Nervous System: NCLEX Nursing Questions On Neurological Disorders
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- 1.
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
- A.
Is clear and tests negative for glucose
- B.
Is grossly bloody in appearance and has a pH of 6
- C.
Clumps together on the dressing and has a pH of 7
- D.
Separates into concentric rings and test positive of glucose
Correct Answer
D. Separates into concentric rings and test positive of glucoseExplanation
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material. called a halo sign. The fluid also tests positive for glucose.Rate this question:
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- 2.
A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
- A.
Strict adherence to a bowel retraining program
- B.
Keeping the linen wrinkle-free under the client
- C.
Preventing unnecessary pressure on the lower limbs
- D.
Limiting bladder catheterization to once every 12 hours
Correct Answer
D. Limiting bladder catheterization to once every 12 hoursExplanation
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every four (4) to six (6) hours. and foley catheters should be checked frequently to prevent kinks in the tubing. Other causes include stimulation of the skin from tactile. thermal. or painful stimuli. The nurse administers care to minimize risk in these areas.Option A: Constipation and fecal impaction are other causes. so maintaining bowel regularity is important.Rate this question:
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- 3.
The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated?
- A.
Loosening restrictive clothing
- B.
Restraining the client’s limbs
- C.
Removing the pillow and raising padded side rails
- D.
Positioning the client to side. if possible. with the head flexed forward
Correct Answer
B. Restraining the client’s limbsExplanation
The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins. the nurse lowers the client to the floor. if possible. protects the head from injury. and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.Options A. C. and D: Nursing actions during a seizure include providing for privacy. loosening restrictive clothing. removing the pillow and raising side rails in the bed. and placing the client on one side with the head flexed forward. if possible. to allow the tongue to fall forward and facilitate drainage.Rate this question:
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- 4.
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:
- A.
The client has complete bilateral paralysis of the arms and legs.
- B.
The client has weakness on the right side of the body. including the face and tongue.
- C.
The client has lost the ability to move the right arm but can walk independently.
- D.
The client has lost the ability to move the right arm but can walk independently.
Correct Answer
B. The client has weakness on the right side of the body. including the face and tongue.Explanation
Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue. arm. and leg on one side. Complete bilateral paralysis does not occur in this condition.Options C and D: The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding. bathing. and ambulating.Rate this question:
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- 5.
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated. the nurse avoids doing which of the following?
- A.
Giving the client thin liquids
- B.
Thickening liquids to the consistency of oatmeal
- C.
Placing food on the unaffected side of the mouth
- D.
Allowing plenty of time for chewing and swallowing
Correct Answer
A. Giving the client thin liquidsExplanation
Before the client with dysphagia is started on a diet. the gag and swallow reflexes must have returned.Option B: Liquids are thickened to avoid aspiration.Option C: Food is placed on the unaffected side of the mouth.Option D: The client is assisted with meals as needed and is given ample time to chew and swallow.Rate this question:
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- 6.
The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:
- A.
Gets angry with family if they interrupt a task
- B.
Experiences bouts of depression and irritability
- C.
Has difficulty with using modified feeding utensils
- D.
Consistently uses adaptive equipment in dressing self
Correct Answer
D. Consistently uses adaptive equipment in dressing selfExplanation
Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations. use the assistance of others. and have appropriate social interactions.Options A. B. and C are not adaptive behaviors.Rate this question:
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- 7.
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client?
- A.
Speaking to the client at a slower rate
- B.
Allowing plenty of time for the client to respond
- C.
Completing the sentences that the client cannot finish
- D.
Looking directly at the client during attempts at speech
Correct Answer
C. Completing the sentences that the client cannot finishExplanation
Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. The nurse would avoid shouting (because the client is not deaf). appearing rushed for a response. and letting family members provide all the responses for the client.Options A. B. and D: General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time. listening to and watching attempts to communicate. and trying to put the client at ease with a caring and understanding manner.Rate this question:
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- 8.
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
- A.
Getting too little exercise
- B.
Taking excess medication
- C.
Omitting doses of medication
- D.
Increasing intake of fatty foods
Correct Answer
C. Omitting doses of medicationExplanation
Myasthenic crisis often is caused by under medication and responds to the administration of cholinergic medications. such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Option B: Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Options A and D: Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger.Options A and D: Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger a myasthenic crisis.Option B: Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications.Rate this question:
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- 9.
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:
- A.
Eating large. well-balanced meals
- B.
Doing muscle-strengthening exercises
- C.
Doing all chores early in the day while less fatigued
- D.
Taking medications on time to maintain therapeutic blood levels
Correct Answer
D. Taking medications on time to maintain therapeutic blood levelsExplanation
Taking medications correctly to maintain blood levels that are not too low or too high is important.Option A: Overeating is a cause of exacerbation of symptoms. as is exposure to heat. crowds. erratic sleep habits. and emotional stress.Option B: Muscle-strengthening exercises are not helpful and can fatigue the client.Option C: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength.Rate this question:
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- 10.
A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:
- A.
Unknown. but possibly includes ischemia. viral infection. or an autoimmune problem
- B.
Unknown. but possibly includes long-term tissue malnutrition and cellular hypoxia
- C.
Primary genetic in origin. triggered by exposure to meningitis
- D.
Primarily genetic in origin. triggered by exposure to neurotoxins
Correct Answer
A. Unknown. but possibly includes ischemia. viral infection. or an autoimmune problemExplanation
Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown but may include vascular ischemia. infection. exposure to viruses such as herpes zoster or herpes simplex. autoimmune disease. or a combination of these factors.Rate this question:
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