Download NCLEX RN Exam Questions: Neurology and Neurological Disorders and more Exams Nursing in PDF only on Docsity!
NCLEX RN EXAM 150 QUESTIONS AND ANSWERS WITH
RATIONALES UPDATE 2025/
- When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about
a. triggers that lead to facial pain.
b. visual problems caused by ptosis.
c. poor appetite caused by a loss of taste.
d. decreased sensation on the affected side.
CORRECT ANSWER: D
RATIONALE: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and numbness are not characteristics of trigeminal neuralgia, although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by eating.
- During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should
a. examine the mouth and teeth thoroughly.
b. have the patient clench and relax the jaw and eyes.
c. identify trigger zones by lightly touching the affected side.
d. gently palpate the face to compare skin temperature bilaterally.
CORRECT ANSWER: A
RATIONALE: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
- A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the nurse will evaluate that the patient has had a successful outcome for the surgery if the patient
a. uses an eye shield at night to protect the cornea from injury.
b. develops and implements a daily routine of facial exercises.
c. is careful to chew foods on the unaffected side of the mouth.
d. talks about enjoying social activities with family and friends.
CORRECT ANSWER: D
RATIONALE: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment of social activities indicates successful reduction of symptoms. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
Cognitive Level: Application Text Reference: pp. 1583-
Nursing Process: Evaluation NCLEX: Physiological Integrity
- When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is
a. teach facial and jaw relaxation techniques.
b. assess intake and output and dietary intake.
c. apply ice packs for no more than 20 minutes.
d. spend time at the bedside talking with the patient.
CORRECT ANSWER: B
RATIONALE: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
Nursing Process: Planning NCLEX: Physiological Integrity
- When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?
a. "You should call the doctor if pain or herpes lesions occur near the ear."
b. "Treatment of herpes with antiviral agents will prevent development of Bell's palsy."
c. "Medications to treat Bell's palsy work only if started before paralysis onset."
d. "You may be able to prevent Bell's palsy by doing facial exercises regularly."
CORRECT ANSWER: A
RATIONALE: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before
Cognitive Level: Comprehension Text Reference: pp. 1585-
Nursing Process: Implementation NCLEX: Physiological Integrity
- A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is
a. monitoring the cardiac rhythm continuously.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities.
d. performing constant evaluation of respiratory function.
CORRECT ANSWER: D
RATIONALE: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.
Cognitive Level: Comprehension Text Reference: p. 1586
Nursing Process: Assessment NCLEX: Physiological Integrity
- When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?
a. The patient complains of severe tingling pain in the feet.
b. The patient has continuous drooling of saliva.
c. The patient's blood pressure (BP) is 106/50 mm Hg.
d. The patient's quadriceps and triceps reflexes are absent.
CORRECT ANSWER: B
RATIONALE: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.
Cognitive Level: Application Text Reference: pp. 1586-
Nursing Process: Assessment NCLEX: Physiological Integrity
- A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include
a. intubation and mechanical ventilation.
b. insertion of a nasogastric (NG) feeding tube.
c. administration of methylprednisolone (Solu-Medrol).
d. IV infusion of immunoglobulin (Sandoglobulin).
CORRECT ANSWER: D
RATIONALE: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
Cognitive Level: Application Text Reference: p. 1586
Nursing Process: Implementation NCLEX: Physiological Integrity
- A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to
a. obtain baseline vital signs.
b. administer an intradermal test dose.
c. ask the patient about a history of allergies.
d. document the presence of neurologic symptoms.
CORRECT ANSWER: B
RATIONALE: To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although baseline vital signs, allergy history, and symptom assessment and documentation are appropriate, these assessments will not impact on the decision to administer the antitoxin.
Cognitive Level: Application Text Reference: pp. 1587-
Nursing Process: Implementation NCLEX: Physiological Integrity
- When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to
a. administer oxygen at 7 to 9 L/min with a face mask.
b. place the hands on the epigastric area and push upward when the patient coughs.
c. encourage the patient to use an incentive spirometer every 2 hours during the day.
d. suction the patient's oral and pharyngeal airway.
CORRECT ANSWER: B
RATIONALE: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
Cognitive Level: Application Text Reference: p. 1602
Nursing Process: Implementation NCLEX: Physiological Integrity
- As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
a. Assessment of the patient for left leg pain
b. Assessment of the patient for left arm weakness
c. Positioning the patient's right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position
CORRECT ANSWER: C
RATIONALE: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
Cognitive Level: Application Text Reference: pp. 1591-
Nursing Process: Implementation NCLEX: Physiological Integrity
- A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that
a. use of the shoulders will be preserved.
b. full function of the patient's arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of injury.
CORRECT ANSWER: B
RATIONALE: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
Cognitive Level: Application Text Reference: p. 1594
Nursing Process: Implementation NCLEX: Physiological Integrity
- The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess
a. blood pressure and heart rate.
b. respiratory effort and O2 saturation.
c. motor and sensory function of the legs.
d. bowel sounds and abdominal distension.
CORRECT ANSWER: C
RATIONALE: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.
Cognitive Level: Application Text Reference: p. 1596
Nursing Process: Evaluation NCLEX: Physiological Integrity
- A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
c. turns and repositions self independently when in bed.
d. pushes a manual wheelchair on flat, smooth surfaces.
CORRECT ANSWER: D
RATIONALE: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
Cognitive Level: Application Text Reference: p. 1594
Nursing Process: Planning NCLEX: Physiological Integrity
- A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to
a. ask for the patient's input into the plan for care.
b. clarify that abusive behavior will not be tolerated.
c. reassure the patient that the anger will pass and rehabilitation will then progress.
d. ignore the patient's anger and continue to perform needed assessments and care.
CORRECT ANSWER: A
RATIONALE: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed.
Cognitive Level: Application Text Reference: p. 1608
Nursing Process: Implementation NCLEX: Psychosocial Integrity
- A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to
a. advise the patient to talk to his wife to determine how she feels about his sexual function.
b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury.
c. inform the patient that most patients with upper motor neuron injuries have reflex erections.
d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
CORRECT ANSWER: D
RATIONALE: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.
Cognitive Level: Application Text Reference: p. 1608
Nursing Process: Implementation NCLEX: Psychosocial Integrity
- A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to
a. tell the family members that the patient can perform ADLs independently.
b. remind the patient about the importance of independence in daily activities.
c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities.
d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.
CORRECT ANSWER: D
RATIONALE: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.
Cognitive Level: Application Text Reference: p. 1609
Nursing Process: Implementation NCLEX: Psychosocial Integrity
- The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of these data obtained when assessing the patient requires most immediate action by the nurse?
a. The patient has new onset weakness of both legs.
b. The patient complains of chronic level 6 pain on a 10-point scale.
RATIONALE: Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.
Cognitive Level: Application Text Reference: p. 1588
Nursing Process: Implementation NCLEX: Physiological Integrity
- When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?
a. Continuous cardiac monitoring for bradycardia
b. Administration of methylprednisolone (Solu-Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression devices to both legs
CORRECT ANSWER: C
RATIONALE: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort.
Cognitive Level: Application Text Reference: p. 1602
Nursing Process: Assessment NCLEX: Physiological Integrity
MULTIPLE RESPONSE
- When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care? (Select all that apply.)
a. Endotracheal suctioning
b. Continuous cardiac monitoring
c. Avoidance of cool room temperature
d. Nasogastric tube feeding
e. Retention catheter care
f. Administration of H2 receptor blockers
CORRECT ANSWER: B, C, E, F
RATIONALE: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distension, a retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
Cognitive Level: Application Text Reference: pp. 1594-1595, 1597, 1603
Nursing Process: Planning NCLEX: Physiological Integrity
- In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department?
a. Administer O2 using a non-rebreathing mask.
b. Monitor cardiac rhythm and blood pressure.
c. Immobilize the patient's head, neck, and spine.
d. Transfer the patient to radiology for spinal CT.
CORRECT ANSWER: C, A, B, D
RATIONALE: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.
Cognitive Level: Application Text Reference: p. 1596
Nursing Process: Implementation NCLEX: Physiolo
Acetylcholine(ACh) is a neurotransmitter that provides for communication between muscles and nerves. When there is a problem with the interaction between acetylcholine and the acetylcholine receptor sites on the muscles, which condition(s) can occur?
A. Myasthenia gravis
B. Botulism
C. Multiple sclerosis
D. A and B
A. Myasthenia gravis
The symptoms do not indicate depression or dementia, although these are common in Parkinson's disease.
Antipsychotic medication will often mimic Parkinson's disease extrapyramidal symptoms and is not indicated
The client with a diagnosis of bipolar disorder, manic phase, states to the nurse, "I am the Queen of England. Bow before me." The nurse interprets this statement as important to document as which area of the mental status examination?
A. psychomotor behavior
B. mood and affect
C. attitude toward the nurse
D. thought content
D. thought content ( an example of a grandiose delusion and refers to thought content
RATIONALE: The client's statement "I am the Queen of England. Bow before me" is an example of a grandiose delusion and refers to thought content of the mental status examination. Examples of psychomotor behavior to be documented would include excited, typically exaggerated, and repetitive physical movements, and excessive talking and gesturing.
Mood is a subjective state, and affect is an observable expression of emotion. Mood is what a client tells you she is feeling, and affect is what you see the client feeling. For example, the client may state that she feels sad or happy in reference to mood. Affect refers to the display of physical emotion, commonly described as "appropriate" or "flat."
Attitude toward the nurse refers to the client's behavior in the presence of the nurse during the mental status examination (pleasant and cooperative, irritable and guarded).
A client with generalized anxiety disorder states, "I'm afraid I'm going to die from cancer. My mother had cancer." What is the most appropriate response by the nurse?
A. "We all live in fear of dying from cancer."
B. "Did your father also have cancer?"
C. "I wouldn't worry about it just yet. You seem to be in good health."
D. "Has something happened that is causing you to worry?"
D. "Has something happened that is causing you to worry?"
RATIONALE: By asking the client about what is making him/her worry, the nurse assists the client in determining the cause of the anxiety. The other responses deflect and minimize the client's concerns (Analysis).
The client with major depression and suicidal ideation has been taking bupropion (Wellbutrin) 100 mg PO (by mouth) three times daily for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which behavior?
A. seizure activity
B. suicide attempt
C. visual disturbances
D. increased libido
B. suicide attempt
RATIONALE: The nurse must monitor the client for suicide attempt at this time when the client is starting to feel better because the depressed client may now have enough energy to carry out an attempt. Bupropion (Wellbutrin) inhibits dopamine reuptake; it is an activating antidepressant and could cause agitation. Although bupropion (Wellbutrin) lowers the seizure threshold, especially at doses greater than 450 mg/day, and visual disturbances and increased libido are possible adverse effects but not necessarily specifically at this time.
Dopamine is an important neurotransmitter. Which disease or disorder results when the neurons in the brain that produce dopamine die?
A. Multiple sclerosis (MS)
B. Lou Gehrig's disease (amyotrophic lateral sclerosis)
C. Parkinson's disease
D. Seizure disorder
C. Parkinson's disease
RATIONALE: Parkinson's is the result of the loss of dopamine-producing brain cells. Dopamine is a chemical messenger responsible for transmitting signals within the brain. Parkinson's disease occurs when certain nerve cells, or neurons, die or become impaired. Normally, these neurons produce dopamine. Loss of dopamine causes the nerve cells to fire out of control, leaving patients unable to direct or control their movement in a normal manner.
RATIONALE: During a myasthenic crisis, the respiratory muscles are affected and aspiration is a concern. This compromises respirations and may result in infections, aspiration, and respiratory insufficiency. Mechanical ventilation may be required. The immune, cardiovascular, and hepatic and renal systems may be involved but are not the primary body systems in jeopardy.
The nurse is reviewing the laboratory report with the client's lithium level prior to administering the 1700 hours dose. The lithium level is 1.8 mEq/L. The nurse should:
A. administer the 1700 hours dose of lithium
B. hold the 1700 hours dose of lithium
C. give the client 240 mL of water with the lithium
D. give the lithium after the client's supper
B. hold the 1700 hours dose of lithium
RATIONALE: The nurse should hold the 1700 hours dose of lithium because a level of 1.8 mEq/L (0.4 - 1. mEq/L) can cause adverse reactions, including diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination, which are early signs of lithium toxicity. The nurse should report the lithium level to the HCP including any symptoms of toxicity.
Administering the 1700 hours dose of lithium, giving the client the lithium with 240 mL of water or giving it after supper would result in an increase of the lithium level, thus increasing the risk of lithium toxicity.
What is a common neurotransmitter?
A. Acetylcholine
B. Gamma-aminobutyric acid (GABA)
C. Serotonin
D. All of the above
D. All of the above
- RATIONALE: Acetylcholine is an excitatory neurotransmitter, meaning it makes cells more excitable. It is found in the nerves in the body, where it stimulates muscles and glands. It is also found in the brain, where it helps regulate dopamine (another neurotransmitter) in the brain.
Alzheimer's disease is associated with a shortage of acetylcholine.
GABA is short for gamma-aminobutyric acid. It is an inhibitory transmitter, meaning it makes cells less excitable, and it helps the brain maintain muscle control.
Serotonin is an inhibitory transmitter that helps the brain regulate acetylcholine.
Which information should the nurse include in the education for a client prescribed sumatriptan (Imitrex)? Select all that apply.
A. Do not drive until the effects of the medication are known.
B. Avoid pseudoephedrine (Sudafed) while taking the prescription.
C. Take the prescription with a meal high in protein.
D. Take the prescription with food.
E. Increase fluid intake.
A. Do not drive until the effects of the medication are known.
B. Avoid pseudoephedrine (Sudafed) while taking the prescription.
RATIONALE: Drowsiness and dizziness can occur with sumatriptan (Imitrex). Pseudoephedrine (Sudafed) is a vasoconstrictor as is sumatriptan (Imitrex). The combination could dramatically increase the client's blood pressure. Sumatriptan (Imitrex) does not need to be taken with protein or with food and it is not necessary to increase fluid intake.
Which of the following drug categories can be used for treating anxiety?
A. Antitussives
B. Anticoagulants
C. Anticonvulsants
