NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?
Correct Answer: D
Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (
D) confirms the diagnosis via CSF analysis. CT (
A) may precede LP, blood cultures (
B) are supportive, and EMG (
C) is unrelated.
Question 2 of 5
The client is undergoing post-thrombolytic therapy for a stroke. The health-care provider has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump?
Correct Answer: 20 mL/hr
Rationale: Calculate: (1,000 units/hr ÷ 25,000 units) × 500 mL = 20 mL/hr. The pump should be set to 20 mL/hr.
Question 3 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 4 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.
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.
Question 5 of 5
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
Correct Answer: A
Rationale: In terminal ALS, passive ROM every 2 hours (
A) prevents contractures and maintains comfort. Negative nitrogen balance (
B) is undesirable, low-protein diets (
C) are not indicated, and coughing/deep breathing (
D) may be infeasible.