NCLEX-PN
Neurological Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
Which assessment finding is most important to consider before developing the client's care plan?
Correct Answer: A
Rationale: The ability to perform ADLs determines the level of assistance needed, guiding the care plan for a client with Parkinson's disease.
Question 2 of 5
The nurse is monitoring clients for development of a brain abscess. Which client would be the nurse’s lowest priority for monitoring for a brain abscess?
Correct Answer: B
Rationale: The client with endocarditis has an infective process within the body’s circulation and is at risk for septic emboli, which could progress to a brain abscess. The client who has idiopathic epilepsy has the lowest risk of developing a brain abscess because epilepsy from an unknown cause does not have the risk factors of an active infectious process or an impaired immune system. The client with the liver transplant is at risk for brain abscess because immunosuppressant medications depress the immune system. The client with meningitis has an infective process in close proximity to the brain and should be monitored for a brain abscess.
Question 3 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 4 of 5
During the immediate postoperative assessment, the nurse notices the dressing is moist. Which action is most appropriate to take first?
Correct Answer: B
Rationale: Reinforcing the dressing controls minor drainage and maintains sterility while further assessment is conducted.
Question 5 of 5
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (
C). Eyes turning with head movement (
A) indicates intact reflexes, EEG waveforms (
B) suggest brain activity, and decorticate posturing (
D) indicates some brain function.