NCLEX Neurological Disorders
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Question 1 of 5.
The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client's history of the injury should the nurse associate with the TBI? Select all that apply.
A. The client has had no episodes of vomiting after the accident.
B. The client remembers events before and right after the accident.
C. The client has had headache and dizziness daily since the accident.
D. The client has difficulty concentrating and focusing while at work.
E. The client lost consciousness momentarily at the time of the injury.
Explanation: The client with mild TBI usually experiences symptoms commonly associated with mild concussion, such as vomiting. The client with mild TBI usually experiences amnesia and is unable to recall events regarding the accident. Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. Cognitive difficulties, including inability to concentrate and forgetfulness, occur with mild TBI. At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes.
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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