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Saturday, October 4, 2008

Neurosensory Disorders: Passing Nclex Sata (Select All That Applies)

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1. The nurse is assessing a client's extraocular eye movements as part of the neurologic examination. Which cranial nerves are the nurse assessing?

Select all that apply: Nclex SATA

1. Cranial nerve II
2. Cranial nerve III
3. Cranial nerve IV
4. Cranial nerve V
5. Cranial nerve VI
6. Cranial nerve VIII

2. The nurse is assessing a 2-year-old client diagnosed with bacterial meningitis. Which of the following signs and symptoms of meningeal irritation is the nurse likely to observe?

Select all that apply: Nclex SATA

1. Generalized seizures
2. Nuchal rigidity
3. Positive Brudzinski's sign
4. Positive Kernig's sign
5. Babinski reflex
6. Photophobia

3. The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client?

Select all that apply: Nclex SATA

1. Spontaneous eye opening
2. Tachypnea, bradycardia, and hypotension
3. Unequal pupil size
4. Orientation to person, place, and time
5. Motor response to pain localized
6. Incomprehensible sounds

4. The nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client?

Select all that apply: Nclex SATA

1. Elevating the head of the bed 90 degrees
2. Loosening constrictive clothing
3. Using a fan to reduce diaphoresis
4. Assessing for bladder distention and bowel impaction
5. Administering antihypertensive medication
6. Placing the client in a supine position with legs elevated

5. The nurse is preparing a female client with tonic-clonic seizure disorder for discharge. Which instructions should the nurse include about phenytoin (Dilantin)?

Select all that apply: Nclex SATA

1. "Monitor for skin rash."
2. "Maintain adequate amounts of fluid and fiber in the diet."
3. "Perform good oral hygiene, including daily brushing and flossing."
4. "Receive necessary periodic blood work."
5. "Report to the physician any problems with walking, coordination, slurred speech, or nausea."
6. "Feel safe about taking this drug, even during pregnancy."

Nclex SATA Answers: Neurosensory Disorders
1. 2, 3, 5
2. 2, 3, 4, 6
3. 1, 4
4. 1, 2, 4, 5
5. 1, 3, 4, 5

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