources. Discussing coping with messiness (
C) addresses chorea-related coordination issues. Football padding (
B) is inappropriate, meal restrictions (
D) are unnecessary, and chest percussion (E) is unrelated.

Question 2 of 5

The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, 'Why not try chemotherapy first? It has helped my other tumors.' The nurse’s response is based on which scientific rationale?

A. Chemotherapy is only used as a last resort in caring for clients with brain tumors. B. The blood-brain barrier prevents medications from reaching the brain. C. Radiation therapy will have fewer side effects than chemotherapy. D. Metastatic tumors become resistant to chemotherapy and it becomes useless.

Correct Answer: B

Rationale: The blood-brain barrier (
B) limits chemotherapy penetration into the brain, making radiation more effective for brain metastases. Chemotherapy is used in some cases (
A), radiation side effects vary (
C), and resistance (
D) is not universally true.

Question 3 of 5

The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client’s condition is becoming worse?

A. The client has purposeful movement with painful stimuli. B. The client has assumed adduction of the upper extremities. C. The client is aimlessly thrashing in the bed. D. The client has become flaccid and does not respond to stimuli.

Correct Answer: D

Rationale: Flaccid paralysis and unresponsiveness (
D) indicate severe brain dysfunction or progression to brain death, worse than decorticate posturing. Purposeful movement (
A) or thrashing (
C) suggest improvement, and adduction (
B) is not a standard indicator.

Question 4 of 5

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?

A. Purposeless movement in response to painful stimuli. B. Flaccid paralysis in all four extremities. C. Decerebrate posturing when painful stimuli are applied. D. Pupils that are 6 mm in size and nonreactive on painful stimuli.

Correct Answer: A

Rationale: Purposeless movement (
A) indicates a higher level of brain function compared to decorticate posturing, suggesting improvement. Flaccid paralysis (
B) or decerebrate posturing (
C) indicates worsening, and nonreactive pupils (
D) suggest severe brain damage.

Question 5 of 5

The client has right homonymous hemianopia following an ischemic stroke. The nurse asks the NA to help the client with meals knowing that this problem may result in which client response?

A. Tendency to fall to the contralateral side B. Eating food on only half of the plate C. Using the silverware inappropriately D. Choking when swallowing any liquids

Correct Answer: B

Rationale: Tendency to fall to the contralateral side would be a concern if the client were weak or paralyzed. Homonymous hemianopia (hemianopsia) is a visual field abnormality that results in blindness in half of the visual field in the same side of both eyes. It results from damage to the optic tract or occipital lobe. Using the silverware inappropriately is a concern if the client has agnosia. Choking when swallowing any liquids is a concern if the client has dysphagia.

Neurological Disorder NCLEX | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN