Uworld NCLEX Questions and Answers

Uworld NCLEX Questions and Answers Already Passed

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

• Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
• Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood pressure
• Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
• Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

✔✔2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.

• Encourage the client to cough to expectorate secretions.
• Elevate the head of the bed 15 - 20 degrees.
• Contact the HCP if ICP is >15 mmHg.
• Monitor neurologic status using the Glasgow Coma Scale.
• Stimulate the client with active range-of-motion exercises. ✔✔2, 3, 4

The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range of motion exercises will increase ICP and should be avoided in the early postoperative stage.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

• Compress the nares
• Tilt the head back
• Collect the drainage
• Administer an antihistamine for postnasal drip ✔✔3

The clear drainage must be analyzed to determine whether it is nasal drainage or CSF. The nurse should not give the client tissues because it is important to know how much leakage of CSF is

occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

• Fluid is clear and tests negative for glucose.
• Fluid is grossly blood in appearance and has a pH of 6
• Fluid clumps together on the dressing and had a pH of 7

Fluid separates into concentric rings and tests positive for glucose. ✔✔4 Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull fractures. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke.Which characteristics are associated with this condition? Select all that apply.

• The client is aphasic.
• The client has weakness on the right side of the body.
• The client has complete bilateral paralysis of the arms and legs.
• The client has weakness on the right side of the face and tongue.
• The client has lost the ability to move the right arm but is able to walk independently
• The client has lost the ability to ambulate independently, but is able to feed and bathe himself

or herself without assistance. ✔✔1, 2, 4 Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautions and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse has instructed the family of a client with stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understand the measures to use when caring for the client?

• We need to discourage him from wearing eyeglasses.
• We need to place objects in his impaired field of vision.