Neurologic NCLEX Questions _ Prioritization and Delegation_TEACHER COPY.

Neurologic NCLEX Questions _ Prioritization and Delegation_TEACHER COPY. 1. What is the priority nursing diagnosis for a client experiencing a migraine headache? o 1.Acute Pain related to biologic and chemical factors o 2.Anxiety related to change in or threat to health status o 3.Hopelessness related to deteriorating physiologic condition o 4.Risk for Injury related to side effects of medical therapy Ans: 1 The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating. 2. You are creating a teaching plan for a client with newly-diagnosed migraine headaches. Which key items will you include in the teaching plan? (Select all that apply.) o 1.Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. o 2.Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. o 3.Abortive therapy is aimed at eliminating the pain during the aura. o 4.A potential side effect of medications is rebound headache. o 5.Complementary therapies such as biofeedback and relaxation may be helpful. o 6.Estrogen therapy should be continued as prescribed by your physician. Ans: 1, 2, 3, 4, 5 Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate. 3. After a client has a seizure, which action can you delegate to the UAP? o 1.Documenting the seizure o 2.Performing neurologic checks o 3.Taking the client’s vital signs o 4.Restraining the client for protection Ans: 3 Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client’s movements if necessary. 4. You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN/LVN? o 1.Completing the admission assessment o 2.Setting up oxygen and suction equipment o 3.Placing a padded tongue blade at the bedside o 4.Padding the side rails before the client arrives Ans: 2 The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client’s mouth after a seizure begins. 5. A nursing student is teaching a client and family about epilepsy before the client’s discharge. For which statement should you intervene? o 1.“You should avoid consumption of all forms of alcohol.” o 2.“Wear your medical alert bracelet at all times.” o 3.“Protect your loved one’s airway during a seizure.” o 4.“It’s OK to take over-the-counter medications.” Ans: 4 A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families. 6. A client with Parkinson disease has received a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe the UAP performing all of these actions. For which action must you intervene? o 1.Helping the client ambulate to the bathroom and back to bed o 2.Reminding the client not to look at his feet when he is walking o 3.Performing the client’s complete bathing and oral care o 4.Setting up the client’s tray and encouraging the client to feed himself Ans: 3 The UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence 7. You are preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? o 1.“I will avoid exercise because the pain gets worse.” o 2.“I will use heat or ice to help control the pain.” o 3.“I will not wear high-heeled shoes at home or work.” o 4.“I will purchase a firm mattress to replace my old one.” Ans: 1 Exercises are used to strengthen the back, relieve pressure on compressed nerves, and protect the back from reinjury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at all times 8. A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should you take first? o 1.Administer the ordered acetaminophen (Tylenol). o 2.Check the Foley tubing for kinks or obstruction. o 3.Adjust the temperature in the client’s room. o 4.Notify the physician about the change in status. Ans: 2 These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client’s headache. Notifying the physician may be necessary if nursing actions do not resolve symptoms. 9. Which client should you, as charge nurse, assign to a new RN graduate who is on orientation to the neurologic unit? o 1.28-year-old newly-admitted client with an SCI o 2.67-year-old who had a stroke 3 days ago and has left-sided weakness o 3.85-year-old with dementia who is to be transferred to long-term care today o 4.54-year-old with Parkinson disease who needs assistance with bathing Ans: 2 The new RN graduate who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the UAP. The client being transferred to the nursing home and the newly-admitted client with SCI should be assigned to experienced nurses. 10. A client with an SCI at level C3-C4 is being cared for in the emergency department (ED). What is the priority assessment? o 1.Determine the level at which the client has intact sensation. o 2.Assess the level at which the client has retained mobility. o 3.Check blood pressure and pulse for signs of spinal shock. o 4.Monitor respiratory effort and oxygen saturation level. Ans: 4 The first priority for the client with an SCI is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise, because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority. 11. You are floated from the ED to the neurologic floor. Which action should you delegate to the UAP when providing nursing care for a client with an SCI? o 1.Assessing the client’s respiratory status every 4 hours o 2.Taking the client’s vital signs and recording every 4 hours o 3.Monitoring the client’s nutritional status, including calorie counts o 4.Instructing the client how to turn, cough, and breathe deeply every 2 hours Ans: 2 The UAP’s training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses. 12. You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the client to void? (Select all that apply.) o 1.Stroking the client’s inner thigh o 2.Pulling on the client’s pubic hair o 3.Initiating intermittent straight catheterization o 4.Pouring warm water over the client’s perineum o 5.Tapping the bladder to stimulate the detrusor muscle Ans: 1, 2, 4, 5 All of the strategies except straight catheterization may stimulate voiding in clients with an SCI. Intermittent bladder catheterization can be used to empty the client’s bladder, but it will not stimulate voiding. 13. A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? (Select all that apply.) o 1.Checking the client’s skin for pressure from the device o 2.Assessing the client’s neurologic status for changes o 3.Observing the halo insertion sites for signs of infection o 4.Cleaning the halo insertion sites with hydrogen peroxide o 5.Developing the nursing plan of care for the client Ans: 1, 3, 4 Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN. 14. You are preparing a nursing care plan for a client with an SCI for whom the nursing diagnoses of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. The client tells you, “I don’t know why we’re doing all this. My life’s over.” Based on this statement, which additional nursing diagnosis takes priority? o 1.Risk for Injury related to altered mobility o 2.Imbalanced Nutrition: Less than Body Requirements o 3.Impaired Individual Resilience related to spinal cord injury o 4.Disturbed Body Image related to immobilization Ans: 3 The client’s statement indicates impaired individual resilience in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate for a client with SCI but are not related to the client’s statement. 15. Which client should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? o 1.34-year-old with newly diagnosed multiple sclerosis (MS) o 2.68-year-old with chronic amyotrophic lateral sclerosis (ALS) o 3.56-year-old with Guillain-Barré syndrome (GBS) in respiratory distress o 4.25-year-old admitted with a C4-level SCI Ans: 2 The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care. 16. A client with MS tells the UAP after physical therapy that she is too tired to take a bath. What is the priority nursing diagnosis at this time? o 1.Fatigue related to disease state o 2.Activity Intolerance due to generalized weakness o 3.Impaired Physical Mobility related to neuromuscular impairment o 4.Bathing Self-Care Deficit related to fatigue and neuromuscular weakness Ans: 4 At this time, based on the client’s statement, the priority is Bathing Self-Care Deficit related to fatigue after physical therapy. The other three nursing diagnoses are appropriate to a patent with MS but are not related to the client’s statement. 17. An LPN/LVN, under your supervision, is providing nursing care for a client with GBS. What observation should you instruct the LPN/LVN to report immediately? o 1.Reports of numbness and tingling o 2.Facial weakness and difficulty speaking o 3.Rapid heart rate of 102 beats/min o 4.Shallow respirations and decreased breath sounds Ans: 4 The priority intervention for a client with GBS is maintaining adequate respiratory function. Clients with GBS are at risk for respiratory failure, which requires urgent intervention. The other findings are important and should be reported to the nurse, but they are not life threatening. 18. The UAP reports to you, the RN, that a client with myasthenia gravis has an elevated temperature (102.2° F [39° C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and was incontinent of urine and stool. What is your best first action at this time? o 1.Administer an acetaminophen suppository.