NCLEX-PN
NCLEX Questions on Neurological Disorders Quizlet Questions
Extract:
Question 1 of 5
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.
Question 2 of 5
Which collaborative intervention should the nurse implement when caring for the client with West Nile virus?
Correct Answer: D
Rationale: IV fluids (
D) support hydration in West Nile virus while monitoring for overload prevents complications. Neurovascular exams (
A) are less relevant, intake/output (
B) is routine, and symptom assessment (
C) is nursing-driven.
Question 3 of 5
Which clinical findings would the nurse find on assessment in the brain-dead client? Select all that apply.
Correct Answer: D,E
Rationale: Absent corneal reflex and dilated nonreactive pupils are consistent with brain death, indicating loss of brainstem function.
Question 4 of 5
The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department?
Correct Answer: B
Rationale: Signs of shock (weak pulse, shallow respirations, cool pale skin,
B) suggest internal bleeding or serious injury post-fall, warranting ED transfer. Minor drainage (
A) is expected, normal pupils (
C) are reassuring, and a resolving headache (
D) is not urgent.
Question 5 of 5
The nurse assesses the client, who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem?
Correct Answer: B
Rationale: A complete spinal cord transection results in no reflexes or movement distal to the injury. With a C4 injury, the client initially would have some difficulty breathing due to edema of the spinal cord that occurs above the level of the injury. The client is experiencing spinal shock that manifests within a few hours after the injury. Hypotension, flaccid paralysis, and absence of muscle contractions occur. Spinal shock lasts 7 to 20 days, and the SCI cannot be classified accurately until spinal shock resolves. An injury of the upper motor neuron results in spastic paralysis. Quadriplegia, now termed tetraplegia, is paralysis involving all four extremities.