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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 &reå
the client for this test"
A. )mmobili$e the neck before the
client is moved onto a stretcher.. etermine whether the client is
allergic to iodine, contrast dyes, or
shellfish.
C. !lace a cap over the clients head.
D. Administer a sedative as ordered.
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7. uring a routine &hysical
examination to assess a male
client8s dee& tendon reflexes, the
nurse should ma!e sure to'
A. use the pointed end of the reflex
hammer &hen striking the Achilles
tendon.
. su&&ort the -oint where the
tendon is being tested.
C. tap the tendon slo&ly and softly
D. hold the reflex hammer tightly.
9. A female client is admitted in a
disoriented and restless state aftersustaining a concussion during a
car accident. hich nursing
diagnosis ta!es highest &riority in
this client8s &lan of care"
A. Disturbed sensory perception
*visual+
B. ,elf-care deficient
Dressing/grooming
C. )mpaired verbal communication. :is! for in-ury
;. A female client with amyotro&hic
lateral sclerosis (A feel so
frustrate. > can8t do anything
without hel&?4 %his comment best
su&&orts which nursing diagnosis"
A. Anxiety
. @owerlessness
C. )neffective denial
D. Risk for disuse syndrome
1. Bor a male client with sus&ected
increased intracranial &ressure
(>C@), a most a&&ro&riate
res&iratory goal is to'
A. prevent respiratory alkalosis.
B. lo&er arterial p%.
C. &romote carbon dioxide
elimination.
D. maintain partial pressure of arterial
oxygen *!a01+ above 23 mm %g
11. urse Dary witnesses a
neighbor8s husband sustain a fall
from the roof of his house. %he
nurse rushes to the victim and
determines the need to o&ens theairway in this victim by using which
method"
A. Flexed position
B. %ead tilt-chin lift
C. Eaw thrust maneuver
D. 4odified head tilt-chin lift
1$. %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
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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
.
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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
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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/
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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/
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. 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
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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
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C. Grine retention or incontinence
D. 6emperature of GG.1H F *8
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@.#. 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
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$$. 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'
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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
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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$ure
9. @rinary incontinence
6. hich of the following signs and
sym&toms of increased >C@ after
head trauma would a&&ear first"
. Bradycardia
1. >arge amounts of very dilute urine
*. :estlessness and confusion
9. idened pulse pressure
7. @roblems with memory and
learning would relate to which of
the following lobes"
. Frontal
1. 0ccipital
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8. !arietal
. %em&oral
9. hile coo!ing, your client
couldn8t feel the tem&erature of ahot oven. hich lobe could be
dysfunctional"
. Frontal
1. 0ccipital
*. @arietal
9. 6emporal
;. %he nurse is assessing the motorfunction of an unconscious client.
%he nurse would &lan to use which
of the following to test the client8s
&eri&heral res&onse to &ain"
. ,ternal rub
1. !ressure on the orbital rim
8. ,5uee$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
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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.
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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"
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. Congenital anatomic abnormality
of the meninges
$.
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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 ;
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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.
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