Prioritization, Delegation Assignment: Neurologic NCLEX questions

Prioritization, Delegation & Assignment: Neurologic NCLEX questions

ScienceMedicineNursing maci_mclain Save Neurological NCLEX Questions 55 terms marissaxxcarol Preview Prioritization NCLEX questions 28 terms madisoncastello Preview Chapter 11 - Prioritization, Delegatio...32 terms Brittany182Preview DANB 56 terms coy The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action?A.) Perform a complete neurologic assessment.B.) Assess the cranial nerve functions.C.) Contact the Rapid Response Team.D.) Reassess the client in 30 minutes.C.) Contact the Rapid Response Team.A change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or health care provider immediately. The nurse should also perform a focused assessment to determine if there are any other changes.

The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that apply.

1.)When did you first experience the headache symptoms?

2.)Who is the Mayor of Cleveland?

3.)What is your health care provider's name?

4.)What year and month is this?

5.)What is your parents' address?

6.) What is the name of this health care facility?

1,3,4,6

1.)When did you first experience the headache symptoms?

3.)What is your health care provider's name?

4.)What year and month is this?

6.) What is the name of this health care facility?After determining alertness in a client, the next step is to evaluate orientation. When the client's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the client from memorizing the answers.Responses that indicate orientation include the ability to answer questions about person, place, and time by asking for information such as the client's ability to relate the onset of symptoms, the name of his or her health care provider or nurse, the year and month, his or her address, and the name of the referring physician or health care agency. Asking about mayors' names or parents' address may be inappropriate to assess orientation.What is the priority nursing concern for a client experiencing a migraine headache?

1.)Pain 2.)Anxiety 3.)Hopelessness 4.)Risk for brain injury 1.)Pain The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other problems are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating.

The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply.

1.) Foods that contain tyramine, such as alcohol and aged cheese, should be avoided.

2.)Drugs such as nitroglycerin and nifedipine should be avoided.

3.)Abortive therapy is aimed at eliminating the pain during the aura.

4.) A potential side effect of medications is rebound headache.

5.)Complementary therapies such as biofeedback and relaxation may be helpful.

6.)Estrogen therapy should be continued as prescribed by the client's health care provider.

1,2,3,4,5

1.) Foods that contain tyramine, such as alcohol and aged cheese, should be avoided.

2.)Drugs such as nitroglycerin and nifedipine should be avoided.

3.)Abortive therapy is aimed at eliminating the pain during the aura.

4.) A potential side effect of medications is rebound headache.

5.)Complementary therapies such as biofeedback and relaxation may be helpful.Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate and should be included in the teaching plan.The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN?

1.) Completing the admission assessment 2.)Setting up oxygen and suction equipment 3.)Placing a padded tongue blade at the bedside 4.)Padding the side rails before the client arrives 2.)Setting up oxygen and suction equipment The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family.Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene?

1.)"You should avoid consumption of all forms of alcohol." 2.)"Wear your medical alert bracelet at all times." 3.)"Protect your loved one's airway during a seizure." 4.)"It's OK to take over-the-counter medications." 4.)"It's OK to take over-the-counter medications." A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families.A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene?A.) Helping the client ambulate to the bathroom and back to bed B.) Reminding the client not to look at his feet when he is walking C.) Performing the client's complete bathing and oral care D.) Setting up the client's tray and encouraging the client to feed himself C.) Performing the client's complete bathing and oral care Although all of these actions fall within the scope of practice for a UAP, the UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence.The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching?A.) "I will avoid exercise because the pain gets worse." B.) "I will use heat or ice to help control the pain." C.) "I will not wear high-heeled shoes at home or work." D.) "I will purchase a firm mattress to replace my old one." A.) "I will avoid exercise because the pain gets worse." Exercises are used to strengthen the back, relieve pressure on compressed nerves, and protect the back from reinjury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at all times.