Neurological Disorder NCLEX

Extract:

Question 1 of 5

Which intervention is most effective for managing autonomic dysreflexia in a client with a spinal cord injury?

Correct Answer: D

Rationale: Autonomic dysreflexia is often triggered by bladder distension; immediate catheterization relieves the stimulus.

Question 2 of 5

The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?

A. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78. B. The client complains of generalized body aches and pains. C. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA). D. The client becomes lethargic and is difficult to arouse using verbal stimuli.

Correct Answer: D

Rationale: Lethargy and difficulty arousing (
D) indicate neurological deterioration, requiring immediate intervention. Mild fever (
A), body aches (
B), and positive ELISA (
C) are expected.

Question 3 of 5

The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding?

A. A residual of 125 mL. B. The abdomen is soft. C. Three episodes of diarrhea. D. The potassium level is 3.4 mEq/L.

Correct Answer: A

Rationale: A gastric residual of 125 mL (
A) indicates delayed gastric emptying, requiring the feeding to be held to prevent aspiration. Soft abdomen (
B) is normal, diarrhea (
C) requires monitoring but not holding, and low potassium (
D) is unrelated.

Question 4 of 5

Which client statement indicates a need for further teaching about post-craniotomy care?

A. I'll avoid coughing forcefully.' B. I'll sleep with my head elevated.' C. I can lift heavy objects after a week.' D. I'll report severe headaches immediately.'

Correct Answer: C

Rationale: Lifting heavy objects post-craniotomy can increase intracranial pressure; clients should avoid this for several weeks.

Question 5 of 5

The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?

A. I will brush my teeth after every meal.' B. I will check my Dilantin level daily.' C. My urine will turn orange while on Dilantin.' D. I won’t have any seizures while on this medication.'

Correct Answer: A

Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene (
A) is essential and indicates understanding. Dilantin levels (
B) are checked periodically by providers, not daily. Urine color change (
C) is not typical, and seizures may still occur (
D) if not fully controlled.

Neurological Disorder NCLEX | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN