NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 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?
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 2 of 5
The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home?
Correct Answer: B
Rationale: Close contacts of meningococcal meningitis patients require antimicrobial chemoprophylaxis (
B), such as rifampin, to prevent infection. Vaccines (
A) are not for immediate prophylaxis, corticosteroids (
C) treat inflammation, and gamma globulin (
D) is not indicated.
Question 3 of 5
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
Correct Answer: A
Rationale: Reflecting the client’s feelings (
A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (
B), challenge the client inappropriately (
C), or assume solutions (
D).
Question 4 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?
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 5 of 5
An unconscious client has left-sided paralysis. Which intervention should the nurse implement to best prevent foot drop?
Correct Answer: D
Rationale: Pressure exerted on the soles of the feet when placed firmly against the footboard can impair circulation and lead to skin breakdown. Pillows provide inadequate support to prevent plantar flexion (foot drop). Performing ROM daily helps to maintain muscle tone, but it is inadequate to prevent plantar flexion when the client is in bed. Applying a foot boot brace provides good support to prevent foot drop. Removing and reapplying it every two hours allows for pressure reduction and promotes circulation.