NCLEX Secrets - Neurology Board Review
36. Which of the following nursing diagnosis should be given highest priority by the nurse in a client diagnosed with Guillain-Barre Syndrome (GBS)?
a) activity intolerance related to muscle weakness
b) ineffective breathing pattern related to respiratory muscle weakness
c) ineffective sexuality pattern related to paralysis
d) ineffective coping related to body changes
37. A client has been diagnosed to have Alzheimer's disease. Which of the following is most appropriate nursing action to prevent sundowning syndrome?
a) make the client stay in his room before dark
b) turn lights on before dark
c) feed the client before dark
d) administer the client's medication before dark
38. Which of the following manifestations is most likely observed in a child with hydrocephalus?
a) depressed anterior fontanel
b) sunsetting eyes
c) loud, vigorous cry
d) short and thick neck
39. The client has been diagnosed to have ALS (amyotrophic lateral sclerosis). Which of the following manifestations characterize the disease? Select all that apply
a) muscle weakness
b) intention tremors
c) muscle atrophy
d) fatigue
e) shuffling gait
f) respiratory difficulty
40. The client had undergone cerebral angiography. Which of the following potential complications should the nurse be most alert for?
a) nausea and vomiting
b) skin rashes
c) hypertension
d) hypotension
NCLEX Secrets - Neurology Board Review:
ANSWERS AND RATIONALE
36) B
- in GBS, respiratory muscle weakness and paralysis occur.
37) B
- turning lights on before dark prevents sundowning syndrome.
38) B
- sunsetting eyes characterize hydrocephalus. Other signs and symptoms include: sudden enlargement of head, bulging fontanels, dilated scalp veins, separated sutures, Macewen sign, frontal enlargement/bossing, and thinning of skull bones.
39) A, C, D, F
- amyotrophic lateral scerosis (ALS) is a motor neuron disorder. It is characterized by fatigue, awkwardness of fine finger movement, muscle wasting, dysphagia, muscle weakness, atrophy, fasciculations, dysarthria, jaw clonus, respiratory difficulty, spasticity of flexor muscles. This disease is also known as "Lou Gehrig's disease."
40) D
- the contrast medium used in cerebral angiography has profound diuretic effect. Therefore, it may cause hypotension.
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NCLEX Secrets - Neurology Board Review (36-40)
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