NCLEX Test CVA, Neuro 24

8/20/2019 NCLEX Test CVA, Neuro 24

1/19

1. A white female client is admitted

to an acute care facility with a

diagnosis of cerebrovascular

accident (CVA). Her history reveals

bronchial asthma, exogenous

obesity, and iron deficiency anemia.

hich history finding is a ris!

factor for CVA"

A. Caucasian race

B. Female sex

C. #besity

D. Bronchial asthma

$. %he nurse is teaching a female

client with multi&le sclerosis. hen

teaching the client how to reduce

fatigue, the nurse should tell the

client to'

A. take a hot bath.

. rest in an airconditioned room.

C. increase the dose of muscle

relaxants.D. avoid naps during the day.

*. A male client is having a tonic

clonic sei+ures. hat should the

nurse do first"

A. Elevate the head of the bed.

B. Restrain the clients arms and legs.

C. !lace a tongue blade in the clients

mouth.. %a!e measures to &revent in-ury.

. A female client with /uillain

arr0 syndrome has &aralysis

affecting the res&iratory muscles

and reuires mechanical

ventilation. hen the client as!s the

nurse about the &aralysis, how

should the nurse res&ond"

A. 23ou may have difficultybelieving this, but the &aralysis

caused by this disease is

tem&orary.4

B. "#oull have to accept the fact that

youre permanently paraly$eD.

%o&ever' you &ont have any sensory

loss.(

C. ")t must be hard to accept the

permanency of your paralysis.(D. "#oull first regain use of your legs

and then your arms.(

5. %he nurse is wor!ing on a

surgical floor. %he nurse must

logroll a male client following a'

A. laminectomy.

B. thoracotomy.

C. hemorrhoidectomy.D. cystectomy.

6. A female client with a sus&ected

brain tumor is scheduled for

com&uted tomogra&hy (C%). hat

should the nurse do when &re&aring

the client for this test"

A. )mmobili$e the neck before the

client is moved onto a stretcher.. etermine whether the client is

allergic to iodine, contrast dyes, or

shellfish.

C. !lace a cap over the clients head.

D. Administer a sedative as ordered.


2/19

7. uring a routine &hysical

examination to assess a male

client8s dee& tendon reflexes, the

nurse should ma!e sure to'

A. use the pointed end of the reflex

hammer &hen striking the Achilles

tendon.

. su&&ort the -oint where the

tendon is being tested.

C. tap the tendon slo&ly and softly

D. hold the reflex hammer tightly.

9. A female client is admitted in a

disoriented and restless state aftersustaining a concussion during a

car accident. hich nursing

diagnosis ta!es highest &riority in

this client8s &lan of care"

A. Disturbed sensory perception

*visual+

B. ,elf-care deficient

Dressing/grooming

C. )mpaired verbal communication. :is! for in-ury

;. A female client with amyotro&hic

lateral sclerosis (A feel so

frustrate. > can8t do anything

without hel&?4 %his comment best

su&&orts which nursing diagnosis"

A. Anxiety

. @owerlessness

C. )neffective denial

D. Risk for disuse syndrome

1. Bor a male client with sus&ected

increased intracranial &ressure

(>C@), a most a&&ro&riate

res&iratory goal is to'

A. prevent respiratory alkalosis.

B. lo&er arterial p%.

C. &romote carbon dioxide

elimination.

D. maintain partial pressure of arterial

oxygen *!a01+ above 23 mm %g

11. urse Dary witnesses a

neighbor8s husband sustain a fall

from the roof of his house. %he

nurse rushes to the victim and

determines the need to o&ens theairway in this victim by using which

method"

A. Flexed position

B. %ead tilt-chin lift

C. Eaw thrust maneuver

D. 4odified head tilt-chin lift

1$. %he nurse is assessing the motor

function of an unconscious maleclient. %he nurse would &lan to use

which &lan to use which of the

following to test the client8s

&eri&heral res&onse to &ain"

A. ,ternal rub

. ail bed &ressure

C. !ressure on the orbital rim

D. ,5uee$ing of the

sternocleidomastoid muscle

1*. A female client admitted to the

hos&ital with a neurological

&roblem as!s the nurse whether

magnetic resonance imaging may be

done. %he nurse inter&rets that the


3/19

client may be ineligible for this

diagnostic &rocedure based on the

client8s history of'

A. %ypertension

B. %eart failure

C. @rosthetic valve re&lacement

D. Chronic obstructive pulmonary

disorder

1. A male client is having a lumbar

&uncture &erforme. %he nurse

would &lan to &lace the client in

which &osition"

A. ,ide-lying' &ith a pillo& under the

hip

B. !rone' &ith a pillo& under the

abdomen

C. !rone' in slight-6rendelenburgs

position

. =idelying, with the legs &ulled

u& and head bent down onto chest.

15. %he nurse is &ositioning thefemale client with increased

intracranial &ressure. hich of the

following &ositions would the nurse

avoid"

A. %ead mildline

. Head turned to the side

C. 7eck in neutral position

D. %ead of bed elevated 83 to 9:

degrees

16. A female client has clear fluid

lea!ing from the nose following a

basilar s!ull fracture. %he nurse

assesses that this is cerebros&inal

fluid if the fluid'

A. )s clear and tests negative for

glucose

B. )s grossly bloody in appearance

and has a p% of ;

C. Clumps together on the dressing

and has a p% of <

. =e&arates into concentric rings

and test &ositive of glucose

17. A male client with a s&inal cord

in-ury is &rone to ex&eriencing

automatic dysreflexiA. %he nurse

would avoid which of the following

measures to minimi+e the ris! of

recurrence"

A. ,trict adherence to a bo&el

retraining program

B. =eeping the linen &rinkle-free

under the client

C. !reventing unnecessary pressure

on the lo&er limbs

.


4/19

sided hemi&aresis. %he nurse &lans

care !nowing that this condition'

A. 6he client has complete bilateral

paralysis of the arms and legs.

. %he client has wea!ness on the

right side of the body, including the

face and tongue.

C. 6he client has lost the ability to

move the right arm but is able to &alk

independently.

D. 6he client has lost the ability to

move the right arm but is able to &alk

independently.

$. %he client with a brain attac!

(stro!e) has residual dys&hagiA.

hen a diet order is initiated, the

nurse avoids doing which of the

following"

A. /iving the client thin liuids

B. 6hickening li5uids to the

consistency of oatmeal

C. !lacing food on the unaffected sideof the mouth

D. Allo&ing plenty of time for

che&ing and s&allo&ing

$1. %he nurse is assessing the

ada&tation of the female client to

changes in functional status after a

brain attac! (stro!e). %he nurse

assesses that the client is ada&ting

most successfully if the client'

A. ?ets angry &ith family if they

interrupt a task

B. Experiences bouts of depression

and irritability

C. %as difficulty &ith using modified

feeding utensils

. Consistently uses ada&tive

eui&ment in dressing self

$$. urse Fristine is trying to

communicate with a client with

brain attac! (stro!e) and a&hasiA.

hich of the following actions by

the nurse would be least hel&ful to

the client"

A. ,peaking to the client at a slo&er

rate

B. Allo&ing plenty of time for theclient to respond

C. Com&leting the sentences that

the client cannot finish

D. >ooking directly at the client

during attempts at speech

$*. A female client has ex&erienced

an e&isode of myasthenic crisis. %he

nurse would assess whether the

client has &reci&itating factors suchas'

A. ?etting too little exercise

B. 6aking excess medication

C. #mitting doses of medication

D. )ncreasing intake of fatty foods

$. %he nurse is teaching the female

client with myasthenia gravis about

the &revention of myasthenic and

cholinergic crises. %he nurse tells

the client that this is most

effectively done by'

A. Eating large' &ell-balanced meals

B. Doing muscle-strengthening


5/19

exercises

C. Doing all chores early in the day

&hile less fatigued

. %a!ing medications on time to

maintain thera&eutic blood levels

$5. A male client with ell8s &alsy

as!s the nurse what has caused this

&roblem. %he nurse8s res&onse is

based on an understanding that the

cause is'

A. Gn!nown, but &ossibly includes

ischemia, viral infection, or an

autoimmune &roblemB. @nkno&n' but possibly includes

long-term tissue malnutrition and

cellular hypoxia

C. !rimary genetic in origin' triggered

by exposure to meningitis

D. !rimarily genetic in origin'

triggered by exposure to neurotoxins

$6. %he nurse has given the male

client with ell8s &alsy instructionson &reserving muscle tone in the

face and &reventing denervation.

%he nurse determines that the client

needs additional information if the

client states that he or she will'

A. x&osure to cold and drafts

B. 4assage the face &ith a gentle

up&ard motion

C. !erform facial exercises

D. rinkle the forehead' blo& out the

cheeks' and &histle

$7. Bemale client is admitted to the

hos&ital with a diagnosis of

/uillainarre syndrome. %he

nurse inuires during the nursing

admission interview if the client has

history of'

A. ,ei$ures or trauma to the brain

B. 4eningitis during the last : years

C. Back inury or trauma to the spinal

cord

. :es&iratory or gastrointestinal

infection during the &revious

month.

$9. A female client with /uillain

arre syndrome has ascending&aralysis and is intubated and

receiving mechanical ventilation.

hich of the following strategies

would the nurse incor&orate in the

&lan of care to hel& the client co&e

with this illness"

A. ?iving client full control over care

decisions and restricting visitors

B. !roviding positive feedback andencouraging active range of motion

C. @roviding information, giving

&ositive feedbac!, and encouraging

relaxation

D. !roviding intravenously

administered sedatives' reducing

distractions and limiting visitors

$;. A male client has an im&airment

of cranial nerve >>. =&ecific to this

im&airment, the nurse would &lan

to do which of the following to

ensure client to ensure client safety"

http://nurseslabs.com/assess-cranial-nerves/http://nurseslabs.com/assess-cranial-nerves/


6/19

A. ,peak loudly to the client

B. 6est the temperature of the sho&er

&ater

C. Check the temperature of the food

on the delivery tray.

. @rovide a clear &ath for

ambulation without obstacles

*. A female client has a

neurological deficit involving the

limbic system. =&ecific to this ty&e

of deficit, the nurse would

document which of the following

information related to the client8s

behavior.

A. )s disoriented to person' place' and

time

. Affect is flat, with &eriods of

emotional lability

C. Cannot recall &hat &as eaten for

breakfast today

D. Demonstrate inability to add and

subtract does not kno& &ho is

president

7C>E exam 5uestionnaire about

Degenerative Diseases and some

5uestions about CA

1. >f a male client ex&erienced a

cerebrovascular accident (CVA)

that damaged the hy&othalamus,

the nurse would antici&ate that the

client has &roblems with'

A. body tem&erature control.

B. balance and e5uilibrium.

C. visual acuity.

D. thinking and reasoning.

$. A female client admitted to an

acute care facility after a caraccident develo&s signs and

sym&toms of increased intracranial

&ressure (>C@). %he client is

intubated and &laced on mechanical

ventilation to hel& reduce >C@. %o

&revent a further rise in >C@ caused

by suctioning, the nurse antici&ates

administering which drug

endotracheally before suctioning"

A. phenytoin *Dilantin+

B. mannitol *0smitrol+

C. lidocaine (Iylocaine)

D. furosemide *>asix+

*. After stri!ing his head on a tree

while falling from a ladder, a youngman age 19 is admitted to the

emergency de&artment. He8s

unconscious and his &u&ils are

nonreactive. hich intervention

would be the most dangerous for

the client"

A. ?ive him a barbiturate.

B. !lace him on mechanical

ventilation.

C. @erform a lumbar &uncture.

D. Elevate the head of his bed.

http://nurseslabs.com/nursing-board-exam-questions/nclex-exams-practice-questions/http://nurseslabs.com/nursing-board-exam-questions/nclex-exams-practice-questions/


7/19

. hen obtaining the health

history from a male client with

retinal detachment, the nurse

ex&ects the client to re&ort'

A. light flashes and floaters in front

of the eye.

B. a recent driving accident &hile

changing lanes.

C. headaches' nausea' and redness of

the eyes.

D. fre5uent episodes of double vision.

5. hich nursing diagnosis ta!es

highest &riority for a client with

@ar!inson8s crisis"

A. )mbalanced nutrition >ess than

body re5uirements

. >neffective airway clearance

C. )mpaired urinary elimination

D. Risk for inury

6. %o encourage adeuate

nutritional inta!e for a female

client with Al+heimer8s disease, the

nurse should'

A. stay with the client and

encourage him to eat.

B. help the client fill out his menu.

C. give the client privacy during

meals.

D. fill out the menu for the client.

7. %he nurse is &erforming a mental

status examination on a male client

diagnosed with subdural

hematoma. %his test assesses which

of the following"

A. Cerebellar functionB. )ntellectual function

C. Cerebral function

D. ,ensory function

9. =hortly after admission to an

acute care facility, a male client

with a sei+ure disorder develo&s

status e&ile&ticus. %he &hysician

orders dia+e&am (Valium) 1 mg

>.V. stat. How soon can the nurse

administer a second dose of

dia+e&am, if needed and

&rescribed"

A. )n 83 to 9: seconds

. >n 1 to 15 minutes

C. )n 83 to 9: minutesD. )n to 1 hours

;. A female client com&lains of

&eriorbital aching, tearing, blurred

vision, and &hoto&hobia in her right

eye. #&hthalmologic examination

reveals a small, irregular,

nonreactive &u&il J a condition

resulting from acute iris

inflammation (iritis). As &art of the

client8s thera&eutic regimen, the

&hysician &rescribes atro&ine

sulfate (Atro&isol), two dro&s of

.5K solution in the right eye twice


8/19

daily. Atro&ine sulfate belongs to

which drug classification"

A. !arasympathomimetic agent

B. ,ympatholytic agentC. Adrenergic blocker

. Cholinergic bloc!er

1. mergency medical technicians

trans&ort a $7yearold iron wor!er

to the emergency de&artment. %hey

tell the nurse, 2He fell from a two

story building. He has a large

contusion on his left chest and a

hematoma in the left &arietal area.

He has a com&ound fracture of his

left femur and he8s comatose. e

intubated him and he8s maintaining

an arterial oxygen saturation of

;$K by &ulse oximeter with a

manualresuscitation bag.4 hich

intervention by the nurse has thehighest &riority"

A. Assessing the left leg

B. Assessing the pupils

C. !lacing the client in

6rendelenburgs position

D. Assessing level of consciousness

11. An auto mechanic accidentally

has battery acid s&lashed in his

eyes. His cowor!ers irrigate his eyes

with water for $ minutes, and then

ta!e him to the emergency

de&artment of a nearby hos&ital,

where he receives emergency care

for corneal in-ury. %he &hysician

&rescribes dexamethasone

(Daxidex #&hthalmic =us&ension),

two dro&s of .1K solution to beinstilled initially into the

con-unctival sacs of both eyes every

hourL and &olymyxin sulfate

(eos&orin #&hthalmic), .5K

ointment to be &laced in the

con-unctival sacs of both eyes every

* hours. examethasone exerts its

thera&eutic effect by'

A. increasing the exudative reaction

of ocular tissue.

. decreasing leu!ocyte infiltration

at the site of ocular inflammation.

C. inhibiting the action of carbonic

anhydrase.

D. producing a miotic reaction by

stimulating and contracting the

sphincter muscles of the iris.

1$. urse Amber is caring for a

client who underwent a lumbar

laminectomy $ days ago. hich of

the following findings should the

nurse consider abnormal"

A. 4ore back pain than the first

postoperative day

B. !aresthesia in the dermatomes near

the &ounds


9/19

C. Grine retention or incontinence

D. 6emperature of GG.1H F *8


10/19

@.#. every * hours. efore

administering this

anticholinesterase agent, the nurse

reviews the client8s history. hich

&reexisting condition wouldcontraindicate the use of

&yridostigmine"

A. @lcerative colitis

B. Blood dyscrasia

C. >ntestinal obstruction

D. ,pinal cord inury

19. A female client is admitted to

the facility for investigation of

balance and coordination &roblems,

including &ossible D0niMre8s

disease. hen assessing this client,

the nurse ex&ects to note'

A. vertigo, tinnitus, and hearing

loss.B. vertigo' vomiting' and nystagmus

C. vertigo' pain' and hearing

impairment.

D. vertigo' blurred vision' and fever.

1;. A male client with a conductive

hearing disorder caused by

an!ylosis of the sta&es in the oval

window undergoes a sta&edectomy

to remove the sta&es and re&lace

the im&aired bone with a &rosthesis.

After the sta&edectomy, the nurse

should &rovide which client

instruction"

A. ">ie in bed &ith your head

elevated' and refrain from blo&ing

your nose for 19 hours.(

B. "6ry to ambulate independently

after about 19 hours.(C. ",hampoo your hair every day for

3 days to help prevent ear infection.(

. 2on8t fly in an air&lane, climb

to high altitudes, ma!e sudden

movements, or ex&ose yourself to

loud sounds for * days.4

$. urse Darty is monitoring a

client for adverse reactions to

dantrolene (antrium). hich

adverse reaction is most common"

A. Excessive tearing

B. @rine retention

C. Duscle wea!ness

D. ,lurred speech

$1. %he nurse is monitoring a male

client for adverse reactions to

atro&ine sulfate (Atro&ine Care)

eyedro&s. =ystemic absor&tion of

atro&ine sulfate through the

con-unctiva can cause which

adverse reaction"

A. %achycardia

B. )ncreased salivation

C. %ypotension

D. Apnea


11/19

$$. A male client is admitted with a

cervical s&ine in-ury sustained

during a diving accident. hen

&lanning this client8s care, the nurse

should assign highest &riority towhich nursing diagnosis"

A. )mpaired physical mobility

. >neffective breathing &attern

C. Disturbed sensory perception

*tactile+

D. ,elf-care deficit

Dressing/grooming

$*. A male client has a history of

&ainful, continuous muscle s&asms.

He has ta!en several s!eletal

muscle relaxants without

ex&eriencing relief. His &hysician

&rescribes dia+e&am (Valium), $ mg

@.#. twice daily. >n addition to

being used to relieve &ainful muscles&asms, dia+e&am also is

recommended for'

A. long-term treatment of epilepsy.

B. postoperative pain management of

laminectomy clients.

C. postoperative pain management of

diskectomy clients

. treatment of s&asticity associated

with s&inal cord lesions.

$. A female client who was found

unconscious at home is brought to

the hos&ital by a rescue sua. >n

the intensive care unit, the nurse

chec!s the client8s oculoce&halic

(doll8s eye) res&onse by'

A. introducing ice &ater into theexternal auditory canal.

B. touching the cornea &ith a &isp of

cotton.

C. turning the client8s head

suddenly while holding the eyelids

o&en.

D. shining a bright light into the pupil.

$5. hile reviewing a client8s chart,

the nurse notices that the female

client has myasthenia gravis. hich

of the following statements about

neuromuscular bloc!ing agents is

true for a client with this condition"

A. 6he client may be less sensitive to

the effects of a neuromuscular blocking agent.

B. ,uccinylcholine shouldnt be used

pancuronium may be used in a lo&er

dosage.

C. !ancuronium shouldnt be used

succinylcholine may be used in a

lo&er dosage.

. @ancuronium and

succinylcholine both reuire

cautious administration.

$6. A male client is color blind. %he

nurse understands that this client

has a &roblem with'


12/19

A. rods.

. cones.

C. lens.

D. a5ueous humor.

$7. A female client who was tra&&ed

inside a car for hours after a head

on collision is rushed to the

emergency de&artment with

multi&le in-uries. uring the

neurologic examination, the client

res&onds to &ainful stimuli with

decerebrate &osturing. %his finding

indicates damage to which &art of

the brain"

A. Diencephalon

B. 4edulla

C. Didbrain

D. Cortex

$9. %he nurse is assessing a *7yearold client diagnosed with multi&le

sclerosis. hich of the following

sym&toms would the nurse ex&ect

to find"

A. Vision changes

B. Absent deep tendon reflexes

C. 6remors at rest

D. Flaccid muscles

$;. %he nurse is caring for a male

client diagnosed with a cerebral

aneurysm who re&orts a severe

headache. hich action should the

nurse &erform"

A. ,it &ith the client for a fe&

minutes.

B. Administer an analgesic.

C. )nform the nurse manager.

. Call the &hysician immediately.

*. uring recovery from a

cerebrovascular accident (CVA), a

female client is given nothing by

mouth, to hel& &revent as&iration.

%o determine when the client is

ready for a liuid diet, the nurse

assesses the client8s swallowing

ability once each shift. %his

assessment evaluates'

A. cranial nerves ) and )).

B. cranial nerves ))) and .

C. cranial nerves ) and ))).

. cranial nerves >I and I.

7C>E-style examination about

7eurological Disorders that covers

topics like 4eningitis' >evel of

Consciousness' ,ei$ures

1. A client admitted to the hos&ital

with a subarachnoid hemorrhage

has com&laints of severe headache,

nuchal rigidity, and &ro-ectile


13/19

vomiting. %he nurse !nows lumbar

&uncture (C@

9. 6o dra& &ater into the vascular

system to increase blood pressure

*. A client with subdural hematoma

was given mannitol to decrease

intracranial &ressure (>C@). hich

of the following results would best

show the mannitol was effective"

1. Grine out&ut increases

1. !upils are 2 mm and nonreactive

8. ,ystolic blood pressure remains at

:3 mm %g

9. B@7 and creatinine levels return to

normal

. hich of the following values is

considered normal for >C@"

1. to 15 mm Hg

1. 1: mm %g

8. 8: to 9: mm %g

9. 13/23 mm %g

5. hich of the following sym&tomsmay occur with a &henytoin level of

*$ mgNdl"

1. Ataxia and confusion

1. ,odium depletion

8. 6onic-clonic sei$ure

9. @rinary incontinence

6. hich of the following signs and

sym&toms of increased >C@ after

head trauma would a&&ear first"

. Bradycardia

1. >arge amounts of very dilute urine

*. :estlessness and confusion

9. idened pulse pressure

7. @roblems with memory and

learning would relate to which of

the following lobes"

. Frontal

1. 0ccipital


14/19

8. !arietal

. %em&oral

9. hile coo!ing, your client

couldn8t feel the tem&erature of ahot oven. hich lobe could be

dysfunctional"

. Frontal

1. 0ccipital

*. @arietal

9. 6emporal

;. %he nurse is assessing the motorfunction of an unconscious client.

%he nurse would &lan to use which

of the following to test the client8s

&eri&heral res&onse to &ain"

. ,ternal rub

1. !ressure on the orbital rim

8. ,5uee$ing the sternocleidomastoidmuscle

. ail bed &ressure

1. %he client is having a lumbar

&uncture &erformed. %he nurse

would &lan to &lace the client in

which &osition for the &rocedure"

1. =idelying, with legs &ulled u&and head bent down onto the chest

1. ,ide-lying' &ith a pillo& under the

hip

8. !rone' in a slight 6rendelenburgs

position

9. !rone' &ith a pillo& under the

abdomen.

11. A nurse is assisting with caloric

testing of the oculovestibular reflexof an unconscious client. Cold water

is in-ected into the left auditory

canal. %he client exhibits eye

con-ugate movements toward the

left followed by a ra&id nystagmus

toward the right. %he nurse

understands that this indicates the

client has'

. A cerebral lesion

1. A temporal lesion

*. An intact brainstem

9. Brain death

1$. %he nurse is caring for the client

with increased intracranial

&ressure. %he nurse would notewhich of the following trends in

vital signs if the >C@ is rising"

. )ncreasing temperature' increasing

pulse' increasing respirations'

decreasing blood pressure.

$. >ncreasing tem&erature,

decreasing &ulse, decreasing

res&irations, increasing blood

&ressure.

8. Decreasing temperature' decreasing

pulse' increasing respirations'

decreasing blood pressure.

9. Decreasing temperature' increasing


15/19

pulse' decreasing respirations'

increasing blood pressure.

1*. %he nurse is evaluating the

status of a client who had acraniotomy * days ago. %he nurse

would sus&ect the client is

develo&ing meningitis as a

com&lication of surgery if the client

exhibits'

1. A &ositive rud+ins!i8s sign

1. A negative =ernigs sign

8. Absence of nuchal rigidity

9. A ?lasco& Coma ,cale score of :

1. A client is arousing from a coma

and !ee&s saying, 2Eust sto& the

&ain.4 %he nurse res&onds based on

the !nowledge that the human body

ty&ically and automatically

res&onds to &ain first with attem&tsto'

. 6olerate the pain

1. Decrease the perception of pain

*. sca&e the source of &ain

9. Divert attention from the source of

pain.

15. uring the acute stage ofmeningitis, a *yearold child is

restless and irritable. hich of the

following would be most

a&&ro&riate to institute"

. >imiting conversation &ith the

child

$. Fee&ing extraneous noise to a

minimum

8. Allo&ing the child to play in the bathtub

9. !erforming treatments 5uickly

16. hich of the following would

lead the nurse to sus&ect that a

child with meningitis has develo&ed

disseminated intravascular

coagulation"

1. Hemorrhagic s!in rash

1. Edema

8. Cyanosis

9. Dyspnea on exertion

17. hen interviewing the &arents

of a $yearold child, a history of

which of the following illnesseswould lead the nurse to sus&ect

&neumococcal meningitis"

. Bladder infection

$. Diddle ear infection

8. Fractured clavicle

9. ,eptic arthritis

19. %he nurse is assessing a childdiagnosed with a brain tumor.

hich of the following signs and

sym&toms would the nurse ex&ect

the child to demonstrate" =elect all

that a&&ly.


16/19

1. Head tilt

$. Vomiting

8. !olydipsia

. C@ and

notes that the child has exhibited

signs of decerebrate &osturing. #n

assessment of the child, the nurse

would ex&ect to note which of the

following if this ty&e of &osturing

was &resent"

. Abnormal flexion of the upper

extremities and extension of the lo&er

extremities

$. :igid extension and &ronation of

the arms and legs

8. Rigid pronation of all extremities

9. Flaccid paralysis of all extremities

$$. hich of the followingassessment data indicated nuchal

rigidity"

1. @ositive Fernig8s sign

1. 7egative Brud$inskis sign

8. !ositive homans sign

9. 7egative =ernigs sign

$*. Deningitis occurs as anextension of a variety of bacterial

infections due to which of the

following conditions"


17/19

. Congenital anatomic abnormality

of the meninges

$.


18/19

and receives tissue &lasminogen

activator (t@A) administration.

hich is the &riority nursing

assessment"

. Current medications.

1. Complete physical and history.

*. %ime of onset of current stro!e.

9. @pcoming surgical procedures.

. uring the first $ hours after

thrombolytic thera&y for ischemic

stro!e, the &rimary goal is to

control the client8s'

. !ulse

1. Respirations

*. lood &ressure

9. 6emperature

5. hat is a &riority nursing

assessment in the first $ hoursafter admission of the client with a

thrombotic stro!e"

. Cholesterol level

$. @u&il si+e and &u&illary res&onse

8. o&el sounds

9. Echocardiogram

6. hat is the ex&ected outcome ofthrombolytic drug thera&y"

. )ncreased vascular permeability.

1. asoconstriction.

*. issolved emboli.

9. !revention of hemorrhage

7. %he client diagnosed with atrial

fibrillation has ex&erienced a

transient ischemic attac! (%>A).

hich medication would the nurse

antici&ate being ordered for the

client on discharge"

1. An oral anticoagulant

medication.

1. A beta-blocker medication.

8. An anti-hyperuricemic medication.

9. A thrombolytic medication.

9. hich client would the nurse

identify as being most at ris! for

ex&eriencing a CVA"

1. A 55yearold African American

male.

1. An 29-year-old Japanese female.

8. A ;


19/19

mmHg.

9. 6he presence of bronchogenic

carcinoma.

1. %he nurse and unlicensedassistive &ersonnel (GA@) are

caring for a client with rightsided

&aralysis. hich action by the GA@

reuires the nurse to intervene"

. 6he assistant places a gait belt

around the clients &aist prior to

ambulating.

1. 6he assistant places the client on

the back &ith the clients head to the

side.

*. %he assistant &laces her handunder the client8s right axilla to

hel& himNher move u& in bed.

9. 6he assistant praises the client for

attempting to perform AD>s

independently.

NCLEX Test CVA, Neuro 24

Documents

Transcript of NCLEX Test CVA, Neuro 24