Neurological Disorders NCLEX Questions
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Question 1 of 5.
When the nursing team plans the care of a client with Guillain-Barré syndrome, which assessment finding most accurately determines whether the client is developing ineffective breathing?
A. Respiratory rate is 24.
B. Skin is flushed.
C. Activity is decreased.
D. Pulse oximetry reading is 82%.
Explanation: A pulse oximetry reading of 82% indicates significant hypoxemia, suggesting ineffective breathing, which is a critical concern in Guillain-Barré syndrome due to potential respiratory muscle weakness.
Question 2 of 5.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
A. Position the client to prevent shoulder adduction.
B. Turn and reposition the client every shift.
C. Encourage the client to move the affected side.
D. Perform quadriceps exercises three (3) times a day.
E. Instruct the client to hold the fingers in a fist.
Explanation: For a right-sided CVA, the left side is affected. Positioning to prevent shoulder adduction (A) supports the weak left arm to prevent contractures. Encouraging movement of the affected side (C) promotes neuroplasticity and recovery. Quadriceps exercises (D) strengthen the affected leg. Turning every shift (B) is too infrequent; every 2 hours is standard to prevent pressure ulcers. Instructing to hold fingers in a fist (E) risks contractures and is not therapeutic.
Question 3 of 5.
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
A. Obtain a rubber mat to place under the dinner plate.
B. Purchase a long-handled bath sponge for showering.
C. Purchase clothes with Velcro closure devices.
D. Obtain a raised toilet seat for the client's bathroom.
Explanation: Generalized weakness post-stroke affects mobility and self-care. A long-handled bath sponge (B) aids bathing, Velcro clothes (C) simplify dressing, and a raised toilet seat (D) facilitates safe toileting. A rubber mat (A) is less relevant to generalized weakness.
Question 4 of 5.
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
A. Administer a stool softener bid.
B. Encourage the client to cough hourly.
C. Monitor neurological status every shift.
D. Maintain the dopamine drip to keep BP at 160/90.
Explanation: Post-craniotomy for subarachnoid hemorrhage, preventing increased intracranial pressure is critical. A stool softener (A) prevents straining, which could raise ICP. Coughing (B) increases ICP, neurological checks (C) should be more frequent (e.g., hourly), and dopamine to maintain high BP (D) risks re-bleeding.
Question 5 of 5.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
A. When the client's head is turned to the right, the eyes turn to the right.
B. The electroencephalogram (EEG) has identifiable waveforms.
C. No eye activity is observed when the cold caloric test is performed.
D. The client assumes decorticate posturing when painful stimuli are applied.
Explanation: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.