NCLEX Neurological Disorders

Extract:

Question 1 of 5

Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply.

Correct Answer: A

Rationale: HOB at 30 degrees (
A) promotes venous drainage, reducing ICP. Clustering activities (
B) increases ICP, suctioning every 3 hours (
C) is excessive, enemas (
D) are irrelevant, and Trendelenburg (E) worsens ICP.

Question 2 of 5

The nurse observes a coworker acting erratically. The clients assigned to this coworker don’t seem to get relief when pain medications are administered. Which action should the nurse implement?

A. Try to help the coworker by confronting the coworker with the nurse’s suspicions. B. Tell the coworker that the nurse will give all narcotic medications from now on. C. Report the nurse’s suspicions to the nurse’s supervisor or the facility’s peer review. D. Do nothing until the nurse can prove the coworker has been using drugs.

Correct Answer: C

Rationale: Erratic behavior and ineffective pain relief suggest possible drug diversion. Reporting to the supervisor or peer review (
C) ensures proper investigation while protecting patients. Confronting (
A) may escalate, taking over medications (
B) doesn’t address the issue, and waiting for proof (
D) risks harm.

Question 3 of 5

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?

A. The elderly client who is experiencing a stroke in evolution. B. The client diagnosed with a transient ischemic attack 48 hours ago. C. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. D. The client with Alzheimer's disease who is wandering in the halls.

Correct Answer: A

Rationale: A stroke in evolution (
A) is an acute, progressing condition requiring experienced monitoring. TIA (
B) is stable, Guillain-Barré pain (
C) is manageable, and wandering (
D) needs supervision but is less acute.

Question 4 of 5

Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply.

A. Position the client with the head of the bed up 30 degrees. B. Cluster activities of care. C. Suction the client every three (3) hours. D. Administer soapsuds enemas until clear. E. Place the client in Trendelenburg position.

Correct Answer: A

Rationale: HOB at 30 degrees (
A) promotes venous drainage, reducing ICP. Clustering activities (
B) increases ICP, suctioning every 3 hours (
C) is excessive, enemas (
D) are irrelevant, and Trendelenburg (E) worsens ICP.

Question 5 of 5

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?

A. Notify the health-care provider immediately. B. Prepare to administer an antihistamine. C. Test the drainage for presence of glucose. D. Place a 2 x 2 gauze under the nose to collect drainage.

Correct Answer: C

Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (
C). This is the first step to guide further action. Notifying the provider (
A) follows confirmation, antihistamines (
B) are irrelevant, and gauze (
D) is a secondary measure.

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN