NCLEX Neurological Disorders

Extract:

Question 1 of 5

The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?

Correct Answer: A

Rationale: Reflecting the client’s feelings (
A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (
B), challenge the client inappropriately (
C), or assume solutions (
D).

Question 2 of 5

Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.

A. Calling out the client's name B. Padding the client's body during the seizure activity C. Placing an emesis basin close to the client's mouth D. Rolling the client's body to the side E. Removing environmental hazards to protect the client F. Calling the respiratory therapy department

Correct Answer: D,E

Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.

Question 3 of 5

Which finding in a brain-dead client confirms the diagnosis?

A. Presence of gag reflex B. Apnea during an apnea test C. Reactive pupils D. Spontaneous limb movement

Correct Answer: B

Rationale: Apnea during an apnea test (no spontaneous breathing) is a key criterion for confirming brain death.

Question 4 of 5

The nurse writes the nursing diagnosis 'altered body temperature related to damaged temperature regulating mechanism' for a client with a head injury. Which would be the most appropriate goal?

A. Administer acetaminophen (Tylenol) for elevated temperature. B. The client's temperature will remain less than 100°F. C. Maintain the hypothermia blanket at 99°F for 24 hours. D. The basal metabolic temperature will fluctuate no more than two (2) degrees.

Correct Answer: B

Rationale: The goal for altered body temperature is to maintain a normal range, such as less than 100°F (
B). Administering medication (
A) is an intervention, hypothermia blanket (
C) is specific, and basal fluctuation (
D) is vague.

Question 5 of 5

The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?

A. This must be very hard for you. You’re feeling worthless?' B. You shouldn’t feel worthless—you are still alive.' C. Why do you feel worthless? You still have the use of your arms.' D. If you attended a work rehab program you wouldn’t feel worthless.'

Correct Answer: A

Rationale: Reflecting the client’s feelings (
A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (
B), challenge the client inappropriately (
C), or assume solutions (
D).

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN