NCLEX Neurological Disorders

Extract:

Question 1 of 5

The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first?

Correct Answer: B

Rationale: Dyspnea in ALS indicates respiratory distress. Administering oxygen (
B) addresses hypoxia immediately. Elevating HOB (
A), assessing lung sounds (
C), and pulse oximetry (
D) follow to support respiratory status.

Question 2 of 5

Which client statement indicates understanding of trigeminal neuralgia management?

A. I'll apply heat to my face for pain relief.' B. I'll avoid chewing on the affected side.' C. I'll use a hard toothbrush for oral hygiene.' D. I'll wash my face with cold water.'

Correct Answer: B

Rationale: Avoiding chewing on the affected side reduces pain triggers in trigeminal neuralgia.

Question 3 of 5

The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home?

A. The Haemophilus influenzae vaccine. B. Antimicrobial chemoprophylaxis. C. A 10-day dose pack of corticosteroids. D. A gamma globulin injection.

Correct Answer: B

Rationale: Close contacts of meningococcal meningitis patients require antimicrobial chemoprophylaxis (
B), such as rifampin, to prevent infection. Vaccines (
A) are not for immediate prophylaxis, corticosteroids (
C) treat inflammation, and gamma globulin (
D) is not indicated.

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.

A. “Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm.” B. “Subarachnoid hemorrhage occurs during sleep and is noticed when the client awakens.” C. “The client experiencing a subarachnoid hemorrhage may state having a severe headache.” D. “Tissue plasminogen activator (tPA) should be given to treat a subarachnoid hemorrhage.” E. “A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody.”

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, 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?

A. A normal temperature will strengthen the client’s immune system. B. A hypothermic state may increase the client’s chance of survival. C. A normal temperature will decrease the Glasgow Coma Scale score. D. Hyperthermia increases the likelihood of a larger area of brain infarct.

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.

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN