NCLEX Neurological Disorders

Extract:

Question 1 of 5

The nurse stops at the scene of a motor-vehicle accident and provides emergency first aid at the scene. Which law protects the nurse as a first responder?

Correct Answer: C

Rationale: The Good Samaritan Act (
C) protects nurses providing emergency care from liability. First Aid Law (
A) and First Responder Law (
D) are not standard, and Ombudsman Act (
B) is unrelated.

Question 2 of 5

The nurse writes the nursing diagnosis 'altered body temperature related to damaged temperature regulating mechanism' for a client with a head injury. Which would be the most appropriate goal?

A. Administer acetaminophen (Tylenol) for elevated temperature. B. The client's temperature will remain less than 100°F. C. Maintain the hypothermia blanket at 99°F for 24 hours. D. The basal metabolic temperature will fluctuate no more than two (2) degrees.

Correct Answer: B

Rationale: The goal for altered body temperature is to maintain a normal range, such as less than 100°F (
B). Administering medication (
A) is an intervention, hypothermia blanket (
C) is specific, and basal fluctuation (
D) is vague.

Question 3 of 5

The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?

Your Answer:

Correct Answer: 4 gtts/min

Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.

Question 4 of 5

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?

A. Notify the health-care provider immediately. B. Prepare to administer an antihistamine. C. Test the drainage for presence of glucose. D. Place a 2 x 2 gauze under the nose to collect drainage.

Correct Answer: C

Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (
C). This is the first step to guide further action. Notifying the provider (
A) follows confirmation, antihistamines (
B) are irrelevant, and gauze (
D) is a secondary measure.

Question 5 of 5

The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?

A. The client complains of a headache at '3' to '4' on a 1-to-10 scale. B. The client has an intake of 1,000 mL and an output of 3,500 mL. C. The client complains of a raspy, sore throat. D. The client experiences dizziness when trying to get up too quickly.

Correct Answer: B

Rationale: Significant output (3,500 mL) compared to intake (1,000 mL,
B) suggests diabetes insipidus, a complication of craniotomy due to pituitary dysfunction. Mild headache (
A), sore throat (
C), and orthostatic dizziness (
D) are less concerning.

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN