🎯 High-Yield Points
- Stroke: FAST — Face drooping, Arm weakness, Speech difficulty, Time to call for help; tPA within 3-4.5 hours
- Increased ICP: HOB 30-45 degrees, avoid Valsalva, maintain PaCO2 35-40 mmHg
- Seizures: protect from injury, do NOT restrain or put anything in mouth, time the seizure
- Spinal cord injury: spinal shock vs neurogenic shock; turn every 2 hours for skin integrity
- Lumbar puncture: position fetal, check for headache post-procedure, lay flat 4-8 hours after
[Concept Map: Neurological NCLEX Questions — Clinical Manifestations, Nursing Interventions, Priority Actions]
Practice Questions
Question 1
A client presents with sudden onset left-sided facial drooping, left arm weakness, and garbled speech. Which action is the PRIORITY?
✓ Correct: Notify the provider and activate stroke protocol immediately
This presentation is a classic stroke presentation — FAST criteria met (Face, Arm, Speech). Time is brain: for every minute a stroke is untreated, approximately 1.9 million neurons die. The nurse must immediately notify the provider and activate the stroke protocol. tPA (tissue plasminogen activator) can be administered within 3-4.5 hours of symptom onset for ischaemic stroke, but only if stroke is identified and treated rapidly.
This presentation is a classic stroke presentation — FAST criteria met (Face, Arm, Speech). Time is brain: for every minute a stroke is untreated, approximately 1.9 million neurons die. The nurse must immediately notify the provider and activate the stroke protocol. tPA (tissue plasminogen activator) can be administered within 3-4.5 hours of symptom onset for ischaemic stroke, but only if stroke is identified and treated rapidly.
Question 2
A nurse is caring for a client with increased intracranial pressure (ICP). Which nursing action should the nurse AVOID?
✓ Correct: Suctioning the airway for 90 seconds at a time
Prolonged suctioning (>15 seconds) causes hypoxia and Valsalva-like responses, both of which increase ICP. Suctioning in ICP clients must be limited to 10-15 seconds maximum, with pre-oxygenation before and after. HOB at 30-45 degrees promotes venous drainage from the brain. Clustering activities reduces repeated stimulation that spikes ICP. Mannitol (osmotic diuretic) reduces cerebral oedema.
Prolonged suctioning (>15 seconds) causes hypoxia and Valsalva-like responses, both of which increase ICP. Suctioning in ICP clients must be limited to 10-15 seconds maximum, with pre-oxygenation before and after. HOB at 30-45 degrees promotes venous drainage from the brain. Clustering activities reduces repeated stimulation that spikes ICP. Mannitol (osmotic diuretic) reduces cerebral oedema.
Question 3
A client with tonic-clonic seizures is actively seizing. Which action is PRIORITY?
✓ Correct: Protect the client from injury by clearing the immediate environment
During a seizure, never restrain the client and never insert anything into the mouth (the jaw cannot be forced open and objects cause dental and injury risks). Priority: protect the client from injury (clear the area, pad side rails), position on side (recovery position) to prevent aspiration, and time the seizure. After the seizure, maintain the airway with positioning. Call for help and document the seizure characteristics.
During a seizure, never restrain the client and never insert anything into the mouth (the jaw cannot be forced open and objects cause dental and injury risks). Priority: protect the client from injury (clear the area, pad side rails), position on side (recovery position) to prevent aspiration, and time the seizure. After the seizure, maintain the airway with positioning. Call for help and document the seizure characteristics.
Question 4
A nurse is assessing a client with C5 spinal cord injury who suddenly becomes diaphoretic and has a blood pressure of 210/118 mmHg. The client reports a pounding headache. Which condition is suspected?
✓ Correct: Autonomic dysreflexia
Autonomic dysreflexia is a life-threatening emergency unique to spinal cord injuries above T6. It is triggered by a stimulus below the injury level (most commonly a full bladder or bowel). Massive sympathetic stimulation causes severe hypertension, pounding headache, diaphoresis above the injury, and bradycardia. Immediate action: sit client upright (lowers BP), identify and remove the trigger (check for urinary catheter kink or bowel impaction), and notify provider immediately.
Autonomic dysreflexia is a life-threatening emergency unique to spinal cord injuries above T6. It is triggered by a stimulus below the injury level (most commonly a full bladder or bowel). Massive sympathetic stimulation causes severe hypertension, pounding headache, diaphoresis above the injury, and bradycardia. Immediate action: sit client upright (lowers BP), identify and remove the trigger (check for urinary catheter kink or bowel impaction), and notify provider immediately.
Question 5
After a lumbar puncture, which position is MOST appropriate for the client?
✓ Correct: Flat for 4-8 hours
After lumbar puncture, the client should remain flat (supine) for 4-8 hours to allow the puncture site to seal and equalise CSF pressure gradients. This position reduces the risk of post-lumbar puncture headache (caused by CSF leakage through the dural puncture site). Encourage oral fluids (if not contraindicated) to help restore CSF volume. Sitting up too soon after LP significantly increases headache risk.
After lumbar puncture, the client should remain flat (supine) for 4-8 hours to allow the puncture site to seal and equalise CSF pressure gradients. This position reduces the risk of post-lumbar puncture headache (caused by CSF leakage through the dural puncture site). Encourage oral fluids (if not contraindicated) to help restore CSF volume. Sitting up too soon after LP significantly increases headache risk.
Want More Questions?
Our complete question bank has 500+ NCLEX questions with topic filters and NGN case studies.
Access Full Question Bank — Ksh 12,000