Neurological Disorder NCLEX
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Question 1 of 5.
The nurse is caring for the client who has severe craniocerebral trauma. Which finding indicates that the client is developing DI?
A. Blood glucose level at 230 mg/dL
B. Urinary output 1500 mL over 4 hours
C. Urine specific gravity at 1.042
D. Somnolent when previously alert
Explanation: Elevated glucose levels are not associated with DI. The lack of ADH that occurs in DI results in excreting a large amount of pale, dilute urine. The urine of clients with DI is very dilute and therefore has a very low, not high, specific gravity. Decrease in level of consciousness is not directly associated with DI but rather with craniocerebral swelling or bleeding from the trauma.
Question 2 of 5.
Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
A. A 55-year-old African American male.
B. An 84-year-old Japanese female.
C. A 67-year-old Caucasian male.
D. A 39-year-old pregnant female.
Explanation: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.
Question 3 of 5.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
A. An oral anticoagulant medication.
B. A beta blocker medication.
C. An anti-hyperuricemic medication.
D. A thrombolytic medication.
Explanation: A TIA in a client with atrial fibrillation is likely due to cardioembolic stroke risk. Oral anticoagulants (A), such as warfarin or direct oral anticoagulants, are prescribed to prevent clot formation. Beta blockers (B) control heart rate, anti-hyperuricemics (C) treat gout, and thrombolytics (D) are used acutely, not for discharge prevention.
Question 4 of 5.
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
A. Administer a nonnarcotic analgesic.
B. Prepare for STAT magnetic resonance imaging (MRI).
C. Start an intravenous infusion with D5W at 100 mL/hr.
D. Complete a neurological assessment.
Explanation: A severe headache in a stroke patient may indicate complications like hemorrhagic transformation or increased intracranial pressure. A neurological assessment (D) is the first step to evaluate the cause and guide further actions. Analgesics (A) may mask symptoms, MRI (B) requires assessment first, and IV fluids (C) are not urgent.
Question 5 of 5.
The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?
A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours.
B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.
D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
Explanation: A GCS score of 6 (C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (A) is standard for concussion, left-sided weakness (B) is concerning but less acute, and expressive aphasia (D) is stable.
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