NCLEX Neurological Disorders

Extract:

Question 1 of 5

Which nursing action is priority for a client with a stroke experiencing unilateral neglect?

Correct Answer: D

Rationale: Teaching the client to scan the environment compensates for unilateral neglect, promoting safety and awareness.

Question 2 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.

Question 3 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.

Question 4 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 5 of 5

The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?

A. Social worker. B. Chaplain. C. Health-care provider. D. Occupational therapist.

Correct Answer: A

Rationale: A social worker (
A) can connect the family with community resources, financial aid, and support services. Chaplains (
B) address spiritual needs, providers (
C) focus on medical care, and occupational therapists (
D) address functional deficits.

NCLEX Neurological Disorders | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN