406 Med-Surg: Neurological questions written for the NCLEX-RN, each with a rationale explaining why the correct answer is correct and why the others are not. Free, no account required. 10 examples are shown below.
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The answer: C — Neurological deficit severity — Prepare for immediate alteplase administration if eligible Think of it this way: In ischemic stroke, brain cells die at a rate of approximately 1.9 million neurons per minute of ischemia (blood flow blockage). The entire purpose of stroke care is to restore blood flow as fast as possible. Alteplase (tPA — tissue plasminogen activator) is the clot-busting medication that, when given within the 4.5-hour treatment window, can dissolve the clot and restore flow — potentially reversing deficits. Everything else in stroke management (blood pressure control, glucose management, anticoagulation reversal) is done IN SERVICE of determining eligibility for and delivering thrombolytic therapy. Time is brain. Why C is right: The HIGHEST PRIORITY in acute ischemic stroke is identifying the severity of the neurological deficit (via the NIH Stroke Scale — a standardized assessment of motor, sensory, speech, and visual deficits) and determining whether the patient is eligible for alteplase (tPA). This drives every other decision. Blood pressure management (to <185/110 before tPA), glucose correction, and INR reversal are all prerequisites to alteplase — they are done TO ENABLE option C, not competing priorities with it. The immediate nursing action is to facilitate rapid stroke team activation and prepare for IV thrombolysis in eligible patients. Why the others are wrong or secondary: - A: Elevated blood pressure → IV nicardipine — blood pressure control to <185/110 mmHg IS required before tPA administration (per AHA/ASA guidelines). However, this is a PREREQUISITE to alteplase delivery, not a competing priority. Managing BP is done to ALLOW tPA — it supports option C rather than replacing it as the primary concern. - B: Atrial fibrillation with rapid ventricular response → synchronized cardioversion — AF with RVR in a stroke patient does NOT require cardioversion as an immediate priority. Cardioversion has its own risks (anticoagulation requirements, risk of dislodging thrombus) and is not part of acute stroke management. Rate control (metoprolol, diltiazem) if needed, but this is not the first priority. - D: Elevated blood glucose → insulin — hyperglycemia worsens stroke outcomes and should be corrected, but it is done ALONGSIDE thrombolysis preparation, not before it. Glucose >180 mg/dL should be managed but does not override the tPA preparation priority. - E: Elevated INR → vitamin K + FFP — anticoagulation reversal IS required if INR >1.7 (an exclusion criterion for tPA). However, this is another safety check done as part of the thrombolysis eligibility evaluation, not a separate top-level priority from the stroke treatment goal. Remember: Stroke code = TIME IS BRAIN. Door-to-needle time ≤60 minutes is the target for tPA. All other interventions (BP management, glucose, INR reversal) are done rapidly as steps toward enabling thrombolysis. NIHSS score drives the sense of urgency and documents deficit severity. Absolute contraindications to tPA: hemorrhagic stroke, recent surgery, severe head trauma, coagulopathy (INR >1.7, platelets <100K), and symptom onset >4.5 hours. Technical note: The 4.5-hour tPA window is from LAST KNOWN WELL time (when patient was last seen normal), not from symptom onset if unknown. Wake-up strokes or unknown onset strokes may be evaluated with MRI DWI-FLAIR mismatch imaging to determine eligibility beyond the 4.5-hour window. Mechanical thrombectomy (clot retrieval with a stent-retriever catheter) extends the treatment window to 6-24 hours in selected patients with large vessel occlusion (LVO) and salvageable brain tissue on perfusion imaging.
When a stroke damages the left side of the brain, it causes loss of the right visual field in both eyes — this is called homonymous hemianopsia. Because the client has a blind spot on the right side, they need to learn to compensate by actively turning their head to the right, which brings the right side of the environment into their intact left visual field. Option A is wrong because placing the wheelchair on the left side puts it in the client's seeing side where it doesn't need compensation — the danger zone is the right side. Option B is wrong because approaching from the right side actually puts the nurse in the client's blind spot, making communication harder, not easier. Option C is wrong because objects on the left are already visible — the priority is helping the client safely access and be aware of things on the right side by teaching head-turning as a compensatory strategy.
A client with C4 injury has minimal upper extremity function and would require a motorized wheelchair with specialized controls (sip-and-puff or chin control). This is the highest priority for mobility and independence. Doorway widening, grab bars, and counter modifications are important but secondary to the fundamental need for appropriate mobility equipment. The client would likely need a power wheelchair with specialized control due to lack of hand function.
Trihexyphenidyl is an anticholinergic medication used to reduce tremor and rigidity in Parkinson's disease. Anticholinergics can cause urinary retention, especially in males with pre-existing benign prostatic hyperplasia (BPH). The nurse should monitor for this, particularly in older male clients. Bradycardia, liver failure, and hypoglycemia are not associated with this medication.
Sleep disturbances in Alzheimer's disease are common due to circadian rhythm changes. Maintaining a consistent daily routine with regular times for waking, meals, activities, and bedtime helps regulate the sleep-wake cycle. Sedatives should be avoided as they increase fall risk and can worsen confusion. Keeping the patient awake during the day may cause exhaustion and increased agitation.
In immunocompromised clients with cryptococcal meningitis, altered mental status and focal neurological deficits suggest complications such as increased intracranial pressure, cryptococcomas, or CNS involvement requiring urgent intervention. While headache, fever, and neck stiffness are common symptoms, new neurological deficits indicate potential herniation or stroke and require immediate evaluation.
Clients taking sumatriptan should be taught that if the first dose does not provide relief, they may take a second dose after 2 hours (for oral formulation) but must not exceed the maximum daily dose (usually 200 mg). Taking at the first sign of aura is also recommended for best efficacy, but the key instruction is about dosing limits. Sumatriptan should NOT be combined with ergotamine or other vasoconstrictive medications due to risk of severe vasoconstriction. While lying down may help with comfort, this is not a specific teaching point for the medication itself.
Wandering risk identification programs (like Project Lifesaver) use GPS tracking devices or identification bracelets to locate patients quickly if they wander. This preserves freedom while ensuring safety. Restraints and sedation are inappropriate and can cause harm.
For stable post-operative neurosurgical patients, routine neuro checks are typically performed every 4 hours. More frequent assessments (every 15-60 minutes) are reserved for unstable patients or immediately post-op. Less frequent checks may miss early signs of deterioration.
Spinal shock is characterized by temporary loss of all reflexes, motor function, and sensation below the level of injury. It results in flaccid paralysis, hypotension, and bradycardia. Spinal shock typically lasts days to weeks and is eventually replaced by reflex activity (spasticity) once the reflex arcs below the injury become hyperactive.
