NCLEX Neurological Disorders

Extract:

Question 1 of 5

Which diagnostic test is used to confirm the diagnosis of Amyotrophic Lateral Sclerosis (ALS)?

Correct Answer: A

Rationale: EMG (
A) detects abnormal muscle electrical activity characteristic of ALS, confirming the diagnosis. Muscle biopsy (
B) is less specific, CK (
C) may be elevated but isn’t diagnostic, and pulmonary tests (
D) assess complications, not diagnosis.

Question 2 of 5

The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?

Your Answer:

Correct Answer: 4 gtts/min

Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.

Question 3 of 5

The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply.

A. Hemoglobin 9.5 g/dL and hematocrit is 31.8% B. Taking baclofen 15 mg 3 times per day C. Working 4 to 8 hours per week in the family business D. Stopped taking amitriptyline 8 weeks earlier E. Presence of a cardiac murmur at the tricuspid valve. F. Bilateral leg weakness noted when walking in room

Correct Answer: A,B,D,E,F

Rationale: The lower-than-normal Hgb and Hct indicate anemia. Inadequate cell oxygenation contributes to fatigue. Baclofen (Lioresal), a skeletal muscle relaxant used to relieve spasms, has the adverse effects of drowsiness and fatigue. Working 4 to 8 hours per week is a limited number of hours and should not contribute to the client’s fatigue. The client has stopped amitriptyline (Elavil), an antidepressant, and may be clinically depressed. Fatigue is a major symptom of depression. A tricuspid murmur indicates an incompetent cardiac valve, which will decrease the amount of oxygenated blood reaching the tissues. The increased energy expenditure with ambulation can increase fatigue.

Question 4 of 5

If the drug is administered every 3 to 4 hours, which nursing action is most appropriate at this time in response to the client's statement?

A. Administer another dose of the nonopioid analgesic immediately. B. Rearrange medication times so that the client receives pain medication hourly. C. Consult the physician about ordering an opioid analgesic. D. Use a nondrug intervention such as listening to a guided imagery tape.

Correct Answer: D

Rationale: Using a nondrug intervention like guided imagery is appropriate since it's too early for another dose, and it avoids escalating to opioids prematurely.

Question 5 of 5

The wife of the client diagnosed with chronic alcoholism tells the nurse, 'I have to call his work just about every Monday to let them know he is ill or he will lose his job.' Which would be the nurse’s best response?

A. I am sure that this must be hard for you. Tell me about your concerns.' B. You are afraid he will lose his source of income.' C. Why would you call in for your husband? Can’t he do this?' D. Are you aware that when you do this you are enabling him?'

Correct Answer: A

Rationale: Reflecting and inviting discussion (
A) validates the wife’s feelings and encourages therapeutic communication. Assuming fear (
B) is less open-ended, questioning her actions (
C) may seem judgmental, and labeling enabling (
D) could alienate her.

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN