Neurological Disorder NCLEX

Extract:

Question 1 of 5

The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse that another client, Client B, has 'started using again.' Which action should the nurse implement?

Correct Answer: D

Rationale: Allegations of relapse require direct assessment. Contacting Client B (
D) allows the nurse to evaluate the situation respectfully. Discussing Client B with Client A (
A) or probing Client A (
B) breaches confidentiality, and informing the HCP (
C) is premature without verification.

Question 2 of 5

Which laboratory result is most concerning for a client with suspected meningitis?

A. Elevated white blood cell count B. Decreased glucose in cerebrospinal fluid C. Normal protein levels in cerebrospinal fluid D. Increased red blood cell count in blood

Correct Answer: B

Rationale: Decreased glucose in cerebrospinal fluid is a hallmark of bacterial meningitis, indicating infection and requiring urgent treatment.

Question 3 of 5

Which intervention should be added to the client's care plan in relation to this latest finding?

A. Have the client wear dark glasses when in bright light. B. Cover the client's affected eye with an eye patch. C. Approach the client from the unaffected side. D. Position food on the tray resembling the face of a clock.

Correct Answer: C

Rationale: Approaching from the unaffected side ensures the client with hemianopia can see the nurse, compensating for visual field loss.

Question 4 of 5

The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply.

A. Assess for deep vein thrombosis. B. Administer intravenous anticoagulant. C. Monitor intake and output strictly. D. Apply warm compresses to the eyes. E. Perform passive range-of-motion exercises.

Correct Answer: A,C,E

Rationale: Assessing DVT (
A), monitoring intake/output (
C), and passive ROM (E) prevent complications. Anticoagulants (
B) increase bleeding risk, and warm compresses (
D) are not indicated.

Question 5 of 5

The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?

A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull. B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body. C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse. D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.

Correct Answer: D

Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.

Neurological Disorder NCLEX | Nurselytic

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NCLEX-PN

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