Engaging with a diverse set of NCLEX RN Practice Questions exposes students to a variety of client populations and healthcare settings.
NCLEX Neurological Questions - NCLEX Questions on Neurological
Neurological NCLEX Practice Questions
Question 1.
A patient with a fracture at C6 is admitted to the trauma intensive care unit. When assessing for neurogenic shock, which of the following would the nurse expect to find?
(a) Hyperactive reflexes below C6
(b) Involuntary spastic movement of extremities
(c) Hypotension, bradycardia, warm and pink extremities
(d) Lack of sensation and movement below C6
Answer:
(c) Hypotension, bradycardia, warm and pink extremities
Explanation:
Shock is a life-threatening condition in which there is not enough blood flow through the body. Neurogenic shock is caused by the sudden loss of sympathetic nervous system signals that normally maintain muscle tone in blood vessel walls.
The blood vessels become relaxed and dilated, causing blood to pool in the venous system and general drop in blood pressure. Spinal cord injury is damage that occurs from trauma that affects strength and sensation as well as body function below where the injury occurs. Neurogenic shock is manifested by bradycardia, hypotension, and vasodilation with warm skin.
Rationale:
(a) is incorrect because hyperactive reflexes will not be present during this stage following spinal cord injury. Reflexes below the level of the injury will be decreased or absent.
(b) is incorrect because involuntary spastic movement will not necessarily be present during this stage following spinal cord injury, and this is not related to neurogenic shock.
(d) is incorrect because although lack of sensation and movement occur with spinal cord injury, this is not descriptive of the expected nursing assessment related to neurogenic shock.
Question 2.
The nurse admits a 33-year-old male patient after a motor vehicle accident with injury to the spinal cord that left him with paraplegia and a neurogenic spastic bladder. Which intervention should the nurse include when caring for this patient?
(a) Teach Crede method
(b) Teach self-catheterization
(c) After void, catheterize for residual
(d) Assist to the toilet every two hours
Answer:
(b) Notify the healthcare provider for parenteral antibiotics
Explanation:
Spinal cord injury is damage that occurs from trauma that affects strength and sensation as well as body function below where the injury occurs. The patient has a spastic bladder which responds to overstretching with emptying, so intermittent self-catheterization is appropriate to teach this patient to prevent incontinence. This is a clean process which should be done at regular intervals, every four to six hours, removing 350-400 mL or urine each time.
Rationale:
(a) is incorrect because the Crede method is the manual expression of urine from the bladder and is not safe for long-term use in paralyzed patients, especially men. (The Crede method is recommended for flaccid bladder, not neurogenic spastic bladder.)
(c) is incorrect because catheterization after voiding will not prevent incontinence.
(d) is incorrect because assisting to the toilet every two hours will not help a bladder that does not empty.
Question 3.
The nurse cares for a female patient admitted to the trauma unit 10 days ago with a T2 spinal cord injury from a fall off a horse. The patient tells the nurse, “I want to be transferred to a facility where the staff are more knowledgeable.” What is the best action by the nurse?
(a) Inform the patient that derogatory communication towards the staff is not tolerated.
(b) Request that the patient participate in creating plan of care
(c) Continue to provide care and reassure the patient she is receiving the best care possible
(d) Inform the patient that all nursing staff are evaluated for competency
Answer:
(b) Request that the patient participate in creating plan of care
Explanation:
Spinal cord injury is damage that occurs from trauma that affects strength and sensation as well as body function below where the injury occurs. The patient is experiencing the anger phase in the grief process, as demonstrated by the behavior. The nurse should involve the patient in the plan of care and continue the dialogue to allow the patient to express her feelings.
Rationale:
(a) is incorrect because this is non-therapeutic. The nurse should recognize the patient’s feelings as a normal part of the grieving process and allow the patient to express anger.
(c) is incorrect because this action dismisses the patient’s comments. This can lead to worsened anger and feelings of helplessness. The nurse is responsible for empowering the patient to participate in her care.
(d) is incorrect because this is a form of defensive communication, which is non-therapeutic. Informing the patient about staff competence is not helpful and does not address the feelings of anger.
Question 4.
The nurse is caring for a patient with paraplegia at the T4 level due to a history of a motor vehicle accident. Which of the following interventions should the nurse perform to prevent autonomic dysreflexia in this patient?
(a) Support high-protein diet
(b) Discuss sexuality and fertility options
(c) Plan a bowel program
(d) Teach quad coughing
Answer:
(c) Plan a bowel program
Explanation:
Autonomic dysreflexia (also known as autonomic hyperreflexia) occurs in patients with spinal cord injury above T6. Symptoms include uncontrolled hypertension, pounding headache, profuse sweating, nasal congestion, and bradycardia. If untreated, autonomic dysreflexia can lead to seizures, pulmonary edema, myocardial infarction, hemorrhage, and death. A routine bowel program can help prevent fecal impaction, which is the primary
cause of autonomic dysreflexia. Other causes include bladder distention, unrelieved pain, or tactile stimulation (clothing too tight, wrinkles in linens).
Rationale:
(a) is incorrect because a high-protein diet will promote healing but will not prevent autonomic dysreflexia.
(b) is incorrect because discussion of sexuality and fertility options is important for the spinal injury patient, but it is unrelated to autonomic dysreflexia.
(d) is incorrect because coughing will not prevent autonomic dysreflexia. Quad coughing is assisted coughing to help spinal cord injury patients cough with enough force to expectorate secretions.
Question 5.
A 35-year-old patient has been transferred home from a rehabilitation facility after spinal cord injury. When the home health nurse visits, the spouse is noted to be performing many tasks for the patient that were self-managed in rehabilitation. What is the most appropriate intervention by the nurse?
(a) Remind the patient that independence is important for daily activities
(b) Inform the spouse of the importance of allowing the patient to perform independently
(c) Develop a care plan for increased independence with the patient and spouse
(d) Affirm the importance of the spouse’s involvement and encourage the spouse to continue assistance with care
Answer:
(c) Develop a care plan for increased independence with the patient and spouse
Explanation:
Spinal cord injury impairs an individual’s sensation, movement, and function below the level of the injury. Spinal cord injury affects both the patient and the family members and often leads to a grieving process over the loss of function and independent lifestyle. The optimal care plan includes both the patient and the spouse.
Rationale:
(a) is incorrect because reminding the patient about independence will not necessarily change the spouse’s behavior.
(b) is incorrect because involving care partners in assisting with care is important. The nurse must empower the patient to be independent, but also to recognize the spouse’s need to help.
(d) is incorrect because this does not promote any independence for the patient and can lead to dependency.
Question 6.
The nurse admits a 35-year-old patient to the neurological unit with a C5 spinal cord injury 12 hours ago. Which of the following nursing interventions is priority for this patient?
(a) Teach the patient about the use of assistive feeding devices
(b) Respiratory assessment
(c) Application of compression devices to lower extremities
(d) Methylprednisolone infusion administration
Answer:
(b) Respiratory assessment
Explanation:
A spinal cord injury at the level of C5 may initially impair the respiratory system due to edema of the spinal cord. Edema surrounding the spinal cord injury could lead to damage at the C4 level and above, so respiratory assessment is priority.
Rationale:
(a) is incorrect because respiratory monitoring and support is more important 12 hours after the injury. Once stabilized, the C5 injury patient will likely have some bicep control, neck movement, and partial shoulder strength. The patient will be able to power an electric wheelchair and use assistive feeding devices, depending on stability of the respiratory system.
(c) is incorrect because compression devices are important to promote circulation and prevent clot formation, but this is not a higher priority than respiratory assessment.
(d) is incorrect because methylprednisolone is no longer recommended for spinal cord injury treatment.
Question 7.
The nurse admits a patient with a history of spinal cord injury at level T3 for sacral ulcers. The patient tells the nurse that they have a headache and feels they may vomit. What is the first action the nurse should take?
(a) Check for fecal impaction
(b) Administer prescribed analgesic
(c) Assess blood pressure
(d) Notify the healthcare provider
Answer:
(c) Assess blood pressure
Explanation:
Patients with spinal cord injuiy above T6 are at risk for autonomic dysreflexia (also known as autonomic hyperreflexia) which causes extreme hypertension that can lead to hemorrhage, seizure, stroke, or death. Symptoms include pounding headache, profuse sweating, nasal congestion, and bradycardia. Immediate BP assessment is priority. The nurse should be prepared to give IV push hydralazine or labetalol, and then check for fecal impaction to relieve the rectal stimulation. Other causes include bladder distention, unrelieved pain, or tactile stimulation.
Rationale:
(a) is incorrect because checking for fecal impaction is appropriate after blood pressure is assessed and treated.
(b) is incorrect because analgesic administration is not the priority action. It is critical that the nurse assess for autonomic dysreflexia, first.
(d) is incorrect because other actions must be taken before calling the healthcare provider. If the blood pressure is high (as one would expect, if this is autonomic dysreflexia), the nurse will immediately treat with IV antihypertensive medication before notifying the healthcare provider.
Question 8.
A patient is admitted for evaluation of the possibility of a spinal cord tumor. Which of the following assessment findings by the nurse warrants immediate action?
(a) New onset lower extremity weakness
(b) Chronic back pain 9/10
(c) Patient is crying and feels hopeless
(d) Patient is anxious about surgery, HR
Answer:
(a) New onset lower extremity weakness
Explanation:
Spinal cord tumors, or neoplasms, can arise from spinal cord cells or from metastasis of another tumor. Lower extremity weakness with new onset indicates compression of the spinal cord, which requires emergency medical and surgical intervention to prevent permanent loss of function. Intravenous corticosteroids can be given immediately to reduce
Rationale:
(b) is incorrect because chronic severe back pain is not as immediate of a concern as the new onset weakness. Non-mechanical back pain (pain that occurs without movement) is the most common symptom with a neoplastic spinal cord tumor.
(c) is incorrect because crying and feeling hopeless are psychosocial issues that do not take priority over actual physical problems.
(d) is incorrect because anxiety about surgery is common, and tachycardia is expected with anxiety. This warrants further investigation, reassurance, and possibly anxiolytic medication, but is not the greatest priority.
Question 9.
The nurse is caring for a 40-year-old patient with a cauda equina spinal cord injury. When planning care for this patient, which intervention should the nurse include?
(a) Catheterize every 3-4 hours
(b) Assist with ambulation four times a day
(c) Administer oxybutynin
(d) Stabilize neck when repositioning
Answer:
(a) Catheterize every 3-4 hours
Explanation:
Cauda equina syndrome is caused most often by disc herniation which compresses nerve roots at the end of the spinal cord. These nerve roots are responsible for sending and receiving signals from the lower extremities and the organs of the pelvis. Cauda equina injury can lead to irreversible damage and loss of bowel and bladder function. A reflexic bladder results from cauda equina syndrome, so regular catheterization should be utilized. These patients are at higher risk for UTI related to urine retention and inability to fully empty the bladder.
Rationale:
(b) is incorrect because chronic severe back pain is not as immediate of a concern as the new onset weakness. Non-mechanical back pain (pain that occurs without movement) is the most common symptom with a neoplastic spinal cord tumor.
(c) is incorrect because crying and feeling hopeless are psychosocial issues that do not take priority over actual physical problems.
(d) is incorrect because anxiety about surgery is common, and tachycardia is expected with anxiety. This warrants further investigation, reassurance, and possibly anxiolytic medication, but is not the greatest priority.
Question 10.
A neurological nurse has received the hand-off report on four patients. Which of the following patients should be assessed by the nurse first?
(a) Patient admitted with botulism having a difficult time swallowing
(b) Patient admitted with Bell’s palsy and herpes vesicles in front of the ear
(c) Patient admitted with neurosyphilis, tabes dorsalis, and diminished deep tendon reflexes
(d) Patient who has an abscess from drug use requiring a tetanus immune globulin injection
Answer:
(a) Patient admitted with botulism having a difficult time swallowing
Explanation:
Botulism is a food-borne bacterium that is potentially fatal. Initial symptoms are weakness, difficulty seeing, trouble speaking, and lethargy. This can quickly progress to affect the muscles involved with respiration and can impair gas exchange, so the patient is at risk for respiratory failure. The nurse’s priority is to immediately assess for signs of respiratory distress.
Rationale:
(b) is incorrect because a viral disease such as herpes is a common cause of Bell’s palsy and does not require immediate intervention. Bell’s palsy is damage to the seventh cranial nerve resulting in inability to close the eye, decreased corneal reflex, increased lacrimation, speech difficulty, loss of taste, and inability to control one side of the face.
(c) is incorrect because neurosyphilis is the infection of the brain and/or spinal column by the disease syphilis. Tabes dorsalis (slow demyelination of dorsal column of the spinal cord) and diminished deep tendon reflexes are consistent with neurosyphilis and do not require immediate intervention.
(d) is incorrect because treating an abscess and giving a tetanus shot are not emergency interventions.
Question 11.
The nurse on the neurological unit is caring for patients. Which of the following clinical manifestations in the patient with a spinal cord tumor is the most important to notify the healthcare provider of?
(a) Back pain worsened by coughing
(b) Scoliosis with 13% curvature, RR18, SpO2 96%
(c) Sudden clumsiness of hands
(d) Pain that spreads to the hips, legs and feet, and is worse at night
Answer:
(c) Sudden clumsiness of hands
Explanation:
A spinal cord tumor is an abnormal mass of tissue within or surrounding the spinal column. Primary tumors originate in the spine, and secondary tumors are metastatic from cancer spreading from another site in the body. Any sudden decrease in motor control, bowel, or bladder function is an indication of spinal cord compression which is an emergency that must be evaluated immediately. Untreated spinal cord compression can lead to permanent paralysis or even death.
Rationale:
(a) is incorrect because back pain is the most common presentation with spinal tumor. Pain that worsens with movement requires further assessment but is not an emergency.
(b) is incorrect because a tumor near the spine can cause an abnormal curvature, so this is somewhat expected. (The pulse ox and respiratory rate indicate the patient is not exhibiting respiratory compromise from a tumor pressing on the lungs, so this is not the greatest concern.)
(d) is incorrect because pain associated with a spinal tumor often is worse at night and can spread to other parts of the body.
Question 12.
The nurse is caring for an adult male patient with spinal cord injury. The patient is worried he will no longer be able to be intimate with his wife. What is the best response by the nurse?
(a) “Erections as the result of reflex are common, but you may not be able to orgasm.”
(b) “Increased menstrual bleeding is common while taking amoxicillin.”
(c) “There are many options for maintaining sexuality after a spinal cord injury.”
(d) “Vacuum suction devices, prostheses, and penile injections are options.”
Answer:
(c) “There are many options for maintaining sexuality after a spinal cord injury.”
Explanation:
Spinal cord injury is damage that occurs from trauma that affects strength and sensation as well as body function below where the injury occurs. Sexuality is changed after spinal cord injury, but options are available for sexuality and fertility.
Rationale:
(a) is incorrect because reflex erections and ability to orgasm are dependent upon level and degree of injury.
(b) is incorrect because sildenafil need and effectiveness is dependent upon level and degree of injury. The nurse should be cautious about giving false reassurance and should attempt therapeutic communication and patient education about non-pharmacologic measures first.
(d) is incorrect because vacuum suction, prostheses, and injection need are dependent upon level and degree of injury.
Question 13.
The nurse is teaching at the community health center about how to prevent lower back injuries and pain. Which of the following instructions is most important to be included by the nurse?
(a) “Participation in exercise can strengthen muscles.”
(b) “Purchase an adjustable firmness mattress.”
(c) “Wear flats instead of heels for work. ”
(d) “Maintain your weight within 20% of ideal body weight.”
Answer:
(a) “Participation in exercise can strengthen muscles.”
Explanation:
Lower back pain can be caused by disc herniation, injury, and poor lifting techniques. One of the greatest ways to reduce lower back injuries and prevent back pain is to exercise regularly and increase core strength. Proper lifting techniques should also be taught, and quitting smoking should be encouraged.
Rationale:
(b) is incorrect because use of an adjustable mattress has not been medically proven to prevent or reduce lower back pain. The nurse should provide education that is relevant and realistic for patients to incorporate into their lifestyle. Purchase of new furniture items for the home are not covered by insurance plans, and patients are less likely to follow this advice than simpler instructions for lifestyle modification.
(c) is incorrect because wearing flats instead of heels can prevent lower back pain, but participation in regular exercise is more important. Exercise applies to patients of all populations, while high-heeled shoes applies only to women.
(d) is incorrect because maintaining healthy weight can reduce many complications but is not as directly related to lower back health as regular exercise.
Question 14.
A patient who experienced an injury at work is in the clinic with low back pain. Which instructions does the nurse include when planning care?
(a) “Perform back extension exercise by laying prone and lifting the arms and legs off the floor at the same time, hold for five seconds, then release, and repeat.”
(b) “While lying flat on the floor on your back, perform leg lifts by lifting both legs straight towards the ceiling at the same time, hold for five seconds, then lower, and repeat.”
(c) “Apply a heating pad to the lower back for 20 minutes, four times per day.”
(d) “Avoid warm showers and baths.”
Answer:
(c) “Apply a heating pad to the lower back for 20 minutes, four times per day.”
Explanation:
Lower back pain can be caused by disc herniation, injury, and poor lifting techniques. Use of a heating pad will increase blood flow and promote healing of the injured nerves. Massage and stretching may also be helpful.
Rationale:
(a) is incorrect because this outdated exercise actually places a lot of compression on the lumbar vertebrae. Instead, the patient should lie prone and lift the right arm and left leg at the same time, then reverse.
(b) is incorrect because this method of leg lift places additional compression on the lumbar vertebrae. The exercise should be performed by bending one knee toward the chest, and then lifting the other leg straight towards the ceiling, then lower, and reverse.
(d) is incorrect because avoiding warm showers and baths is not necessary. Often, a warm shower or bath will actually help alleviate back pain.
Question 15.
A patient is admitted to the surgical unit after a discectomy six hours ago. When assessing the patient, which finding by the nurse should be addressed first?
(a) Sleepy but awakens to voice
(b) Dry, cracked oral mucosa
(c) Pain in the lower back
(d) Bladder palpated above the pubis
Answer:
(d) Bladder palpated above the pubis
Explanation:
Discectomy is surgical removal of a displaced or herniated disc or disc material that is pressing on a nerve or the cord. Postoperative nursing care includes neurovascular observations, vital signs, pain assessment, patient-controlled-analgesia (PCA) management, I/O, and surgical wound observation. If the bladder can be palpated above the pubis, this indicates distention, which can signify sacral spinal nerve damage. This should be addressed first.
Rationale:
(a) is incorrect because drowsiness is common and expected after anesthesia. The post-op patient who awakes to voice is not a complication.
(b) is incorrect because dry, cracked oral mucosa is a sign of dehydration, which needs to be addressed, but is not as high priority as bladder distension.
(c) is incorrect because lower back pain is expected after a discectomy procedure. The patient will likely be on a PCA machine and may need further education about how to use the PCA. The nurse should assess dosage, usage and demand, and consider the need to change the PCA settings.
Question 16.
The nurse works at the community health center assessing clients at risk for lower back pain. Which of the following clients is at the greatest risk?
(a) 26-year-old female, smokes one pack of cigarettes a week, history of surgery for scoliosis at age 11
(b) 31-year-old female with Crohn’s disease, takes prednisone daily
(c) 46-year-old male diagnosed with osteoarthritis
(d) 55-year-old female using a walker, chronic cough related to COPD
Answer:
(c) 46-year-old male diagnosed with osteoarthritis
Explanation:
The 46-year-old male with osteoarthritis (OA) has three risk factors for lower back pain: age, gender, and OA.
Non-modifiable risks for lower back pain include, family history of back pain, male gender, middle-aged (45-65) or older, personal history of back injury, history of spinal surgery, osteoarthritis, depression, use of corticosteroids, and chronic coughing. Modifiable risk factors include sedentary lifestyle, smoking, excess body weight, and poor posture.
Rationale:
(a) is incorrect because the patient has two risk factors: smoking and history of back surgery.
(b) is incorrect because this patient has one risk factor: daily use of a corticosteroid medication.
(d) is incorrect because the patient has two risk factors: age and chronic cough.
Question 17.
A patient is admitted the surgical floor with a level T5 spinal cord injury. Their blood pressure is 180/90 mm Hg, and the patient appears flushed and states their vision is blurry. What is the first action the nurse should take?
(a) Place a nasal cannula with oxygen at 4L/min
(b) Place patient supine
(c) Palpate bladder for distention
(d) Administer beta blocker via IV
Answer:
(c) “You need to call your healthcare provider to make an appointment to be checked for infection.”
Explanation:
Autonomic dysreflexia (also known as autonomic hyperreflexia) is a rare complication that can occur in patients with spinal cord injury above T6. This emergency condition causes extremely high blood pressure, which can lead to other detrimental effects, even death. Other symptoms include pounding headache, profuse sweating, nasal congestion, and bradycardia. Immediate reduction of BP is the priority. Beta-blockers and hydralazine are the IV drugs of choice in this situation.
Rationale:
(a) is incorrect because autonomic dysreflexia is a circulatory problem, not an airway/breathing problem. Additional oxygen is not a priority. The nurse’s greatest focus should be on lowering the blood pressure.
(b) is incorrect because placing the patient supine will worsen hypertension associated with autonomic dysreflexia. The best position is having the head of the bed elevated.
(c) is incorrect because lowering the blood pressure is the greatest priority. After the beta blocker is administered, the nurse can then investigate the stimulus, which is likely a full bladder or an impacted bowel.
Question 18.
A patient is brought to the emergency department with a cervical spinal cord injury. What is the first action the nurse should take?
(a) Level of consciousness assessment
(b) Vital signs
(c) Oxygen therapy
(d) Respiratory status evaluation
Answer:
(d) Respiratory status evaluation
Explanation:
Patients with cervical spinal cord injury are at risk for respiratory impairment, due to decreased sensation and motor function of the muscles and organs of the upper chest. Assessing respiratory compromise and early intervention are the biggest priorities. This patient will likely need to be orally intubated to meet breathing and gas exchange needs.
Rationale:
(a) is incorrect because level of consciousness should be assessed after respiratory status. Whether or not the LOC has decreased, if the patient is not oxygenating well independently, intubation will be needed immediately.
(b) is incorrect because vital signs should be assessed after respiratory status.
(c) is incorrect because oxygen therapy may need to be initiated, but respiratory status must be evaluated first. If the patient does not have the ability to move the respiratory muscles involved in inspiration and expiration, applying oxygen will not be sufficient.
Question 19.
A patient with a lower motor neuron lesion desires bladder control. When the nurse teaches this patient, which statement should be included?
(a) “Stroking the inner aspect of the thigh will initiate voiding.”
(b) “Let’s review sterile technique for intermittent catheterization.”
(c) “When your bladder is full, use digital anal stimulation.”
(d) “Stimulate urine flow by tightening abdominal muscles.”
Answer:
(d) “Stimulate urine flow by tightening abdominal muscles.”
Explanation:
Lower motor neuron lesions affect nerve fibers that innervate muscles and causes flaccid bladder paralysis. The Valsalva maneuver, or tightening abdominal muscles, can initiate urine elimination in these patients.
Rationale:
(a) is incorrect because stroking the inner thigh is used to stimulate urination in upper motor neuron dysfunction.
(b)is incorrect because intermittent catheterization is clean, not sterile, and it does not initiate voiding or help with bladder control. Catheterization is an option for patients who do not have the desire to void on their own. If the patient expresses that desire, catheterization technique should be taught by the nurse.
(c) is incorrect because digital anal stimulation will not initiate voiding or help with bladder control. Digital stimulation may be required as a part of a bowel program for paralyzed patients who do not have sensation in the rectum.
Question 20.
The nurse cares for a 39-year-old male patient who suffered a fall from a tree-stand while hunting. The patient now has paraplegia and is scheduled to participate in a physical therapy rehabilitation program. When the patient tells the nurse, “I don't understand the need for rehabilitation because my legs will never work again,” what is the best response by the nurse?
(a) “You have the right to choose whether you want to participate in a rehabilitation program.”
(b) “Rehabilitation has helped many young sportsmen with the same type of injury. Give it a chance.”
(c) “Rehabilitation can help you learn how to maintain functional ability and prevent further disability.”
(d) “Those who are in rehabilitation are the first patients to benefit from new discoveries regarding paraplegia management.”
Answer:
(c) “Rehabilitation can help you learn how to maintain functional ability and prevent further disability.”
Explanation:
Paraplegia is motor and/or sensory impairment that affects the lower extremities. Although return of function and sensation is not common, patients with paraplegia require rehabilitation to prevent disability, maintain functional ability, and preserve their independence with activities of daily living. Rehabilitation programs can also offer a valuable source of peer support from others who have undergone similar injuries.
Rationale:
(a) is incorrect because it does not provide information that will help the patient. While it is the patient’s legal right to refuse treatment, the nurse should use communication strategies that are therapeutic and provide information to help the patient make the decision that will benefit them the most. Discussion of refusal of care is a last resort, after the patient has been given the information about the benefits of rehabilitation therapy.
(b) is incorrect because this response uses casual language which does not answer the patient’s question, and it focuses on other patients. Therapeutic communication involves the nurse staying focused on the patient, providing facts, acknowledging the patient’s feelings, and promoting quality of life.
(d) is incorrect because participating in rehabilitation does not necessarily mean the patient will have early benefit from new research and techniques for paraplegia management and treatment.
Question 21.
A patient has been in the hospital for 27 days after a debilitating spinal cord injury. The nurse is providing discharge teaching. Which of the following patient statements demonstrates they understand how to prevent respiratory problems after discharge?
(a) “I should use the incentive spirometer 10 times every hour while awake.”
(b) “I should drink fluids that have been thinned, for prevention of choking.”
(c) “Cough medicine should be taken for prevention of excessive coughing.”
(d) “I’ll lay on my right side after eating to prevent aspiration.”
Answer:
(a) “I should use the incentive spirometer 10 times every hour while awake.”
Explanation:
Spinal cord injury can cause lifelong impairment in sensation and function below the level of the injury. Weakening of intercostal muscles and accessory breathing muscles used for inspiration and expiration places the patient at increased risk for atelectasis and stasis pneumonia. It is critical that the patient learns technique for use of the incentive spirometer and understands the need for the frequency to keep their lungs expanded fully and prevent atelectasis as a part of their regular routine.
Rationale:
(b) is incorrect because thick liquids are generally easier to swallow. Water, coffee, milk, soda, juice, and broth are thin liquids that should be avoided or used with caution.
(c) is incorrect because the patient needs to cough and clear secretions routinely. Cough suppressants can inhibit the ability of the lungs to fully clear.
(d) is incorrect because the patient should be in high Fowler’s position (sitting upright) for prevention of aspiration. Lying on the right side does promote gastric emptying into the duodenum, but High Fowler’s position, or sitting upright slightly turned towards the right side, are better position options after meal consumption.
Question 22.
A patient is admitted to the emergency department with acute exacerbation of multiple sclerosis (MS). Which of the following prescribed medications should be prepared for administration by the nurse?
(a) Baclofen
(b) Interferon beta-lb
(c) Tetracycline
(d) Methylprednisolone
Answer:
(d) Methylprednisolone
Explanation:
Multiple sclerosis (MS) is a disease of demyelination of the nerve cells, brain, and spinal cord leading to vision, motor, and sensation changes. The etiology of MS is unclear. Late complications of MS include bowel changes and cognitive impairment, but the mentation and intellect generally remain intact.
It is a progressive disease that can exacerbate, leading to permanent neurological symptoms after an attack. Symptoms experienced during an attack may include muscular incoordination, ataxia, spasticity, nystagmus, chewing and swallowing difficulties, and impaired speech. Methylprednisolone is the best medication to administer for acute exacerbations.
Rationale:
(a) is incorrect because baclofen is given specifically to decrease muscle spasticity associated with MS but is not necessarily the priority medication in an exacerbation.
(b) is incorrect because interferon beta-lb is given routinely for treatment and control of MS, to decrease specific symptoms, and to slow the progression of the disease. This is not a medication given for an acute exacerbation.
(c) is incorrect because tetracycline is contraindicated in MS because it can increase muscle weakness.
Question 23.
A patient with multiple sclerosis is given fmgolimod, as ordered, by the nurse. Which adverse effect should the nurse monitor for?
(a) Peripheral edema
(b) Black, tarry stools
(c) Bradycardia
(d) Nausea and vomiting
Answer:
(c) Bradycardia
Explanation:
Multiple sclerosis (MS) is a disease in which nerve cells become demyelinated in the brain and spinal cord. Symptoms include vision, motor and sensation changes, progressing to bowel changes, and cognitive impairment, but the mentation and intellect generally remain intact.
Fingolimod is an immune-omodulating drug that sequesters lymphocytes in lymph nodes, preventing them from contributing to an auto-immune reaction. Bradycardia can occur within six hours of administration, so heart rate monitoring is a nursing priority. Other more common side effects include headache, head cold, and fatigue.
Rationale:
(a) is incorrect because peripheral edema is not an adverse effect of fingolimod. (SSRIs, hormonal antineoplastic agents, calcium channel blockers, thiazide diuretics and metformin can all cause peripheral edema.)
(b) is incorrect because black, tarry stools are indicative of GI bleeding, which is not an adverse effect of fingolimod. (Black, tarry stools can result from gastric ulcer, typhoid fever, blood clotting disorder, indomethacin use, iron supplementation, or Crohn’s disease.)
(d) is incorrect because nausea and vomiting are common side effects to many drugs but not specific to fingolimod.
Question 24.
A patient with multiple sclerosis is learning about recently prescribed cyclophosphamide and methylprednisolone. When providing discharge instructions, which statement should be included by the nurse?
(a) “Warm baths can be taken for muscle relaxation.”
(b) “Avoid large crowds and sick people.”
(c) “Your gait will weaken if you rely on a walker.”
(d) “Be sure to take your medications when you have symptoms.”
Answer:
(b) “Avoid large crowds and sick people.”
Explanation:
Multiple sclerosis (MS) is a disease in which nerve cells become demyelinated in the brain and spinal cord. Symptoms include vision, motor, and sensation changes, progressing to bowel changes and cognitive impairment, but the mentation and intellect generally remain intact. MS is a progressive disease that can exacerbate, leading to permanent neurological symptoms after an attack. Cyclophosphamide and methylprednisolone are immunosuppressive drugs, so they will lessen the body’s ability to fight infection. People who have upper respiratory illness are often found in large crowds, so these should be avoided to prevent contraction of infection.
Rationale:
(a) is incorrect because a warm bath will exacerbate symptoms. For many MS patients, even slight elevations in body temperatures can cause neurological changes. In fact: for many years, the “Hot Bath Test” was used to diagnose MS. A person suspected of having MS was immersed in a hot tub of water. The appearance of neurologic symptoms or their worsening was taken as evidence the person had MS.
(c) is incorrect because a walker may be needed for safety when ambulating. The nurse is responsible for teaching the MS patient how to use a walker for safe ambulation and how to also maximize gait and muscle strength. The nurse may also consult with physical therapy and occupational therapy for assistance with this type of patient education, when available.
(d) is incorrect because MS medications should be taken daily at regular intervals, as scheduled, not just when the patient is symptomatic.
Question 25.
A nurse working on the neurological unit is caring for four patients. Which order for a patient would require the nurse to confirm informed consent is completed before the test or procedure?
(a) Sensation measurement with pinprick method
(b) Computed tomography of cranial vault
(c) Lumbar puncture with cerebrospinal fluid sampling
(d) Venipuncture for venous blood analysis of autoantibodies
Answer:
(c) Lumbar puncture with cerebrospinal fluid sampling
Explanation:
Invasive procedures require informed consent. Lumbar puncture is an invasive procedure in which a needle is inserted into the subarachnoid space to obtain a CSF specimen, inject dye, inject medications, or relieve pressure. This procedure is done either at the bedside or in a treatment room. Because it is invasive and has potentially serious complications, such as headache, decreased ICP, and infection, this procedure requires signed informed consent. The healthcare provider must explain the procedure and obtain the patient’s signature, and the nurse signs as a witness.
Rationale:
(a) is incorrect because sensation measurement with pinprick measurement is not invasive and requires only verbal consent.
(B) is incorrect because computed tomography is not invasive and generally does not require signed informed consent. (In some facilities, if the CT is to be done with contrast injected or swallowed, informed consent may be necessary due to the increased risks from the contrast dye.)
(d) is incorrect because venipuncture only requires verbal consent.
Question 26.
A patient is scheduled for magnetic resonance imaging (MRI) without contrast. Which of the following actions should be implemented by the nurse before the test?
(a) NPO status for eight hours
(b) Withhold daily medications until after MRI
(c) Administer morphine for prevention of claustrophobia
(d) Place patient in gown with cloth ties
Answer:
(d) Place patient in gown with cloth ties
Explanation:
MRI has a magnetic field, and metal objects are a hazard around the MRI. A gown with cloth ties (as opposed to metal snaps) should be placed on the patient to prevent injury to the patient. All metal objects and jewelry must be removed.
Rationale:
(a) is incorrect because NPO status is unnecessary for MRI. NPO is required for procedures that require sedation and for many GI procedures which require the stomach and GI tract to be empty for the test. Note: MRI is not routinely done with sedation, although sedation may be necessary for MRI in children or patients who are unable to lie still for the duration of the test.
(b) is incorrect because withholding daily medications is unnecessary for MRI without contrast.
(c) is incorrect because morphine will not prevent claustrophobia in MRI. Lorazepam is a short-term anxiolytic medication that is most commonly used as a pre-medication for those who are anxious or claustrophobic.
Question 27.
A patient with a spinal cord injury is admitted to the neurological unit. Which of the following interdisciplinary team members would the nurse consult regarding activities of daily living?
(a) Social worker
(b) Physical therapist
(c) Occupational therapist
(d) Case manager
Answer:
(c) Occupational therapist
Explanation:
Spinal cord injury is damage that occurs from trauma that affects strength and sensation as well as body function below where the injury occurred. An occupational therapist (OT) will evaluate physical and environmental barriers in the home and provide training in the use of low- and high-tech assistive and adaptive technology equipment.
The nurse collaborates with the OT in instructing caregivers and family members regarding transfer, feeding, dressing, positioning, bathing, and skin care. The OT will also help modify activities and environments where needed and evaluate and recommend wheelchair seating and positioning systems to optimize function, mobility, and engagement in the community.
Rationale:
(a) is incorrect because the social worker does not consult for activities of daily living. The role of the social worker in spinal cord injury is to provide initial crisis intervention. They also act as a liaison between the medical team and the family, provide information, allow the family to vent feelings and concerns, and provide counseling to help increase the patient’s self-esteem, self-worth and self-efficacy. Additionally, the social worker will identify resources and referrals to agencies that can help with a variety of concerns and provide continual counseling throughout the process of adjustment to address anxiety, re-entry into social/work environments, and relationship/caregiver issues.
(b) is incorrect because the physical therapist (PT) does not consult for activities of daily living. The most common PT activities with spinal cord injury patients involve muscle strengthening exercises, stretching, transfer training, wheelchair mobility training, and gait training.
(d) is incorrect because the case manager does not consult for activities of daily living. The case manager is responsible for coordination of care with the multidisciplinary team. Other duties include overseeing follow-up consultations and facilitating communication between care providers.
Question 28.
A patient diagnosed with amyotrophic lateral sclerosis (ALS) tells the nurse they do not wish to be intubated and placed on mechanical ventilation. What is the best response by the nurse?
(a) “This should be discussed with your healthcare provider.”
(b) “Why don’t you want to be on the breathing machine?”
(c) “Incentive spirometer use every hour will delay need for being placed on the ventilator.”
(d) “What would you prefer we do if you experience difficulty with breathing?”
Answer:
(d) “What would you prefer we do if you experience difficulty with breathing?”
Explanation:
ALS (Lou Gehrig’s Disease) is a progressive, degenerative disease involving the lower motor neurons of the spinal cord and cerebral cortex. The voluntary motor system is primarily involved. ALS is characterized by weakness that sets in progressively, wasting of muscles, and spasticity that leads to paralysis. When breathing muscles become involved, the patient must have an advance directive that indicates the patient’s wishes regarding breathing assistance. Respiratory insufficiency is the usual cause of death for patients with ALS.
Rationale:
(a) is incorrect because the statement does not promote the nurse-patient relationship. While it is important to discuss the issue with the healthcare provider, it is more therapeutic and patient-centered for the nurse to address the patient’s wishes and help explain alternatives to mechanical ventilation.
(b) is incorrect because it is non-therapeutic to ask a patient “why?” It is important to determine the patient’s concerns, but the nurse should do so without asking “why?” A better statement would be “What are your concerns about the mechanical ventilation?”
(C) is incorrect because the statement does not address patient needs. It is a true statement, and it provides factual information, but it doesn’t address the patient’s stated concern.
Question 29.
A patient is in the clinic with chronic back pain and the healthcare provider prescribes ziconotide. While assessing the patient's health history, which question should the nurse ask?
(a) “Do you take nonsteroidal anti-inflammatory drugs?”
(b) “Is there a mental health disorder present?”
(c) “Can you swallow medications?”
(d) “Do you use illegal drugs or smoke cigarettes?”
Answer:
(b) “Is there a mental health disorder present?”
Explanation:
Ziconotide is an analgesic agent (atypical) used for amelioration of chronic and severe pain. Ziconotide can rarely cause new or worsening depression, paranoia but should not be taken by patients who have a history of psychosis, clinical depression, schizophrenia, or bipolar disorder.
Rationale:
(a) is incorrect because taking nonsteroidal anti-inflammatory drugs is not a contraindication for ziconotide. NSAIDs have a different mechanism of action and can be used in conjunction with ziconotide for pain relief.
(c) is incorrect because ability to swallow medications is not a contraindication for ziconotide. This medication is only approved for use when injected intrathecally, directly into the cerebrospinal fluid.
(D) is incorrect because use of illegal drugs or smoking cigarettes is not a direct contraindication for ziconotide. (However, this is an appropriate general question to ask any patient because smoking and illegal drug use should be discouraged and the patient should be educated about associated health risks with these habits.)
Question 30.
A 52-year-old mountain climber is admitted to the emergency room with confusion and bizarre behavior. After oxygen is administered, which priority intervention should be implemented by the nurse?
(a) Administration of dexamethasone
(b) Complete mini-mental state examination (MMSE)
(c) Prepare for brain computed tomography
(d) Request psychiatric consult
Answer:
(a) Administration of dexamethasone
Explanation:
This patient has signs of high altitude cerebral edema (HACE) and acute mountain sickness (AMS). Effects vary for each individual, but the most classic initial symptoms include headache, insomnia, anorexia, nausea, and dizziness. Dexamethasone is a glucocorticoid steroid which will reduce cerebral edema due to its anti-inflammatory effects on the central nervous system.
Rationale:
(b) is incorrect because completing a mini-mental state examination (MMSE) will not diagnose or treat HACE or AMS. The MMSE is a structured assessment of a patient’s behavioral and cognitive function and is used to differentiate types of dementias.
(c) is incorrect because computed tomography of the brain may help in diagnosing HACE, but dexamethasone should be given first to reduce brain swelling.
(d) is incorrect because a psychiatric consult is not required.
Question 31.
A patient who experienced damage to the left temporal lobe of the brain will be educated by the nurse. When teaching the patient about new medications, which action should be taken by the nurse?
(a) Assist the patient in identifying medications by color
(b) Give the patient large print written materials
(c) Sit on patient’s right side and use written materials for medication education
(d) Use a white board for the patient to write questions
Answer:
(c) Sit on patient’s right side and use written materials for medication education
Explanation:
The auditory center is located in the temporal lobe. Damage to the left temporal lobe will affect sound interpretation and hearing is impaired on the left side. The nurse needs to sit on the right side and speak into the patient’s right ear. Left temporal lobe damage can also disturb recognition of words and impaired memory for verbal material, so written materials are best to help the patient retain the information.
Rationale:
(a) is incorrect because identifying medications by color will not address damage to the left temporal lobe. Many medications may be similarly colored, so if a patient has the inability to read the labels on the prescription bottles, it is best to help teach them how to identify their meds by color, shape, and size.
(b) is incorrect because large print is not necessary, as the vision is not impaired with left temporal lobe injury. Also, simply giving the patient written materials is not enough; the nurse must also actively explain the information.
(d) is incorrect because use of a white board will not address damage to the left temporal lobe. The patient with left temporal lobe damage will still be able to talk. Right temporal damage can cause a loss of inhibition of talking.
Question 32.
A patient's recent memory is tested by the nurse. Which statement by the patient demonstrates that the patient's recent memory is unimpaired?
(a) “The young girl wearing a shroud sleeps on clouds.”
(b) “I was born April 4,1968, at Johnson Community Hospital.”
(c) “Apple, pencil, and table are what you just stated.”
(d) “I ate cereal with a banana and apple juice for breakfast.”
Answer:
(d) “I ate cereal with a banana and apple juice for breakfast.”
Explanation:
Recent memory (also called short-term memory or working memory) is best tested by asking about verifiable events, including what was consumed for breakfast.
Rationale:
(a) is incorrect because making up a rhyme tests a higher level of cognition. Other ways to test higher cognition include multiple choice questions, problem-solving, and short essay questions.
(b) is incorrect because asking about personal historical events is a test of remote memory, not recent memory. Remote memory involves memory of events that may have happened years ago.
(c) is incorrect because repeating words assesses immediate memory, which is the ability to remember a small amount of information over a few seconds.
Question 33.
A patient displays a positive Romberg's sign with their eyes closed, but not open, when tested by the nurse. Which condition is associated with the nurse's finding?
(a) Difficulty with proprioception
(b) Peripheral motor disorder
(c) Impaired cerebellar function
(d) Positive pronator drift
Answer:
(a) Difficulty with proprioception
Explanation:
Romberg’s test is a neurological assessment for body position and balance. The nurse asks the patient to stand with feet together and eyes opened for a minute. Then, the nurse assesses the patient for another minute with the eyes closed. Romberg’s test is positive if the patient sways or falls when the eyes are closed. This indicates a proprioception disorder which is compensated by vision. Proprioception disorder results from neuropathy or posterior vertebral column disease.
Rationale:
(b) is incorrect because peripheral motor disorder would not cause a positive Romberg’s sign. Nerve conduction studies are used to diagnose peripheral motor disorder.
(c) is incorrect because Romberg’s test is not used to diagnose cerebellar disease. Finger-to- nose and finger-to-finger testing, heel-to-shin testing, and gait assessment are some tests used to assess cerebellar damage.
(d) is incorrect because positive pronator drift would not cause a positive Romberg’s sign. Pronator drift is a sign of upper motor neuron lesion.
Question 34.
The patient asks the nurse why deep breaths are requested during electroencephalography (EEG). What is the best response by the nurse?
(a) “Hyperventilation will cause cerebral artery dilation, which leads to decreased electoral brain activity.”
(b) “Deep breathing helps with relaxation and a better waveform with electroencephalography. ”
(c) “Hyperventilation will cause cerebral vasoconstriction and increased likelihood of a seizure.”
(d) “Deep breathing blows off carbon dioxide and decreases pressure in the intracranial cavity.”
Answer:
(c) “Hyperventilation will cause cerebral vasoconstriction and increased likelihood of a seizure.”
Explanation:
Electroencephalography (EEG) is performed to record the electrical activity in the brain. The procedure is done by an EEG technician in a quiet room. The patient may be asked to hyperventilate (20-30 deep breaths per minute for three to four minutes), which causes cerebral vasoconstriction and alkalosis. This can stimulate seizure activity (which is what the EEG is monitoring for). It is also common to expose the patient to bright, flashing lights prior to the EEG, as this can cause seizure activity as well.
Rationale:
(a) is incorrect because the statement is inaccurate.
(b) is incorrect because the statement is inaccurate. Deep breathing may be used for relaxation in some patients, but this is not the purpose related to EEG testing.
(d) is incorrect because although deep breathing does reduce CO2, the purpose during EEG is not to decrease ICP. The purpose is to stimulate seizure activity.
Question 35.
A patient recovering from cerebral angiography via right femoral artery is assessed by the nurse. Which assessment should be completed by the nurse?
(a) Palpate lower extremity pulses bilaterally
(b) Assess for orthostatic hypotension
(c) Perform fundoscopic examination
(d) Assess gag reflex before meals
Answer:
(a) Palpate lower extremity pulses bilaterally
Explanation:
The brachial or femoral artery is accessed with a catheter to perform cerebral angiography. Following the procedure, the affected extremity is immobilized. Adequate circulation is checked by assessing skin color and temperature, pulses, and capillary refill. Decrease in circulation should be reported to the healthcare provider immediately.
Rationale:
(b) is incorrect because orthostatic blood pressure assessment requires the BP to be monitored in several positions. Post-femoral-angiography, the patient must remain on bedrest with the affected leg extended and the head-of bed flat.
(c) is incorrect because fundoscopic examination is unaffected by cerebral angiography. Fundoscopic examination is ophthalmic examination of the fundus of the eye, used to assess retinal damages from hypertension.
(d) is incorrect because assessing gag reflex before meals is not routine for post-angiography patients.
Question 36.
A patient has deteriorating neurologic function. When the patient tells the nurse they are worried about being able to care for their young children, what is the best response by the nurse?
(a) “Child care is priority. You need to ask for help, even though you may not want to.”
(b) “There are community resources to help with household tasks so you can care for your children.”
(c) “You seem to be distressed. Can I have the psychologist speak to you about adjustment to your condition?”
(d) “Tell me more about what you are worried about so I can see what we can do to make adjustments.”
Answer:
(d) “Tell me more about what you are worried about so I can see what we can do to make adjustments.”
Explanation:
The nurse needs to find out specifically what the patient is concerned about regarding role changes and neurologic status before providing information.
Rationale:
(a) is incorrect because the nurse should remain focused on the patient’s concerns without being blunt and non-therapeutic.
(b) is incorrect because community resources are possibly available, but appropriateness has not been determined.
(c) is incorrect because the nurse needs to find out what the concerns are before consulting with the psychologist. This answer “passes the buck” to another member of the healthcare team. The nurse should remain focused on strengthening the nurse-patient relationship.
Question 37.
The nurse is assessing pain discrimination on a 64-year-old patient. With eyes closed, the patient correctly identifies a sharp sensation on the right hand when touched with a pin. What is the next action the nurse should take?
(a) Repeat the assessment on the left hand
(b) Notify the healthcare provider with results
(C) Ask about current medications
(d) Continue with the feet next
Answer:
(a) Repeat the assessment on the left hand
Explanation:
The pain discrimination assessment is performed to test sensory receptors and identify if a specific side of the brain has been affected by disease or damage. When testing is started on the right hand and correctly identified by the patient, the assessment is continued with the left hand to assess for equality of findings.
Rationale:
(b) is incorrect because the patient correctly identified the sharp sensation which does not warrant notification of the healthcare provider. Since this is an expected finding, it should be documented in the patient’s chart. (The healthcare provider is notified when unexpected findings are present.)
(c) is incorrect because current medications are unnecessary to assess with this finding.
(d) is incorrect because the left hand is assessed before continuing with the lower extremities.
Question 38.
The nurse is caring for a patient with cranial nerve II impairment. Which statement should be included by the nurse when delegating care for this patient to the unlicensed assistive personnel (UAP)?
(a) “Be sure to tell the patient where food is located on the tray.”
(b) “Make sure the patient is in high-Fowler’s for meals.”
(c) “Ensure the patient’s food is spread out on the tray so the patient can visualize the separate food items.”
(d) “Place the patient’s fork in the left hand.”
Answer:
(a) “Be sure to tell the patient where food is located on the tray.”
Explanation:
Cranial nerve II (the optic nerve) provides the central as well as peripheral vision. When this cranial nerve is impaired, the patient’s normal vision will be impaired. It is appropriate for the UAP to tell the patient where food is located on the tray.
Rationale:
(b) is incorrect because semi-Fowler’s (HOB 30-45 degrees) is appropriate for this patient during meals. High-Fowler’s (sitting upright) is appropriate for a patient who is at risk for aspiration, such as a spinal cord injury patient.
(c) is incorrect because the patient with cranial nerve II impairment is unable to see.
(d) is incorrect because upper extremity coordination and muscle control will not be affected by cranial nerve II impairment, so the patient should be able to determine in which hand to hold the fork (dominant side).
Question 39.
A nurse caring for a patient with Guillain-Barre is learning the pathophysiology includes segmental demyelination. The nurse understands that this causes what?
(a) Delayed impulses of afferent nerves, not efferent nerves
(b) Affected muscle paralysis
(c) Unilateral paresthesia
(d) Nerve impulse transmission slowing
Answer:
(d) Nerve impulse transmission slowing
Explanation:
Guillain-Barre is a progressive, inflammatory autoimmune disorder which causes peripheral nerve root compression. The immune system attacks nerves, causing demyelination, which slows peripheral nerve impulse conduction and can leads to paralysis, over time. Acute, rapidly progressing ascending sensory and motor deficit can stop at any point along the CNS, or progress to the spinal cord.
Rationale:
(a) is incorrect because Guillain-Barre causes delayed impulses of both afferent and efferent nerves. Afferent nerves bring signals from the body to the central nervous system (sensation). Efferent nerves send signals from the CNS to the rest of the body (muscle control).
(b) is incorrect because Guillain-Barre does not cause muscle paralysis in any specific muscle and is not associated with a single affected muscle. The muscle weakness and decreased sensation (or numbness, tingling) generally are experienced bilaterally, more in the lower extremities than in the upper extremities.
(c) is incorrect because Guillain-Barre causes bilateral symptoms.
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