NCLEX Qs Module 9

14) A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: A. Tolerate the pain B. Decrease the perception of pain C. Escape the source of pain D. Divert attention from the source of pain.

C. The client's innate responses to pain are directed initially toward escaping from the source of pain. Variations in individuals' tolerance and perception of pain are apparent only in conscious clients, and only conscious clients are able to employ distraction to help relieve pain.

9) The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing the sternocleidomastoid muscle D. Nail bed pressure

D. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

7) Problems with memory and learning would relate to which of the following lobes? A. Frontal B. Occipital C. Parietal D. Temporal

D. Temporal The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases B. Pupils are 8 mm and nonreactive C. Systolic blood pressure remains at 150 mm Hg D. BUN and creatinine levels return to normal

A. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

4) Which of the following values is considered normal for ICP? A. 0 to 15 mm Hg B. 25 mm Hg C. 35 to 45 mm Hg D. 120/80 mm Hg

A. Normal ICP is 0-15 mm Hg.

12) The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. 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 arise.

19) Which of the following assessment data indicated nuchal rigidity? A. Positive Kernig's sign B. Negative Brudzinski's sign C. Positive homan's sign D. Negative Kernig's sign

A. A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition.

5) Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? A. Ataxia and confusion B. Sodium depletion C. Tonic-clonic seizure D. Urinary incontinence

A. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

16) Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A. Hemorrhagic skin rash B. Edema C. Cyanosis D. Dyspnea on exertion

A. DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon

13) The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A positive Brudzinski's sign B. A negative Kernig's sign C. Absence of nuchal rigidity D. A Glascow Coma Scale score of 15

A. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

10) The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A. Side-lying, with legs pulled up and head bent down onto the chest B. Side-lying, with a pillow under the hip C. Prone, in a slight Trendelenburg's position D. Prone, with a pillow under the abdomen.

A. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.

15) During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child B. Keeping extraneous noise to a minimum C. Allowing the child to play in the bathtub D. Performing treatments quickly

B. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing

17) A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose B. Cloudy CSF, elevated protein, and decreased glucose C. Clear CSF, elevated protein, and decreased glucose D. Clear CSF, decreased pressure, and elevated protein

B. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.

20) Which of the following pathologic processes is often associated with aseptic meningitis? A. Ischemic infarction of cerebral tissue B. Childhood diseases of viral causation such as mumps C. Brain abscesses caused by a variety of pyogenic organisms D. Cerebral ventricular irritation from a traumatic brain injury

B. Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Incidences of brain abscess are high in bacterial meningitis, and ischemic infarction of cerebral tissue can occur with tubercular meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.

18) A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities B. Rigid extension and pronation of the arms and legs C. Rigid pronation of all extremities D. Flaccid paralysis of all extremities

B. Decebrate posturing is characterized by the rigid extension and pronation of the arms and legs

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues B. Intracranial pressure (ICP) is increased C. The client needs mechanical ventilation D. Blood is anticipated in the cerebralspinal fluid (CSF)

B. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

11) A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death

C. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

6) Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure B. To prevent acute tubular necrosis C. To promote osmotic diuresis to decrease ICP D. To draw water into the vascular system to increase blood pressure

C. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

8) While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? A. Frontal B. Occipital C. Parietal D. Temporal

C. Parietal The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.