16. A client has a neurological deficit involving the limbic system. Which assessment finding is specific to this type of deficit?
a) Is disoriented to person, place, and time
b) Affect is flat, with periods of emotional lability
c) Cannot recall what was eaten for breakfast today
d) Demonstrates inability to add and subtract; does not know who is the president of the United States
17. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client’s safety? Select all that apply.
a) Padding the side rails of the bed
b) Placing an airway at the bedside
c) Placing the bed in the high position
d) Putting a padded tongue blade at the head of the bed
e) Placing oxygen and suction equipment at the bedside
f) Having intravenous equipment ready for insertion of an intravenous catheter
c) Cannot recall what was eaten for breakfast today
d) Demonstrates inability to add and subtract; does not know who is the president of the United States
17. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client’s safety? Select all that apply.
a) Padding the side rails of the bed
b) Placing an airway at the bedside
c) Placing the bed in the high position
d) Putting a padded tongue blade at the head of the bed
e) Placing oxygen and suction equipment at the bedside
f) Having intravenous equipment ready for insertion of an intravenous catheter
18. Neurological Disorders NCLEX Questions about the nurse who is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?
a) A negative Kernig sign
b) Absence of nuchal rigidity
c) A positive Brudzinski sign
d) A Glasgow Coma Scale score of 15
19. The nurse has completed discharge instructions for a client with application of a halo device. Which action indicates that the client needs further clarification of the instructions?
a) Uses a straw for drinking.
b) Drives only during the daytime.
c) Uses caution because the device alters balance.
d) Washes the skin daily under the lamb’s wool liner of the vest.
20. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client’s room?
a) Nebulizer and pulse oximeter
b) Blood pressure cuff and flashlight
c) Flashlight and incentive spirometer
d) Electrocardiographic monitoring electrodes and intubation tray
a) A negative Kernig sign
b) Absence of nuchal rigidity
c) A positive Brudzinski sign
d) A Glasgow Coma Scale score of 15
19. The nurse has completed discharge instructions for a client with application of a halo device. Which action indicates that the client needs further clarification of the instructions?
a) Uses a straw for drinking.
b) Drives only during the daytime.
c) Uses caution because the device alters balance.
d) Washes the skin daily under the lamb’s wool liner of the vest.
20. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client’s room?
a) Nebulizer and pulse oximeter
b) Blood pressure cuff and flashlight
c) Flashlight and incentive spirometer
d) Electrocardiographic monitoring electrodes and intubation tray
Neurological Disorders NCLEX Questions
Answers and Rationale
16) B
- Rationale: The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.
- Test-Taking Strategy: Focus on the subject, neurological deficit of the limbic system. Recall that the limbic system is responsible for feelings and emotions to direct you to the correct option.
- Rationale: The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.
- Test-Taking Strategy: Focus on the subject, neurological deficit of the limbic system. Recall that the limbic system is responsible for feelings and emotions to direct you to the correct option.
17) A, B, E, F
- Neurological Disorders NCLEX Questions Rationale: Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client’s teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
- Test-Taking Strategy: Focus on the subject, seizure precautions. Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for placing the bed in the high position and using a tongue blade.
- Test-Taking Strategy: Focus on the subject, seizure precautions. Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for placing the bed in the high position and using a tongue blade.
18) C
- Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.
- Neurological Disorders NCLEX Questions Test-Taking Strategy: Focus on the subject, a client’s diagnosis of meningitis. You can eliminate options A, B, and D because they are comparable or alike and are normal findings.
- Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.
- Neurological Disorders NCLEX Questions Test-Taking Strategy: Focus on the subject, a client’s diagnosis of meningitis. You can eliminate options A, B, and D because they are comparable or alike and are normal findings.
19) B
- Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.
- Test-Taking Strategy: Note the strategic words needs further clarification. These words indicate a negative event query and ask you to select an option that is incorrect. Visualize this device to answer correctly. The inability to turn the head without turning the torso would contraindicate driving.
- Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.
- Test-Taking Strategy: Note the strategic words needs further clarification. These words indicate a negative event query and ask you to select an option that is incorrect. Visualize this device to answer correctly. The inability to turn the head without turning the torso would contraindicate driving.
20) D
- Rationale: The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.
- Test-Taking Strategy: Note the strategic words most essential. With an ascending paralysis, the client is at risk for involvement of respiratory muscles and subsequent respiratory failure. The correct option is the only one that includes an intubation tray, which would be needed if the client’s status deteriorated to needing intubation and mechanical ventilation. This option most directly addresses the airway.
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Neurological Disorders NCLEX Questions 21-25
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