NCLEX Practice Questions Specialty Topics

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NCLEX 3500

87 terms chzarlotte8Preview Practic 124 term Lau The nurse is performing a neurological assessment on an adult client suspected of having a traumatic brain injury (TBI). Which signs/symptoms would indicate to the nurse that the client's ICP is increasing.

• Projectile vomiting
• Narrowing pulse pressure
• Delay in verbal response

4. DTR: left 2+/4+, right 2+/4+

• (-) Babinski
• Glasgow Coma Scale Score 13

1,3 Which intervention would the nurse include when planning care for a client who has increased intracranial pressure (IICP)?Select All That Apply

• Place client supine.
• Hyperextend head to maintain airway.
• Maintain body temperature below 100.4 F (38 C).
• Cluster nursing care.
• Monitor vital signs for Cushing's Triad.
• Limit suctioning.

3,5,6 The goal of treatment is to relieve the IICP by reducing cerebral edema, reducing the amount of cerebrospinal fluid, or reducing the blood volume in the brain, We also have to maintain cerebral perfusion.

Which signs/symptoms would lead the clinic nurse to suspect that a client may have bacterial meningitis?Select All That Apply

• Nuchal rigidity
• Photophobia
• (+) Kernig
• (-) Brudzinski
• Fever 102.8 F (39.3 C)
• Reports headache 9/10

1,2,3,5,6

Signs and Symptoms of meningitis include nuchal rigidity, photophobia, a positive Kernig sign, chills and high fever, and severe headache.A client is admitted with a diagnosis of bacterial meningitis. Which action should the nurse initiate first?Choose One

• Darken room.
• Provide sponge bath for fever of 102 F (38.8 C).
• Pad side rails.
• Place on Droplet precautions

4 Bacterial meningitis is transmitted through the respiratory system. According to the Center of Disease Control (CDC), clients with bacterial meningitis should be placed on "Droplet Precautions".What assessment finding by the nurse would support a client diagnosis of basilar skull fracture?Select All That Apply

• (+) Halo test
• Hyper-reflexia
• Raccoon eyes
• Battle's sign
• Kernig sign

1,3,4 Basilar skull fractures are the most serious fracture. You see bleeding where? Eyes, ears, nose, and throat. So, you will see cerebrospinal rhinorrhea with a (+) Halo test. If you have a bloody spot on the sheet, or wherever, when CSF is present, it will settle out and form a ring or halo around the blood spot. Raccoon eyes, is perioribital bruising which is seen with a basilar skull fracture. Battle's sign or bruising over the mastoid is also indicative of a skull fracture.

A client, with a T5 injury, has not had a bowel movement in three days. Today, the client reports a headache rated 10/10. The nurse takes the client's vital signs: BP 180/110, HR 52, RR 20. What action by the nurse takes priority?Choose One

• Administer hydralazine 20 mg IV.
• Elevate head of bed 45 degrees.
• Remove impaction with topical anesthetic.
• Close air vents in the room.

2 These signs/symptoms should lead the nurse to realize that the client is experiencing autonomic dysreflexia. The priority is to lower the blood pressure by raising the head of the bed to a semi-fowler's position.The nurse is performing a neurological assesment on a client who reports frequent headaches. What question(s) should the nurse ask during this assessment?Select All That Apply

• "When did the headaches begin?"
• "What symptoms accompany the headaches?"
• "Does anything relieve the headaches?"
• "Does anything make the headaches worse?"
• "Are you experiencing depression?"

1,2,3,4

In what position should the nurse place a client post lumbar puncture?Choose One

• Reverse trendelenburg
• Prone
• Side-lying
• Supine HOB elevated 45 degrees

2 Post lumbar puncture, the client should lie flat or preferably prone for 4-8 hours so that a seal will form at the puncture site.What action should the nurse take when caring for a client who has a subarachnoid screw?Choose One

• Keep connections tight.
• Use clean technique when caring for screw.
• Clean daily with hydrogen peroxide.
• Maintain a wet to dry dressing around site.

Submit 1 In order to prevent infection, all connections should be tight. We do not want leaking of the CSF.

A client comes to the clinic and states that she believes she is pregnant. What probable signs of pregnancy does the nurse expect to see?Select All That Apply

• Amenorrhea
• Facial chloasma
• Fetal movement
• Breast tenderness
• Positive pregnancy test
• Urinary frequency

2,5 Probable signs are things that most likely indicate pregnancy and are signs the primary healthcare provider will identify. Facial chloasma, also known as the mask of pregnancy, is a probable sign. A positive pregnancy test is also a probable sign of pregnancy. Why isn't it a positive sign of pregnancy? There are other conditions that can increase hCG levels.A client in her first trimester of pregnancy has been attending educational sessions on pregnancy. What statements by the client would indicate to the nurse that client teaching has been successful?Select All That Apply

• "Good food sources of iron includes spinach, raisins, and dark chocolate.

"2. "I will eat at least 40 grams of protein a day."

• "Taking folic acid will help prevent heart defects from occurring."
• "Swimming is an acceptable exercise for me while I am pregnant."
• "I can gain 2 pounds (0.9 kg) per week during my first trimester."
• "I need to stay out of hot tubs while pregnant."

1,4,6 Good sources of iron include liver, spinach, lentils, raisins, fortified cereals, dark chocolate, and dried fruits. Walking and swimming are the best exercises for a pregnant woman. Remember, no high impact. We also do not want them to get overheated, so do not let mom get into hot tubes or under heating blankets because this will increase body temperature and can cause birth defects.A client in her third trimester comes to the clinic for a routine prenatal visit. The nurse notes a weight gain of 4 pounds (1.8 kg) in a week. What action should the nurse take?Choose One

• Check urine for protein.
• Educate on proper weight gain during pregnancy.
• Notify the primary healthcare provider.
• Send client to the labor and delivery unit.

1 We are worried about pre-eclampsia, so we need to check the client's BP and check urine for protein.