NCLEX-PN
Neurological Disorder NCLEX Questions
Extract:
Question 1 of 5
The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Informed consent (
A) is required, emptying the bladder (
B) ensures comfort, side-lying with back arched (
C) facilitates needle insertion, and explaining the procedure (E) reduces anxiety. Rapid breathing (
D) is not advised.
Question 2 of 5
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene (
A) is essential and indicates understanding. Dilantin levels (
B) are checked periodically by providers, not daily. Urine color change (
C) is not typical, and seizures may still occur (
D) if not fully controlled.
Question 3 of 5
The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering?
Correct Answer: A
Rationale: Delirium tremens requires thiamine (vitamin B1, not B6) to prevent Wernicke’s encephalopathy and benzodiazepines like Librium (
A) to manage withdrawal symptoms. Other options are unrelated to delirium tremens management.
Question 4 of 5
The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest 'Lou Gehrig’s' disease. Which is the nurse’s most appropriate response?
Correct Answer: B
Rationale: There is no information that the client is working too much. Telling the client to avoid thinking the worst belittles the client’s concern. This is the most appropriate response because it focuses on the client’s concern, encourages verbalization, and solicits more information. ALS (Lou Gehrig’s disease) is a degenerative disease that affects the motor system and does not have a dementia component; thus, a question about memory is inappropriate. This response does not take the client seriously and does not address the client’s concern.
Question 5 of 5
The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan?
Correct Answer: C
Rationale: Neither traction nor weights are part of the halo device. The halo external fixation device includes a vest that is worn continuously and should not be removed. The neurosurgeon will discontinue it when the injury has stabilized and sufficient healing has occurred. A halo external fixation device is a static device that consists of a “halo” that is screwed into the skull by four pins. It is attached to a vest that the client wears. The device provides immobilization and stability to the spinal cord while healing occurs with or without surgical intervention. Care includes inspection and cleansing of the pin sites. The nurse should not tighten the pins. These are secured in the skull to maintain alignment of the cervical vertebrae. If loose, the nurse should contact the HCP for tightening.