NCLEX RN Neurological Questions

NCLEX RN Neurological Questions Related

Review NCLEX RN Neurological Questions related questions and content

The following scenario applies to the next 1 items
The nurse cares for a 75-year-old client who arrives at the emergency department
Item 1 of 1
History And Physical
Vital Signs
1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45 minutes prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress: Condition

  • A. Transport the client for computed tomography (CT) scan
  • B. Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood glucose)
  • C. Complex Migraine
  • D. Severe Hypoglycemia
  • E. Cerebral Vascular Accident
  • F. Vital Signs
  • G. Glasgow Coma Scale (GCS)
Correct Answer: A,B,E,F,G

Rationale: Symptoms (facial droop, hemiparesis, aphasia) indicate a stroke (CVA). CT scan and lab work are critical for stroke diagnosis and thrombolytic eligibility. GCS and vital signs monitor neurological and hemodynamic status in stroke.

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The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?

  • A. Cocaine intoxication
  • B. Respiratory acidosis
  • C. Tonic-clonic seizures
  • D. Aggression
Correct Answer: B

Rationale: Midazolam, a benzodiazepine, can cause respiratory depression, which is dangerous in clients with respiratory acidosis. Tonic-clonic seizures are an indication for midazolam, while cocaine intoxication and aggression are less directly contraindicated.

The nurse is performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus?

  • A. Rubor of the feet and ankles when the leg is in the dependent position
  • B. Rapid, rhythmic muscle contractions
  • C. Popping or clicking of the knee joint with movement
  • D. Audible cracking and palpable grating with movement of the joints
Correct Answer: B

Rationale: Clonus is characterized by rapid, rhythmic muscle contractions, often seen in neurological disorders.

The nurse cares for geriatric clients. The nurse knows which of the following is the leading cause of cognitive impairment in old age?

  • A. Stroke
  • B. Malnutrition
  • C. Alzheimer's disease
  • D. Loss of cardiac reserve
Correct Answer: C

Rationale: Alzheimer's disease is the most common cause of cognitive impairment in the elderly.

The nurse observes a novice nurse caring for a client experiencing status epilepticus. Which action by the novice nurse requires immediate intervention?

  • A. Prepares to administer intravenous valproate.
  • B. Place the client in a lateral position.
  • C. Activates the rapid response team (RRT).
  • D. Loosens any restrictive clothing.
Correct Answer: A

Rationale: Valproate is not a first-line treatment for status epilepticus; benzodiazepines like lorazepam are preferred.

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 5 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.

For each physician order, click to specify the appropriate nursing intervention: Lumbar puncture

  • A. Assess the client for an allergy to contrast dye
  • B. Obtain laboratory work prior to the procedure
  • C. Position the client flat before the procedure
  • D. Monitor the client's temperature for efficacy
  • E. Place an incontinence pad under the client for increased urinary output
  • F. administer immediately after lumbar puncture
  • G. establish a patent vascular access device
Correct Answer: B,F,G

Rationale: Obtaining labs (e.g., coagulation studies) ensures safety before lumbar puncture. Ketorolac may help reduce fever; monitoring temperature assesses its efficacy. Ceftriaxone is administered post-lumbar puncture to treat confirmed or suspected bacterial meningitis. Padding the bed prevents injury during potential seizures.

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