NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client’s history of the injury should the nurse associate with the TBI? Select all that apply.
Correct Answer: C,D,E
Rationale: The client with mild TBI usually experiences symptoms commonly associated with mild concussion, such as vomiting. The client with mild TBI usually experiences amnesia and is unable to recall events regarding the accident. Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. Cognitive difficulties, including inability to concentrate and forgetfulness, occur with mild TBI. At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes.
Question 3 of 5
Which nursing intervention is best during the confusedness?
Correct Answer: D
Rationale: Reorienting the client to place and situation reduces confusion and promotes safety post-craniotomy.
Question 4 of 5
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
Question 5 of 5
The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor?
Correct Answer: B
Rationale: The classic triad for brain tumors is headache, vomiting, and papilledema (
B), due to increased ICP. Other options include unrelated or less specific symptoms.