NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
The client, who has a deteriorating status after having a stroke, has a rectal temperature of 102.3°F (39.1°C). Which should be the nurse’s rationale for initiating interventions to bring the temperature to a normal level?
Correct Answer: D
Rationale: A normal temperature does not strengthen the immune system. Although hypothermia may increase the client’s chance for survival, the question is asking for the rationale for bringing the temperature to a normal level. Hyperthermia, not a normal temperature, is associated with lower scores on the Glasgow Coma Scale. The nurse should initiate temperature reduction measures because a temperature elevation in the client poststroke can cause an increase in the infarct size. This may be due to the increased oxygen demand with hyperthermia and peripheral vasodilation that decreases cerebral perfusion.
Question 2 of 5
The friend of an 18-year-old male client brings the client to the emergency department (ED). The client is unconscious and his breathing is slow and shallow. Which action should the nurse implement first?
Correct Answer: C
Rationale: Slow, shallow breathing in an unconscious client indicates respiratory depression, a life-threatening condition. Calling for a ventilator (
C) ensures immediate airway support. Asking about drugs (
A), starting an IV (
B), and applying oxygen (
D) follow airway management.
Question 3 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 4 of 5
The client diagnosed with Parkinson’s disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data?
Correct Answer: B
Rationale: Difficulty swallowing and immobility (
B) in PD increase aspiration risk, leading to pneumonia, which presents as fever and lung infiltrates. Other manifestations are less directly related to pulmonary complications.
Question 5 of 5
The client with PD has a new surgically implanted DBS. After the stimulator is operational, which criterion should the nurse use to evaluate that the DBS is effective?
Correct Answer: B
Rationale: Cogwheel rigidity, a symptom of PD, is interrupted muscular movement and is not treated with the DBS. DBS is a treatment used for intractable tremors associated with PD. The electrical current interferes with the brain cells initiating the tremors. Severe facial pain is associated with trigeminal neuralgia, not PD rau. The DBS will not affect facial expression. Auras are unusual sensations experienced before a seizure occurs and are not associated with PD.