Neurological NCLEX Questions practice exam solution

Neurological NCLEX Questions practice exam solution questions and answers solution 2021

• If a male client experienced a cerebrovascular accident (CVA) that damaged the

hypothalamus, the nurse would anticipate that the client has problems with:

• body temperature control.• balance and equilibrium.• visual acuity.• thinking and reasoning.

Rational:

The body’s thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury.Thinking and reasoning problems are the result of injury to the cerebrum.

• A female client admitted to an acute care facility after a car accident develops signs and

symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?• phenytoin (Dilantin) • mannitol (Osmitrol) • lidocaine (Xylocaine) • furosemide (Lasix)

Rational:

Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they’re administered parenterally, not endotracheally. Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn’t administered endotracheally.

• After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to

the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?• Give him a barbiturate.• Place him on mechanical ventilation.• Perform a lumbar puncture.• Elevate the head of his bed.

Rational:

The client’s history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn’t be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

• When obtaining the health history from a male client with retinal detachment, the nurse

expects the client to report:

• light flashes and floaters in front of the eye.• a recent driving accident while changing lanes.• headaches, nausea, and redness of the eyes.• frequent episodes of double vision.

Rational:

The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.

• Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

• Imbalanced nutrition: Less than body requirements

• Ineffective airway clearance • Impaired urinary elimination • Risk for injury

Rational:

In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren’t immediately life-threatening.

• To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the

nurse should:

• stay with the client and encourage him to eat.• help the client fill out his menu.• give the client privacy during meals.• fill out the menu for the client.

Rational:

Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer’s disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn’t ensure adequate nutritional intake.

• The nurse is performing a mental status examination on a male client diagnosed with subdural

hematoma. This test assesses which of the following?• Cerebellar function • Intellectual function • Cerebral function • Sensory function

Rational:

The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Intellectual functioning isn’t the only cerebral activity. Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Sensory function testing involves assessment of pain, light-touch sensation, and temperature discrimination.

• Shortly after admission to an acute care facility, a male client with a seizure disorder develops

status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?• In 30 to 45 seconds • In 10 to 15 minutes • In 30 to 45 minutes

• In 1 to 2 hours

Rational:

When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the client’s risk of complications associated with status epilepticus.

• A female client complains of periorbital aching, tearing, blurred vision, and photophobia in

her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?• Parasympathomimetic agent • Sympatholytic agent • Adrenergic blocker • Cholinergic blocker

Rational:

Atropine sulfate is a cholinergic blocker. It isn’t a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker.

• Emergency medical technicians transport a 27-year-old iron worker to the emergency

department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the highest priority?• Assessing the left leg • Assessing the pupils • Placing the client in Trendelenburg’s position • Assessing level of consciousness

Rational:

Answer A. In the scenario, airway and breathing are established so the nurse’s next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse