NCLEX Neurological Disorders

Extract:

Question 1 of 5

Which method is most appropriate to provide adequate nutrition for the client at this time?

Correct Answer: B

Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-BarrÃ© syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.

Question 2 of 5

When planning for the client's discharge after the diskectomy and spinal fusion, the nurse should include which instructions? Select all that apply.

A. Avoid twisting or jerking the back. B. Wear a soft back brace at all times. C. Avoid sitting for long periods during the first week. D. Bend from the waist when picking up items from the floor. E. Monitor urine output for the first week. F. Report lower extremity color changes to the physician.

Correct Answer: A,C,F

Rationale: Avoiding twisting, prolonged sitting, and monitoring for neurological changes (e.g., color changes) promote recovery and prevent complications.

Question 3 of 5

The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?

A. A computed tomography (CT). B. Blood cultures times two (2). C. Electromyogram (EMG). D. Lumbar puncture (LP).

Correct Answer: D

Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (
D) confirms the diagnosis via CSF analysis. CT (
A) may precede LP, blood cultures (
B) are supportive, and EMG (
C) is unrelated.

Question 4 of 5

If the diagnosis is accurate, which assessment findings should the nurse document? Select all that apply.

A. Photophobia B. A stiff neck C. Muscle weakness D. Diarrhea E. Vertigo F. Fever

Correct Answer: A,B,F

Rationale: Meningitis commonly presents with photophobia, stiff neck (nuchal rigidity), and fever due to inflammation of the meninges. Muscle weakness, diarrhea, and vertigo are not typically associated with meningitis.

Question 5 of 5

Which response by the nurse would be best to prevent distress when the client repeatedly asks, 'Where is my mother?'

A. Explain to the client, 'Your mother died several years ago.' B. Tell the client, 'Your mother will visit later.' C. State, 'You miss your mother. What was she like?' D. Ask the client, 'When did you last see your mother?'

Correct Answer: C

Rationale: Redirecting the conversation to memories of the mother validates the client's feelings without causing distress from confronting reality.

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN