NCLEX-PN
Neurological Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
When the nursing team discusses the client's plan of care, which has the highest priority?
Correct Answer: A
Rationale: Preventing skin breakdown is the highest priority to avoid complications like pressure ulcers in clients with spinal cord injuries.
Question 2 of 5
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
Correct Answer: B
Rationale: Skin integrity under a halo device is critical. Instructing to report reddened or irritated skin (
B) prevents pressure ulcers. Removing pins (
A) is done by providers, the vest liner can be changed (
C), and prolonged recliner use (
D) risks immobility complications.
Question 3 of 5
When the nursing team discusses the client's plan of care, which has the highest priority?
Correct Answer: A
Rationale: Preventing skin breakdown is the highest priority to avoid complications like pressure ulcers in clients with spinal cord injuries.
Question 4 of 5
Which assessment finding post-craniotomy requires immediate reporting to the physician?
Correct Answer: A
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a serious complication requiring immediate intervention.
Question 5 of 5
The nurse is caring for the client with an SCI at the level of the sixth cervical vertebra. Which findings support the nurse’s conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Blurred vision results from the hypertension occurring with autonomic dysreflexia. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS). Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR. Headache results from the hypertension occurring with autonomic dysreflexia. Sweating results from the sympathetic stimulation above the level of injury.