NCLEX-PN
Neurological Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
Question 2 of 5
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (
C). Eyes turning with head movement (
A) indicates intact reflexes, EEG waveforms (
B) suggest brain activity, and decorticate posturing (
D) indicates some brain function.
Question 3 of 5
The nurse is caring for the client with an SCI at the level of the sixth cervical vertebra. Which findings support the nurse’s conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Blurred vision results from the hypertension occurring with autonomic dysreflexia. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS). Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR. Headache results from the hypertension occurring with autonomic dysreflexia. Sweating results from the sympathetic stimulation above the level of injury.
Question 4 of 5
The client is withdrawing from a heroin addiction. Which interventions should the nurse implement? Select all that apply.
Correct Answer: C
Rationale: Heroin withdrawal causes discomfort but not seizures, so seizure precautions (
A) are unnecessary. Vital signs every 8 hours (
B) is too infrequent; every 4 hours is standard. A quiet, calm atmosphere (
C) reduces stimulation. HIV testing (
D) requires consent but isn’t withdrawal-specific, and sterile needles (E) are inappropriate.
Question 5 of 5
Which client statement indicates a need for further teaching about meningitis precautions?
Correct Answer: C
Rationale: Sharing a water bottle can transmit meningitis, indicating a misunderstanding of droplet precaution protocols.