NCLEX-PN
Neurological Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the client experiencing Guillain-Barré syndrome (GBS). It is most important for the nurse to monitor the client for which complication?
Correct Answer: D
Rationale: The client with SCI, not GBS, should be monitored for autonomic dysreflexia. The client who has bacterial meningitis should be monitored for septic emboli. Although the client with GBS should be monitored for cardiac dysrhythmias, it is most important to monitor for respiratory failure. It is most important for the nurse to monitor for respiratory failure. Ascending paralysis that occurs in GBS can affect the innervations of the muscles used in respiration, leading to respiratory failure.
Question 2 of 5
Which problem is the highest priority for the client diagnosed with West Nile virus?
Correct Answer: A
Rationale: Fever (alteration in body temperature,
A) is a primary symptom of West Nile virus, requiring priority management to prevent complications. Perfusion (
B), fluid excess (
C), and skin integrity (
D) are less immediate.
Question 3 of 5
The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.
Correct Answer: A,C,D
Rationale: Cervical SCI risks respiratory compromise and autonomic dysreflexia. Monitoring pulse oximetry (
A) ensures oxygenation, coughing/deep breathing (
C) prevents pneumonia, and assessing for autonomic dysreflexia (
D) detects dangerous BP spikes. Pureed foods (
B) are unnecessary without dysphagia, and corticosteroids (E) are not standard for acute SCI management.
Question 4 of 5
When changing the client's position postoperatively, which nursing action is best?
Correct Answer: B
Rationale: Logrolling maintains spinal alignment, preventing strain on the surgical site after diskectomy and spinal fusion.
Question 5 of 5
When documenting a seizure, which information is most important to include initially?
Correct Answer: A
Rationale: Documenting the time the seizure started is critical for tracking seizure patterns and guiding treatment.