NCLEX-RN
NCLEX RN Neurological Questions Questions
Extract:
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 1 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
Question 1 of 5
Which of the following assessment findings require immediate follow-up?
Correct Answer: A,B
Rationale: Altered mental status, fever, and tachycardia suggest a serious condition like meningitis, requiring immediate follow-up.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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