NCLEX Questions on Neurological Disorders Quizlet
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Question 1 of 5.
The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
A. Examine pupil reactions to light.
B. Assess level of consciousness.
C. Observe for seizure activity.
D. Monitor vital signs every shift.
Explanation: Level of consciousness (B) is the first assessment for complications in encephalitis, indicating neurological status. Pupil reactions (A), seizures (C), and vital signs (D) follow.
Question 2 of 5.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document?
A. Hemiparesis of the client's left arm and apraxia.
B. Paralysis of the right side of the body and ataxia.
C. Homonymous hemianopsia and diplopia.
D. Impulsive behavior and hostility toward family.
Explanation: A left-sided CVA affects the right side of the body due to the brain's contralateral control. Paralysis or hemiparesis of the right side is a common manifestation, and ataxia (impaired coordination) may also occur. Hemiparesis of the left arm would indicate a right-sided CVA, visual deficits like homonymous hemianopsia are possible but less specific to motor loss, and behavioral changes are not directly related to motor deficits.
Question 3 of 5.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
A. The assistant places a gait belt around the client's waist prior to ambulating.
B. The assistant places the client on the back with the client's head to the side.
C. The assistant places a hand under the client's right axilla to move up in bed.
D. The assistant praises the client for attempting to perform ADLs independently.
Explanation: Placing a hand under the axilla (C) to move a client with right-sided paralysis risks shoulder subluxation or injury to the weak side. A gait belt (A) is appropriate for safe ambulation, positioning with head to the side (B) prevents aspiration, and praising independence (D) is therapeutic.
Question 4 of 5.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
A. A blood glucose level of 480 mg/dL.
B. A right-sided carotid bruit.
C. A blood pressure (BP) of 220/120 mm Hg.
D. The presence of bronchogenic carcinoma.
Explanation: Severe hypertension (BP 220/120 mm Hg, C) is a major risk factor for hemorrhagic stroke due to vessel rupture. High blood glucose (A) is more linked to ischemic stroke, a carotid bruit (B) indicates atherosclerosis, and bronchogenic carcinoma (D) is unrelated.
Question 5 of 5.
The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department?
A. A 4-cm area of bright red drainage on the dressing.
B. A weak pulse, shallow respirations, and cool pale skin.
C. Pupils that are equal, react to light, and accommodate.
D. Complaints of a headache that resolves with medication.
Explanation: Signs of shock (weak pulse, shallow respirations, cool pale skin, B) suggest internal bleeding or serious injury post-fall, warranting ED transfer. Minor drainage (A) is expected, normal pupils (C) are reassuring, and a resolving headache (D) is not urgent.