NCLEX-PN
NCLEX Questions on Neurological Disorders Quizlet Questions
Extract:
Question 1 of 5
The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated?
Correct Answer: A
Rationale: If untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death. ICP compresses structures within the cranium and leads to a decrease in cerebral perfusion, not increased perfusion. ICP compresses structures within the cranium and leads to acidosis; the pH level is decreased in acidosis. Leakage of CSF could occur if there were an opening in the subarachnoid space that could occur with trauma, but there is no indication that the increased ICP is due to trauma.
Question 2 of 5
The home-care nurse is counseling the client who has MS. The client is experiencing weakness, ataxia, intermittent adductor spasms of the hips, and occasional incontinence from loss of bladder sensation. Which self-care measures should the nurse recommend? Select all that apply.
Correct Answer: B,C,E
Rationale: Hot baths should be avoided; increasing the body temperature can exacerbate symptoms. Burns can occur with sensory loss associated with MS. A stretch—hold—relax routine is often helpful for relaxing the muscle and treating muscle spasms. Walking will help improve the gait, strengthen weakened muscles, and help relieve spasticity in the legs. If a muscle group is irreversibly affected by MS, other muscles can learn to compensate. A walker should be used for safety to help prevent falling. Widening the base of support increases walking stability, especially if ataxia (incoordination) is present; if feet are close together it increases the risk for a fall. Drinking fluids and then using an alarm to void 30 minutes later may be helpful in reducing incontinence from loss of bladder sensation.
Question 3 of 5
When preparing the client for an EEG, which nursing action is most appropriate?
Correct Answer: C
Rationale: Shampooing the client's hair ensures a clean scalp, improving electrode contact for an accurate EEG.
Question 4 of 5
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
Correct Answer: D
Rationale: In trauma with potential head or neck injury, stabilizing the cervical spine (
D) is the first priority to prevent spinal cord injury during movement. Assessing consciousness (
A), organizing removal (
B), or performing a full assessment (
C) follows.
Question 5 of 5
The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (
A) detects cardiovascular changes, and a calm atmosphere (
C) reduces stimulation. Verbalizing reasons (
B) is psychosocial, and bedrest/low-sodium diet (
D) is not indicated.