NCLEX-PN
NCLEX Questions on Neurological Disorders Quizlet Questions
Extract:
Question 1 of 5
Which nursing action is priority when caring for a client with suspected brain death?
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
Question 2 of 5
The client, who has type I DM, is scheduled for an MRI of the brain after an MVA. Which intervention should the nurse implement to prepare the client for the test?
Correct Answer: B
Rationale: Clients undergoing positron emission tomography (PET) scans are made NPO and have insulin held, but not those undergoing MRI. Clients are given earplugs to wear while undergoing the test because the machine makes a loud clanging noise that is unpleasant. Clients undergoing cerebral angiography, not MRI, must be on bedrest with the extremity used for injection straight for several hours after the test. Serum BUN and creatinine levels to assess renal function are required before CT scans or other tests involving contrast material to prevent renal complications.
Question 3 of 5
The nurse in the ED documents that the newly admitted client is 'postictal upon transfer.' What did the nurse observe?
Correct Answer: B
Rationale: Jaundice and icterus are terms for yellowing of the skin. The client had experienced a tonic-clonic seizure recently and is now in a state of deep relaxation and is breathing quietly. During this period the client may be unconscious or awaken gradually, but is often confused and disoriented. Often the client is amnesic regarding the seizure. Pruritus is a term for itching. Paresthesia is the term for abnormal sensations such as tingling and burning of the skin.
Question 4 of 5
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.
Question 5 of 5
The nurse assesses the client, who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem?
Correct Answer: B
Rationale: A complete spinal cord transection results in no reflexes or movement distal to the injury. With a C4 injury, the client initially would have some difficulty breathing due to edema of the spinal cord that occurs above the level of the injury. The client is experiencing spinal shock that manifests within a few hours after the injury. Hypotension, flaccid paralysis, and absence of muscle contractions occur. Spinal shock lasts 7 to 20 days, and the SCI cannot be classified accurately until spinal shock resolves. An injury of the upper motor neuron results in spastic paralysis. Quadriplegia, now termed tetraplegia, is paralysis involving all four extremities.