MS 2 Exam 3 NCLEX questions

MS 2 Exam 3 NCLEX questions Leave the first rating Students also studied Terms in this set (35) Science MedicineNursing Save Med Surg Gastrointestinal NCLEX Q...86 terms Jasmine_Lawson4 Preview NCLEX Stye Review Questions MS 2 ...238 terms jelittPreview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Multipl 20 terms san The nurse performs an initial neurologic assessment on an older client. Which assessment findings would the nurse expect to be the result of normal physiologic aging? Select all that apply.

• Decreased coordination
• Hearing loss
• Long-term memory loss
• Recent memory loss
• Decreased balance control
• Decreased coordination
• Hearing loss
• Recent memory loss
• Decreased balance control

During a client's neurologic assessment, the nurse finds that the client is arousable only with vigorous or painful stimulation. How does the nurse document this client's level of consciousness?

• Stuporous
• Lethargic
• Comatose
• Alert
• Stuporous

The nurse is teaching a client about what to expect immediately after a cerebral angiographic examination.Which statement by the client indicates a need for further teaching?

• "I'll have a pressure dressing on my groin for a couple

of hours."

• "I'll have to keep my leg straight for a while after the

procedure."

• "The nurses will check circulation in my injected leg

frequently."

• "I can use heat on my groin to decrease any

discomfort."

• "I can use heat on my groin to decrease any discomfort."

The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury.Which assessment finding is the immediate concern of the nurse?

• Disorientation
• Numbness in both arms
• Decreased level of consciousness
• Report of headache
• Decreased level of consciousness

The nurse is caring for a client following a cerebral angiography. Which assessment finding will the nurse report immediately to the primary health care provider?

• Discomfort at the injection site
• Bleeding from the injection site
• Fatigue and weakness
• Mild headache
• Bleeding from the injection site

A nurse is assessing a client with a suspected diagnosis of multiple sclerosis. Which assessment findings will the nurse expect? Select all the apply.

• Resting tremors
• Memory loss
• Muscle spasticity
• Fatigue
• Diplopia
• Dysarthria
• Memory loss
• Muscle spasticity
• Fatigue
• Diplopia
• Dysarthria

A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed.The client's blood pressure is 190/110 mm Hg. What is the nurse's priority action at this time?

• Perform a bladder assessment.
• Insert an indwelling urinary catheter.
• Place the patient in a sitting position.
• Turn on a fan to cool the patient.
• Place the patient in a sitting position.

A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider?

• Purulent drainage from the pin sites on the client's

forehead

• Painful pressure injury under the collar
• Inability to move legs or feet
• Oxygen saturation of 95% on room air
• Purulent drainage from the pin sites on the client's forehead

The primary health care provider started a client with multiple sclerosis on mitoxantrone therapy. Which statement will the nurse include in teaching the client about this drug?

• "Report changes in urinary and bowel elimination

immediately."

• "Follow up for annual lab testing to monitor for liver

toxicity."

• "Rotate the sites for your self-administered injections."
• "Avoid crowded places such as malls and large public

gatherings."

• "Avoid crowded places such as malls and large public gatherings."

A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client?

• Assess cardiac sounds.
• Manage the client's airway.
• Check oxygen saturation level.
• Perform a neurologic assessment.
• Manage the client's airway.

Which statement by the client indicates a need for further teaching by the nurse about preventing back injuries?

• "I need to lose weight because I'm too big."
• "I should not stand or sit for a long period of time."
• "It would be best if I could get ergonomic office

furniture."

• "Exercise is not going to help my back very much."
• "Exercise is not going to help my back very much."

Which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse?

• "I'm glad I can keep eating protein like red meat."
• "I'll try to walk at least 20 to 30 minutes each day."
• "I'm going to talk to my doctor about a weight loss

plan."

• "I plan to include more fruits and vegetables in my

diet."

• "I'm glad I can keep eating protein like red meat."

The nurse is caring for a client treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse to report to the primary health care provider?

• Client has a new-onset mild headache.
• Client's blood pressure is 194/120 mm Hg.
• Client has left hemiparesis.
• Client continues to be drowsy.
• Client's blood pressure is 194/120 mm Hg.

The nurse is caring for an older client with receptive (sensory) aphasia. Which nursing action is most appropriate for communicating with the client?

• Refer the client to the speech-language pathologist

(SLP).

• Speak loudly to help the client interpret what is being

said.

• Provide pictures to help the client understand.
• Ask the client to read messages on a whiteboard.
• Provide pictures to help the client understand.

A client returns from the postanesthesia care unit (PACU) after a surgical removal of a frontal lobe tumor. In what position will the nurse place the client at this time?

• Turn the client from side to side to prevent aspiration.
• Elevate the head of the bed to at least 30 degrees at

all times.

• Keep the client flat in bed or up 10 degrees and

reposition from side to side.

• Keep the client in a high-Fowler position in bed at all

times.

• Elevate the head of the bed to at least 30 degrees at all times.

The nurse reassesses a client who was admitted 8 hours after stroke symptoms began and documents the following findings. Which assessment findings would the nurse report immediately to the primary health care provider? Select all that apply.

• Blood pressure increase to 196/100 mm Hg
• Heart rate of 88 beats/min
• Respiratory rate of 22 breaths/min
• New-onset headache reported as 8/10 pain intensity
• Increased drowsiness and dozing frequently
• Urine output of 360 mL since admission
• Blood pressure increase to 196/100 mm Hg
• New-onset headache reported as 8/10 pain intensity
• Increased drowsiness and dozing frequently