NCLEX-PN
NCLEX Questions on Neurological Disorders Quizlet Questions
Extract:
Question 1 of 5
Which clinical findings would the nurse find on assessment in the brain-dead client? Select all that apply.
Correct Answer: D,E
Rationale: Absent corneal reflex and dilated nonreactive pupils are consistent with brain death, indicating loss of brainstem function.
Question 2 of 5
The client asks the nurse, 'What causes Creutzfeldt-Jakob disease?' Which statement would be the nurse's best response?
Correct Answer: A
Rationale: Creutzfeldt-Jakob disease is caused by prions (
A), infectious proteins. Mad cow (
B) is a variant but not the sole cause, and viral (
C) or fungal (
D) causes are incorrect.
Question 3 of 5
The chief executive officer (CEO) of a large manufacturing plant presents to the occupational health clinic with chronic rhinitis and requesting medication. On inspection, the nurse notices holes in the septum that separates the nasal passages. The nurse also notes dilated pupils and tachycardia. The facility has a 'No Drug' policy. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Nasal septal perforation, dilated pupils, and tachycardia suggest cocaine use. A drug screen (
A) objectively confirms substance use while maintaining confidentiality. Discussing drug use (
B) is premature, notifying the supervisor (
C) breaches confidentiality, and ignoring findings (
D) is unethical.
Question 4 of 5
The home-care nurse is counseling the client who has MS. The client is experiencing weakness, ataxia, intermittent adductor spasms of the hips, and occasional incontinence from loss of bladder sensation. Which self-care measures should the nurse recommend? Select all that apply.
Correct Answer: B,C,E
Rationale: Hot baths should be avoided; increasing the body temperature can exacerbate symptoms. Burns can occur with sensory loss associated with MS. A stretch—hold—relax routine is often helpful for relaxing the muscle and treating muscle spasms. Walking will help improve the gait, strengthen weakened muscles, and help relieve spasticity in the legs. If a muscle group is irreversibly affected by MS, other muscles can learn to compensate. A walker should be used for safety to help prevent falling. Widening the base of support increases walking stability, especially if ataxia (incoordination) is present; if feet are close together it increases the risk for a fall. Drinking fluids and then using an alarm to void 30 minutes later may be helpful in reducing incontinence from loss of bladder sensation.
Question 5 of 5
The nurse is caring for the client who has limited intake due to dysphagia following an ischemic stroke. Which serum laboratory result should the nurse review to verify that the client is dehydrated?
Correct Answer: B
Rationale: The serum creatinine is elevated with renal insufficiency or renal failure. The BUN is elevated when the client is dehydrated due to the lack of fluid volume to excrete waste products. The Hgb is decreased with blood loss or anemia from nutritional deficiencies, not with dehydration. A decreased prealbumin indicates a nutritional deficiency.