NCLEX RN Exam Neurological Disorders

NCLEX RN Exam – Neurological Disorders

1) The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed?

• Semi-Fowler's position

2) The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures.

• A

3) A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply

• Pad the bed's side rails.• Place an airway at the bedside.• Place oxygen equipment at the bedside.• Place suction equipment at the bedside.

4) The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

• Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

5) The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?

• Head turned to the side

6) The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial

pressure (ICP) if the nurse observes the client doing which activity?• Exhaling during repositioning

7) The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?

• Separates into concentric rings and tests positive for glucose

8) The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?

• The health care provider reviews the x-ray results.

9) The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?

• Minor Headache

10) The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively?

• Head of bed elevated 30 to 45 degrees, head and neck midline

11) The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?

• Comparing the amount of prescribed weights with the amount in use

12) The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

• "I will drive only during the daytime."

13) The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?

• Severe, throbbing headache

14) The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

• Limiting bladder catheterization to once every 12 hours

15) The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take?

• Raise the head of the bed and remove the noxious stimulus.

16) The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply.

• Face the client when talking.• Speak slowly and maintain eye contact.• Use gestures when talking to enhance words.• Give the client directions using short phrases and simple terms.

17) The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending

paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room?

• Electrocardiographic monitoring electrodes and intubation tray

18) The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding should be an early indication that the level of consciousness (LOC) is deteriorating?

• Drowsiness

19) The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions?

• Maintaining the head of the bed at 15 degrees

20) The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated?

• Restrain the client's limbs.

21) The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client?

• Within the client's reach, on the left side

22) The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which?

• Remind the client to turn the head to scan the lost visual field.