NCLEX Neurological Disorders
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Question 1 of 5.
The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique. The nurse correctly demonstrates quad coughing with which actions? Select all that apply.
A. Places a suction catheter in the client's oral cavity to stimulate the cough reflex
B. Puts hands on the upper abdomen, has client inhale, pushes upward during a cough
C. Cups the hands and percusses the client's anterior, lateral, and posterior lung fields
D. Hyperoxygenates the client by using a resuscitation bag to deliver 100% oxygen
E. Elevates the head of the bed to a high Fowler's position if the client is sitting in bed
Explanation: Stimulating a cough with a suction catheter is not associated with the quad cough technique, and it may cause regurgitation. The nurse's hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI. Cupping the hands and percussing the lung fields is a technique to loosen secretions but is not the quad coughing technique. Hyperoxygenating the client is a measure to prevent hypoxia associated with suctioning but is not included in the quad coughing technique. Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough.
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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