NCLEX-PN
Neurological Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?
Correct Answer: B
Rationale: Autonomic dysreflexia in SCI causes severe headache (
B) due to hypertensive crisis from a trigger like bladder distention. Diaphoresis (
A) is secondary, motor loss (
C) is expected, and spasticity (
D) is chronic.
Question 2 of 5
Which measure for preventing impaired skin integrity is appropriate to add to the care plan at this time?
Correct Answer: B
Rationale: Changing position every 2 hours prevents pressure ulcers in clients with MS who have weakness and numbness.
Question 3 of 5
The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Irritation of the meninges causes nuchal rigidity (stiff neck). Irritation of the meninges causes severe headache. Pill-rolling tremors are associated with PD. Irritation of the meninges causes photophobia (light irritates the eyes). Lethargy, pathological state of sleepiness or unresponsiveness, indicates a decreased level of consciousness which is associated with meningitis.
Question 4 of 5
The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (
C) are appropriate. Aspiration precautions (
A) are unrelated, Reach to Recovery (
B) supports breast cancer recovery, and mastectomy care (
D) is not relevant to brain metastases.
Question 5 of 5
Which client behavior during a seizure requires immediate intervention?
Correct Answer: D
Rationale:
Tongue biting during a seizure can cause airway obstruction or severe injury, requiring immediate intervention to protect the airway.