NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique. The nurse correctly demonstrates quad coughing with which actions? Select all that apply.
Correct Answer: B,E
Rationale: Stimulating a cough with a suction catheter is not associated with the quad cough technique, and it may cause regurgitation. The nurse’s hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI. Cupping the hands and percussing the lung fields is a technique to loosen secretions but is not the quad coughing technique. Hyperoxygenating the client is a measure to prevent hypoxia associated with suctioning but is not included in the quad coughing technique. Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough.
Question 2 of 5
The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
Correct Answer: D
Rationale: Masklike facies and shuffling gait (
D) are hallmark signs of Parkinson’s due to bradykinesia and rigidity. Crackles and JVD (
A) suggest heart failure, weakness and ptosis (
B) indicate myasthenia gravis, and exaggerated arm swinging (
C) is opposite to Parkinson’s.
Question 3 of 5
Because the client with Parkinson's disease is prone to constipation, the nurse should encourage increased consumption of which food?
Correct Answer: A
Rationale: Fresh fruits are high in fiber, which helps alleviate constipation in clients with Parkinson's disease.
Question 4 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 5 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.