NCLEX RN EXAM – NEUROLOGICAL DISORDERS WITH CORRECT ANSWERS

Neurological Disorders Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A Placing the client on the back with a small pillow under the head. B Keeping portable suctioning equipment at the bedside. C Opening the client's mouth with a padded tongue blade. D Cleaning the client's mouth and teeth with a toothbrush. ANSWER: A Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction, so having suction equipment at the bedside is necessary. Padded tongue blades are safe to use. A toothbrush is appropriate to use. A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A Prepare to administer recombinant tissue plasminogen activator (rt-PA). B Discuss the precipitating factors that caused the symptoms. C Schedule for A STAT computer tomography (CT) scan of the head. D Notify the speech pathologist for an emergency consult. ANSWER: C Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A Current medications. B Complete physical and history.