NCLEX-PN
NCLEX Neurological Disorders Questions
Extract:
Question 1 of 5
When implementing seizure precautions, which nursing action is most appropriate?
Correct Answer: C
Rationale: Maintaining the bed in the lowest position minimizes the risk of injury from falls during a seizure.
Question 2 of 5
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
Correct Answer: D
Rationale: Light-headedness and low BP (84/40) in T1 SCI suggest orthostatic hypotension or neurogenic shock. Lowering the HOB (
D) restores cerebral perfusion. Notifying the provider (
A) or increasing IV rate (
C) follows, and talking therapeutically (
B) does not address the urgent issue.
Question 3 of 5
The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client’s plan of care?
Correct Answer: D
Rationale: Brain tumors increase seizure risk, so seizure precautions (
D) are essential. Bedrest (
A) is unnecessary unless indicated, IV rate (
B) depends on status, and diet (
C) is not specific to intracranial regulation.
Question 4 of 5
The client, who has a deteriorating status after having a stroke, has a rectal temperature of 102.3°F (39.1°C). Which should be the nurse’s rationale for initiating interventions to bring the temperature to a normal level?
Correct Answer: D
Rationale: A normal temperature does not strengthen the immune system. Although hypothermia may increase the client’s chance for survival, the question is asking for the rationale for bringing the temperature to a normal level. Hyperthermia, not a normal temperature, is associated with lower scores on the Glasgow Coma Scale. The nurse should initiate temperature reduction measures because a temperature elevation in the client poststroke can cause an increase in the infarct size. This may be due to the increased oxygen demand with hyperthermia and peripheral vasodilation that decreases cerebral perfusion.
Question 5 of 5
When implementing seizure precautions, which nursing action is most appropriate?
Correct Answer: C
Rationale: Maintaining the bed in the lowest position minimizes the risk of injury from falls during a seizure.