Neurological Disorder NCLEX

Extract:

Question 1 of 5

The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?

Correct Answer: B

Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (
B) prevent thromboembolism. Oxygen (
A) is unnecessary without respiratory issues, active ROM (
C) is not feasible due to paralysis, and speech therapy (
D) is irrelevant.

Question 2 of 5

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?

A. Purposeless movement in response to painful stimuli. B. Flaccid paralysis in all four extremities. C. Decerebrate posturing when painful stimuli are applied. D. Pupils that are 6 mm in size and nonreactive on painful stimuli.

Correct Answer: A

Rationale: Purposeless movement (
A) indicates a higher level of brain function compared to decorticate posturing, suggesting improvement. Flaccid paralysis (
B) or decerebrate posturing (
C) indicates worsening, and nonreactive pupils (
D) suggest severe brain damage.

Question 3 of 5

The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?

A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

Correct Answer: C

Rationale: A GCS score of 6 (
C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (
A) is standard for concussion, left-sided weakness (
B) is concerning but less acute, and expressive aphasia (
D) is stable.

Question 4 of 5

Which instruction should be the nurse's priority in this situation?

A. Steps to enhance the client's immune system B. Importance of maintaining a balanced diet C. Techniques to improve the client's safety D. Importance of social interactions

Correct Answer: C

Rationale: Safety is the priority for clients with Parkinson's disease due to risks of falls and injury from motor symptoms.

Question 5 of 5

The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, 'Why not try chemotherapy first? It has helped my other tumors.' The nurse’s response is based on which scientific rationale?

A. Chemotherapy is only used as a last resort in caring for clients with brain tumors. B. The blood-brain barrier prevents medications from reaching the brain. C. Radiation therapy will have fewer side effects than chemotherapy. D. Metastatic tumors become resistant to chemotherapy and it becomes useless.

Correct Answer: B

Rationale: The blood-brain barrier (
B) limits chemotherapy penetration into the brain, making radiation more effective for brain metastases. Chemotherapy is used in some cases (
A), radiation side effects vary (
C), and resistance (
D) is not universally true.

Neurological Disorder NCLEX | Nurselytic

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