NCLEX Neurological Disorders
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Question 1 of 5.
The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply.
A. Hemoglobin 9.5 g/dL and hematocrit is 31.8%
B. Taking baclofen 15 mg 3 times per day
C. Working 4 to 8 hours per week in the family business
D. Stopped taking amitriptyline 8 weeks earlier
E. Presence of a cardiac murmur at the tricuspid valve.
F. Bilateral leg weakness noted when walking in room
Explanation: The lower-than-normal Hgb and Hct indicate anemia. Inadequate cell oxygenation contributes to fatigue. Baclofen (Lioresal), a skeletal muscle relaxant used to relieve spasms, has the adverse effects of drowsiness and fatigue. Working 4 to 8 hours per week is a limited number of hours and should not contribute to the client's fatigue. The client has stopped amitriptyline (Elavil), an antidepressant, and may be clinically depressed. Fatigue is a major symptom of depression. A tricuspid murmur indicates an incompetent cardiac valve, which will decrease the amount of oxygenated blood reaching the tissues. The increased energy expenditure with ambulation can increase fatigue.
Question 2 of 5.
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for a STAT computed tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consult.
Explanation: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.
Question 3 of 5.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
A. Observe the client swallowing for possible aspiration.
B. Position the client in a semi-Fowler's position when sleeping.
C. Place a suction setup at the client's bedside during meals.
D. Refer the client to an occupational therapist for evaluation.
Explanation: Agnosia is the inability to recognize objects, people, or sounds, impacting functional abilities. Referring to an occupational therapist (D) is appropriate to assess and develop strategies for managing agnosia. Swallowing issues (A, C) are related to dysphagia, not agnosia, and semi-Fowler's position (B) is not specific to agnosia management.
Question 4 of 5.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
A. Potential for injury.
B. Powerlessness.
C. Disturbed thought processes.
D. Sexual dysfunction.
Explanation: Expressive aphasia impairs the ability to communicate, leading to frustration and feelings of powerlessness (B). Injury (A) is physical, disturbed thought processes (C) relate to cognition, and sexual dysfunction (D) is not directly linked to aphasia.
Question 5 of 5.
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?
A. Awaken the client every two (2) hours.
B. Monitor for increased intracranial pressure (ICP).
C. Observe frequently for hypervigilance.
D. Offer the client food every three (3) to four (4) hours.
Explanation: For a mild concussion, monitoring for worsening neurological status is key. Awakening every 2 hours (A) allows assessment for altered consciousness. Monitoring ICP (B) is complex and not feasible at home, hypervigilance (C) is not typical, and frequent feeding (D) is unnecessary.
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