Exam 6 NCLEX Style Questions

Exam 6 NCLEX Style Questions 5.0 (1 review) Students also studied Terms in this set (62) Science MedicineNursing Save NCLEX Style questions for neuro

• terms

mcdonakj3Preview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview lumbar puncture 56 terms alafferty0005Preview Lumbar 15 terms leah

• Assist client to eat meals while lying flat in bed
• Administer an opioid medication
• Encourage client to increase fluid intake

-The prone position may relieve a headache following a lumbar puncture -Administering an opioid medication for a client's report of headache pain is an appropriate action by the nurse -Maintaining positive fluid balance may relieve a headache following a lumbar puncture A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse? (Select all that apply)

• Use the Glasgow Coma Scale when assessing the client
• Assist client to eat meals while lying flat in bed
• Administer an opioid medication
• Encourage client to increase fluid intake
• Place client in a "cannonball" position
• Infection

-The nurse should monitor a client with a ventriculostomy for infection, which is a complication. Strict asepsis should be used to avoid this life-threatening condition, which may result in meningitis A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

• Headache
• Infection
• Aphasia
• Hypertension

B. E3+V4+M4=11

-The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following is the correct scoring by the nurse using the Scale that indicates the client has a moderate head injury?

A. E2+V3+M5=10

B. E3+V4+M4=11

C. E4+V5+M6=15

D. E2+V2+M4=8

• "I think I may be pregnant"
• "I take Coumadin"
• "I am allergic to shrimp"

-The client's statement of possible pregnancy should be reported to the provider because the contrast dye may place the fetus at risk -The client taking Coumadin should be reported to the provider due to the potential for bleeding following the angiogram -A client's report of allergy to shrimp, which is a shellfish, should be reported to the provider due to a potential allergic reaction to the contrast dye A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply)

• "I think I may be pregnant"
• "I take Coumadin"
• "I take antihypertensive medication"
• "I am allergic to shrimp"
• "I am allergic to latex"
• "Try to stay awake most of the night prior to the

procedure" -The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity.A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching?

• "Do not wash your hair the morning of the procedure"
• "Try to stay awake most of the night prior to the procedure"
• "The procedure will take approximately 15 minutes"
• "You will need to lie flat for 4 hours after the procedure"
• Implement droplet isolation precautions

-When using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to place the client in droplet precaution isolation when meningitis is suspected to prevent spread of the disease to others A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?

• Administer antibiotics
• Implement droplet isolation precautions
• Initiate IV access
• Decrease bright lights
• Place client in supine position
• Place hands behind the client's neck
• Bend client's head toward chest

-The nurse should place the client in supine position when assessing for Brudzinski's sign

• The nurse should place her hands behind the client's

neck when assessing for Brudzinski's sign, in order to flex the client's neck -The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign; it is a positive if the client reports pain A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following are appropriate actions by the nurse when performing this technique? (Select all that apply)

• Place client in supine position
• Flex client's hip and knee
• Place hands behind the client's neck
• Bend client's head toward chest
• Straighten the client's flexed leg at the knee
• Neisseria meningitidis

-The nurse should plan to administer a vaccine against Neisseria meningitidis because it is recommended that college students living in close proximity be immunized against meningitis A nurse is reviewing the health record of a student newly admitted to a university and living in a dormitory. The health record indicates the student requires follow- up immunizations. Which of the following organisms should the nurse plan to vaccinate the student against?

• Streptococcus pneumoniae
• Neisseria meningitidis
• Bartonella henselae
• Rickettsia rickettsii

• Implement seizure precautions
• Turn off room lights and television
• Monitor for impaired extraocular movements

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following are appropriate nursing actions? (Select all that apply)

• Implement seizure precautions
• Perform neurological checks four times a day
• Administer morphine for the report of neck and generalized pain
• Turn off room lights and television
• Monitor for impaired extraocular movements
• Encourage the client to cough frequently
• Provide an emesis basin at the bedside
• Administer antipyretic medication as prescribed
• Perform a skin assessment

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply)

• Monitor for bradycardia
• Provide an emesis basin at the bedside
• Administer antipyretic medication as prescribed
• Perform a skin assessment
• Keep the head of the bed flat
• Provide privacy
• Ease the client to the floor if standing
• Move furniture away from the client
• Loosen the client's clothing
• Protect the client's head with padding

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply)

• Provide privacy
• Ease the client to the floor if standing
• Move furniture away from the client
• Loosen the client's clothing
• Protect the client's head with padding
• Restrain the client
• Keep the client in a side-lying positionA nurse is caring for a client who just experienced a generalized seizure. Which of

the following actions should the nurse perform first?

• Keep the client in a side-lying position
• Monitor the client's vital signs
• Reorient the client to the environment
• Check the client for injuries
• Take the medication at the same time every day A nurse is providing discharge instructions to a female client who has a

prescription for phenytoin (Dilantin). Which of the following information should the nurse include?

• Consider taking oral contraceptives when on this medication
• Watch for receding gums when taking the medication
• Take the medication at the same time every day
• Provide a urine sample to determine therapeutic levels of the medication
• Overwhelming fatigue should be avoided
• Caffeinated products should be removed from the diet
• Looking at flashing lights should be limited

A nurse is reviewing trigger factors that can cause seizures who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in the review? (Select all that apply)

• Overwhelming fatigue should be avoided
• Caffeinated products should be removed from the diet
• Looking at flashing lights should be limited
• Aerobic exercise may be performed
• Episodes of hypoventilation should be limited
• Use of aerosol hairspray is recommended

• Place a magnet over the implantable device when an

aura occurs A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following information should be nurse include in the teaching?

• The use of a microwave to heat food is permitted
• Inform a provider to order only a MRI when a scan is needed
• Place a magnet over the implantable device when an aura occurs
• The use of ultrasound diathermy for pain management is recommended
• Provide a walker for ambulationA nurse is caring for a client who displays signs of stage 3 Parkinson's disease.

Which of the following actions should the nurse include in the plan of care?

• Recommend a community support group
• Integrate a daily exercise routine
• Provide a walker for ambulation
• Consultation with a dietitian
• Record diet and fluid intake daily
• Add thickener to liquids
• Offer nutritional supplements between meals

A nurse is developing a plan of care for the nutritional needs of a client who has stage 4 Parkinson's disease. Which actions should the nurse include in the plan of care? (Select all that apply)

• Provide three large balanced meals daily
• Record diet and fluid intake daily
• Document weight every other week
• Add thickener to liquids
• Offer nutritional supplements between meals
• Rise slowly when standingA nurse is reinforcing teaching with a client who has Parkinson's disease and has

received a prescription for bromocriptine (Parlodel). Which of the following instructions should the nurse include in the teaching?

• Rise slowly when standing
• Increase carbohydrate intake
• Limit exposure to hear
• Report any skin discoloration
• Pill-rolling tremor of the fingers
• Shuffling gait
• Drooling
• Lack of facial expressions

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply)

• Decreased vision
• Pill-rolling tremor of the fingers
• Shuffling gait
• Drooling
• Bilateral ankle edema
• Lack of facial expressions
• Assist with hygiene as neededA nurse is caring for a client who has Parkinson's disease and displays signs of

bradykinesia. Which of the following is an appropriate action by the nurse?

• Allow client extra time for verbal responses to questions
• Complete passive ROM exercises
• Provide an alternate form of communication
• Assist with hygiene as needed