NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
Correct Answer: D
Rationale: Light-headedness and low BP (84/40) in T1 SCI suggest orthostatic hypotension or neurogenic shock. Lowering the HOB (
D) restores cerebral perfusion. Notifying the provider (
A) or increasing IV rate (
C) follows, and talking therapeutically (
B) does not address the urgent issue.
Question 2 of 5
The client is in status epilepticus. Which interventions, if prescribed, should be included in this client's immediate treatment? Select all that apply.
Correct Answer: B,D,E
Rationale: Anticonvulsant medications such as phenytoin (Dilantin), and not anti-inflammatory medications such as dexamethasone (Decadron), are administered IV to control seizure activity. Status epilepticus is a medical emergency. The client is at risk for brain hypoxia and permanent brain damage. The client needs additional oxygen, and intubation will secure the airway. Defibrillation is treatment for ventricular fibrillation, a lethal heart dysrhythmia. Care is taken to protect the client from injury during the seizure. Either lorazepam (Ativan) or diazepam (Valium) is administered initially to terminate the seizure because they can be administered more rapidly than phenytoin.
Question 3 of 5
Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply.
Correct Answer: A,D,E
Rationale: Turning every 2 hours (
A) prevents pressure ulcers, assessing DVT (
D) addresses immobility risks, and monitoring elimination (E) ensures bowel/bladder function. Increased fluids (
B) depend on status, and supine positioning (
C) may increase ICP.
Question 4 of 5
Which intervention is most appropriate for a client diagnosed with Bell's palsy?
Correct Answer: B
Rationale: Drinking from a straw helps clients with Bell's palsy manage liquids, compensating for facial muscle weakness.
Question 5 of 5
The client comes to the clinic for treatment of a dog bite. Which intervention should the clinic nurse implement first?
Correct Answer: D
Rationale: Determining the animal’s vaccination status (
D) is the first step to assess rabies risk, guiding further interventions. Rabies injections (
A) are premature, animal control (
B) is secondary, and tetanus (
C) follows risk assessment.