NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (
D) prevents injury from falling. Clearing furniture (
A) follows, placing on the side (
B) is done after the client is safe, and vital signs (
C) are assessed post-seizure.
Question 2 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 3 of 5
The nurse is admitting the client for rule-out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply.
Correct Answer: C
Rationale: Encephalitis is often viral, with herpes simplex virus (HSV-1,
C) a common cause, supporting the diagnosis. Recent immunizations (
A), colds (
B), travel (
D), and fungal exposure (E) are less directly linked to encephalitis.
Question 4 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 5 of 5
The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (
C). Bleeding (
A) describes subarachnoid hemorrhage, viral meningitis (
B) is aseptic, and mosquito-related inflammation (
D) refers to encephalitis.