Nervous System NCLEX Questions with correct answers Exam 3 2024 latest updated., Exams of Nursing

Download Nervous System NCLEX Questions with correct answers Exam 3 2024 latest updated. and more Exams Nursing in PDF only on Docsity! Nervous System NCLEX Questions with correct answers Exam 3 2024 latest updated. 1. The nurse is providing care for a client experiencing a myasthenic crisis. What would be most important for the nurse to frequently monitor? A. Ability to swallow B. Development of urinary tract infection C. Pulse rate and presence of dystrthmias D. Daily weights and urinary output - Correct answer A. Ability to swallow 2. 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. 3. What is a common neurotransmitter? A. Acetylcholine B. Gamma-aminobutyric acid (GABA) C. Serotonin D. All of the above - Correct answer D. All of the above 4. -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. 5. Alzheimer's disease is associated with a shortage of acetylcholine. 6. 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. 7. Serotonin is an inhibitory transmitter that helps the brain regulate acetylcholine. 8. 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 - Correct answer A. Myasthenia gravis 9. Rationale: In myasthenia gravis, the immune system creates an antibody that attacks acetylcholine receptors of the muscle cells. When acetylcholine binds to the acetylcholine receptors of the muscle cells, it causes them to contract. When an antibody blocks this binding, the cell fails to contract or contracts only weakly. This can cause drooping eyelids, weak eye muscles, and fatigue of affected muscles after exercise. 10.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 - Correct answer C. Parkinson's disease 11.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. 12.A client is admitted with Parkinson's disease. The client's face is expressionless, and the client's speech is monotone. Which of the following observations by the nurse is most accurate? A. The client is most likely depressed and should be left alone. B. These are common symptoms of Parkinson's disease that produce an undesired façade of an alert and responsive individual. C. The client's antipsychotic medication may need to be adjusted. D. The client probably has dementia. - Correct answer B. These are common symptoms of Parkinson's disease that produce an undesired façade of an alert and responsive individual 13.Rationale: The nurse should recognize that these are common symptoms or manifestations of Parkinson's disease. Parkinson's disease is caused by degeneration of the substantia nigra in the basal ganglia of the brain, where dopamine is produced and stored. This degeneration results in motor 28.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?" - Correct answer D. "Has something happened that is causing you to worry?" 29.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). 30.The nurse has completed medication education for a client prescribed phenelzine (Nardil). Which statements made by the client indicate an understanding of the teaching? Select all that apply. A. "I am really going to miss my morning coffee and sweet roll." 31. "B. I'll have to give up my beer at the football games." 32.C. "I can't eat fried chicken and gravy." 33.D."I am not supposed to have processed meats or cheese." 34.E. "I really shouldn't eat at a restaurant; too many foods are on my restricted list." - Correct answer A. "I am really going to miss my morning coffee and sweet roll." 35. "B. I'll have to give up my beer at the football games." 36.D."I am not supposed to have processed meats or cheese." 37.Rationale: Beer, processed meats and cheese is high in tyramine. Combining tyramine-rich foods with a monoamine oxidase inhibitor can result in a hypertensive crisis. Coffee, a sweet roll, fried chicken and gravy are not high in tyramine and are considered safe. There are many foods that are safe to eat; the client can safely eat at a restaurant. 38.MISCELLANEOUS PORTION SIZE TYRAMINE CONTENT 39.Considered to be low or nonexistent Yeast bread 2 slices 40.Coffee, tea, and soft drinks 4-12 oz (118-355 mL) Chocolate 1 oz (28 g) 41.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 - Correct answer B. suicide attempt 42.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. 43.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 - Correct answer D. thought content ( an example of a grandiose delusion and refers to thought content 44.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. 45.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." 46.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). 47.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 - Correct answer B. hold the 1700 hours dose of lithium 48.Rationale: The nurse should hold the 1700 hours dose of lithium because a level of 1.8 mEq/L (0.4 - 1.4 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. 49.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. 50.The nurse is providing care for a client experiencing a myasthenic crisis. What would be most important for the nurse to frequently monitor? A. Ability to swallow B. Development of urinary tract infection C. Pulse rate and presence of dystrthmias D. Daily weights and urinary output - Correct answer A. Ability to swallow 51.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. 52.What is a common neurotransmitter? A. Acetylcholine B. Gamma-aminobutyric acid (GABA) C. Serotonin D. All of the above - Correct answer D. All of the above 53. -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. 54.Alzheimer's disease is associated with a shortage of acetylcholine. 55.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. 56.Serotonin is an inhibitory transmitter that helps the brain regulate acetylcholine. 57.Acetylcholine(ACh) is a neurotransmitter that provides for communication between muscles and nerves. When there is a problem with the interaction B. Monitor the vital signs and level of consciousness C. Schedule a computed tomography scan and magnetic resonance imaging D. Notify the neurologist on call for a consult - Correct answer A. Administer lorazepam (Ativan) 71.Rationale: Although monitoring vital signs and changes in level of consciousness is important, it is not the priority in this situation. The priority is to prevent further seizure activity by administering an antiseizure medication, such as lorazepam (Ativan), which is a fast-acting benzodiazepine. 72.Diagnostic tests and arranging for a neurologic consult would be done after the medication is given. 73.Which of the following findings will the nurse observe in the client having a generalized tonic-clonic seizure and is in the tonic phase? A. jerking in one extremity that spreads gradually to adjacent areas B. vacant staring and abruptly ceasing all activity C. facial grimaces, patting motions, and lip smacking D. loss of consciousness, body stiffening, and violent muscle contractions - Correct answer D. loss of consciousness, body stiffening, and violent muscle contractions 74.Rationale: A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consist of loss of consciousness, dilated pupils, and muscular stiffening and contraction, which last about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (ie jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking. 75.Which of the following drug categories can be used for treating anxiety? A. Antitussives B. Anticoagulants C. Anticonvulsants D. Antibiotics - Correct answer C. Anticonvulsants 76.Rationale: In addition to anticonvulsants, antidepressants, several other drug classes are used to treat anxiety, including antiseizure or anticonvulsants drugs. Antitussives are used as cough suppressants. Anticoagulants are used to prevent blood clots from forming. Antibiotics are used primarily for bacterial infections. 77.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?" - Correct answer D. "Has something happened that is causing you to worry?" 78.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). 79.The nurse has completed medication education for a client prescribed phenelzine (Nardil). Which statements made by the client indicate an understanding of the teaching? Select all that apply. A. "I am really going to miss my morning coffee and sweet roll." 80. "B. I'll have to give up my beer at the football games." 81.C. "I can't eat fried chicken and gravy." 82.D."I am not supposed to have processed meats or cheese." 83.E. "I really shouldn't eat at a restaurant; too many foods are on my restricted list." - Correct answer A. "I am really going to miss my morning coffee and sweet roll." 84. "B. I'll have to give up my beer at the football games." 85.D."I am not supposed to have processed meats or cheese." 86.Rationale: Beer, processed meats and cheese is high in tyramine. Combining tyramine-rich foods with a monoamine oxidase inhibitor can result in a hypertensive crisis. Coffee, a sweet roll, fried chicken and gravy are not high in tyramine and are considered safe. There are many foods that are safe to eat; the client can safely eat at a restaurant. 87.MISCELLANEOUS PORTION SIZE TYRAMINE CONTENT 88.Considered to be low or nonexistent Yeast bread 2 slices 89.Coffee, tea, and soft drinks 4-12 oz (118-355 mL) Chocolate 1 oz (28 g) 90.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 - Correct answer B. suicide attempt 91.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. 92.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 - Correct answer D. thought content ( an example of a grandiose delusion and refers to thought content 93.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. 94.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." 95.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). 96.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 - Correct answer B. hold the 1700 hours dose of lithium degeneration of the substantia nigra in the basal ganglia of the brain, where dopamine is produced and stored. This degeneration results in motor dysfunction, resulting in symptoms such as an expressionless face and monotone speech. It is caused by the inability of basal ganglia to produce sufficient dopamine. 112. The symptoms do not indicate depression or dementia, although these are common in Parkinson's disease. 113. Antipsychotic medication will often mimic Parkinson's disease extrapyramidal symptoms and is not indicated 114. A client asks the nurse how morphine will control pain. Which response should the nurse provide the client? A. "Inhibits the primary pain neurotransmitters in your brain." B. "Stimulates the receptors that secrete endorphins in your brain." C. "Interacts with receptors in your body that produce analgesia." D. "Promotes the primary pleasure neurotransmitters in your brain." - Correct answer C. "Interacts with receptors in your body that produce analgesia." 115. Rationale: Opioids exert their actions by interacting with the opiate receptors in the brain. Drugs that stimulate these receptors are opioid agonists (binds to receptor & stimulates its function). Opioids do not inhibit neurotransmitters responsible for pain. Opioids do not promote secretion of endorphins. Opioids do not promote release of the pleasurable neurotransmitters. 116. 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. - Correct answer A. Do not drive until the effects of the medication are known. 117. B. Avoid pseudoephedrine (Sudafed) while taking the prescription. 118. 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. 119. Which of the following physician's order should the nurse implement first for a client who has a tonic-clonic seizure? A. Administer lorazepam (Ativan) B. Monitor the vital signs and level of consciousness C. Schedule a computed tomography scan and magnetic resonance imaging D. Notify the neurologist on call for a consult - Correct answer A. Administer lorazepam (Ativan) 120. Rationale: Although monitoring vital signs and changes in level of consciousness is important, it is not the priority in this situation. The priority is to prevent further seizure activity by administering an antiseizure medication, such as lorazepam (Ativan), which is a fast-acting benzodiazepine. 121. Diagnostic tests and arranging for a neurologic consult would be done after the medication is given. 122. Which of the following findings will the nurse observe in the client having a generalized tonic-clonic seizure and is in the tonic phase? A. jerking in one extremity that spreads gradually to adjacent areas B. vacant staring and abruptly ceasing all activity C. facial grimaces, patting motions, and lip smacking D. loss of consciousness, body stiffening, and violent muscle contractions - Correct answer D. loss of consciousness, body stiffening, and violent muscle contractions 123. Rationale: A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consist of loss of consciousness, dilated pupils, and muscular stiffening and contraction, which last about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (ie jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking. 124. Which of the following drug categories can be used for treating anxiety? A. Antitussives B. Anticoagulants C. Anticonvulsants D. Antibiotics - Correct answer C. Anticonvulsants 125. Rationale: In addition to anticonvulsants, antidepressants, several other drug classes are used to treat anxiety, including antiseizure or anticonvulsants drugs. Antitussives are used as cough suppressants. Anticoagulants are used to prevent blood clots from forming. Antibiotics are used primarily for bacterial infections. 126. 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?" - Correct answer D. "Has something happened that is causing you to worry?" 127. 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). 128. The nurse has completed medication education for a client prescribed phenelzine (Nardil). Which statements made by the client indicate an understanding of the teaching? Select all that apply. A. "I am really going to miss my morning coffee and sweet roll." 129. "B. I'll have to give up my beer at the football games." 130. C. "I can't eat fried chicken and gravy." 131. D."I am not supposed to have processed meats or cheese." 132. E. "I really shouldn't eat at a restaurant; too many foods are on my restricted list." - Correct answer A. "I am really going to miss my morning coffee and sweet roll." 133. "B. I'll have to give up my beer at the football games." 134. D."I am not supposed to have processed meats or cheese." 135. Rationale: Beer, processed meats and cheese is high in tyramine. Combining tyramine-rich foods with a monoamine oxidase inhibitor can result in a hypertensive crisis. Coffee, a sweet roll, fried chicken and gravy are not high in tyramine and are considered safe. There are many foods that are safe to eat; the client can safely eat at a restaurant. 136. MISCELLANEOUS PORTION SIZE TYRAMINE CONTENT 137. Considered to be low or nonexistent Yeast bread 2 slices 138. Coffee, tea, and soft drinks 4-12 oz (118-355 mL) Chocolate 1 oz (28 g) 139. 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