Cognitive And Sensory Alterations Support - NCLEX Pn

What is the correct technique to guide a visually impaired client while ambulating?

Have client hold the nurse's arm; walk a half-step behind. Provides secure guidance allowing the client to anticipate changes in terrain.
Which instruction is most appropriate for a client with cataracts to reduce fall risk?

Increase lighting and remove environmental clutter. Enhances visual acuity and eliminates hazards to prevent accidents.
Which medication is commonly administered for ongoing active seizure per emergency protocol?

Benzodiazepine such as lorazepam. Rapidly terminates prolonged seizures by enhancing GABA-mediated inhibition in the brain.
What is the most appropriate immediate nursing response to a client reporting new-onset unilateral weakness?

Activate stroke protocol and note time last known well. Initiates rapid response team and establishes timeline for potential thrombolytic eligibility.
Which approach best reduces delirium in hospitalized older adults?

Frequent reorientation and promote sleep-wake cycle. Mitigates confusion by reinforcing reality and normalizing circadian rhythms.
Which feature best distinguishes delirium from dementia in onset and course?

Delirium is acute and fluctuating. Highlights sudden onset versus dementia's gradual progression for accurate diagnosis.
What is the best communication approach for a client with expressive aphasia?

Use yes/no questions and allow time to respond. Accommodates language production deficits while facilitating effective information exchange.
Which intervention is appropriate for severe hypoglycemia when the client is unconscious?

Administer IV dextrose or glucagon per protocol. Delivers glucose directly when oral administration is unsafe due to impaired consciousness.
Which action is appropriate when caring for a client with dementia who is wandering?

Provide supervised ambulation and a safe, structured routine. Balances safety with mobility needs to minimize agitation and injury risk.
What is the priority nursing action for suspected hypoglycemia with confusion and diaphoresis?

Check blood glucose immediately. Identifies treatable cause of altered mental status to prevent further neurologic damage.
Which postictal nursing action is highest priority immediately after a generalized seizure?

Position side-lying and assess airway and breathing. Prevents aspiration of secretions and ensures respiratory stability in the recovery phase.
What is the correct action regarding an object in the mouth during an active seizure?

Do not place anything in the mouth. Avoids risk of dental injury, aspiration, or airway obstruction during tonic-clonic activity.
What triad of findings defines Cushing triad in late increased intracranial pressure?

Widened pulse pressure, bradycardia, irregular respirations. Represents compensatory response to severe brainstem compression from elevated pressure.
Which neurologic assessment finding is most concerning for acute stroke progression?

New decrease in level of consciousness. Signals potential complications like hemorrhage or edema requiring immediate intervention.
Which option best supports a client with hearing impairment during teaching?

Face the client, speak clearly, and reduce background noise. Optimizes auditory input and supports lip-reading for better comprehension.
Which intervention is appropriate for a conscious client with confirmed hypoglycemia who can swallow?

Give $15$ g rapid-acting carbohydrate. Rapidly elevates blood glucose to alleviate symptoms without risking overcorrection.
Which nursing intervention is most appropriate for a client with unilateral neglect after stroke?

Place needed items on the unaffected side and cue scanning. Encourages attention to neglected field through environmental cues and adaptation.
Which finding is an early sign of increased intracranial pressure (ICP)?

Decreasing level of consciousness. Reflects early cerebral compression before vital sign alterations manifest.
What GCS score range indicates severe neurologic impairment or coma?

GCS $\leq 8$ . Indicates coma or severe brain injury requiring urgent medical intervention.
Which intervention is appropriate to decrease aspiration risk in a client with dysphagia after stroke?

Keep upright for meals and use thickened liquids as ordered. Promotes safe swallowing mechanics and controls bolus flow to minimize pneumonia risk.
Which assessment tool is most appropriate to quantify level of consciousness in an adult?

Glasgow Coma Scale (GCS). Standardized tool evaluates consciousness through eye opening, verbal response, and motor response scores.
Identify the priority action when a seizure begins in a hospitalized client.

Protect from injury; maintain airway; do not restrain. Ensures client safety and airway patency during involuntary movements without exacerbating injury.
Which finding suggests acute angle-closure glaucoma requiring urgent evaluation?

Severe eye pain with halos around lights. Indicates sudden intraocular pressure spike obstructing aqueous humor outflow.
Which head-of-bed position is typically used to help lower intracranial pressure?

Elevate head of bed to $30^{\circ}$ with midline head alignment. Facilitates cerebral venous drainage and reduces pressure without compromising perfusion.

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