uworld NCLEX Questions
4 A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival. (Options 1, 2, and 3) A change in level of consciousness, increased blood pressure, or a feeling of illness should be investigated but alone does not indicate an emergency. Educational objective: Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a ruptured cerebral aneurysm and should be treated as an emergency.
A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? 1. "I am very tired, and it's hard for me to keep my eyes open." 2. "I don't feel good, and I want to be seen." 3. "I have not taken my blood pressure medicine in over a week." 4. "I have the worst headache I've ever had in my life."
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.
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? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly blood in appearance and has a pH of 6 3. Fluid clumps together on the dressing and had a pH of 7 Fluid separates into concentric rings and tests positive for glucose.
3 Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately. (Option 1) Documentation is important, but it is not the priority action. (Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure. (Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting. Educational objective: Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.
A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? 1. Document the amount of emesis 2. Lower the head of the bed 3. Notify the health care provider (HCP) 4. Offer anti-nausea medication
2 Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors.
A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor."
Cushing's triad is related to increased intracranial pressure (ICP). Early signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression. The skull cannot expand after the fontanels close at age 18 months, so anything taking up more space inside the skull (eg, hematoma, tumor, swelling, etc.) is a concern for causing pressure on the brain tissue/brain stem and potential herniation. In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing. The client's intoxication could blunt an accurate history or presentation of a head injury. (Option 1) Atropine is used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An electrocardiogram (ECG) should be obtained prior to administering atropine. In this client, there is no evidence of a cardiac etiology or systemic symptoms of poor perfusion/circulation from the bradycardia. (Option 2) Nifedipine (Procardia) is a calcium channel blocker that is a potent vasodilator. However, all components must be considered in this scenario as to the etiology of the hypertension rather than just treating that sign. Ruling out a cerebral cause of the hypertension is most important. (Option 4) The nurse would continue to perform neurologic assessments (including GCS). However, it is more important to obtain appropriate diagnostic tests and initiate treatment for the changing neurologic symptoms than to just monitor and document. In addition, the nurse should be performing these assessments more frequently than hourly in this rapidly changing client. Educational objective: Cushing's triad/reflex indicates increased intercerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes).
A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? 1. Administer atropine for bradycardia 2. Administer nifedipine for hypertension 3. Have CT scan performed to rule out an intracranial bleed 4. Perform hourly neurologic checks with Glasgow coma scale (GCS)
3. Place the client on droplet precautions. The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out. Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. Viral meningitis and other types of bacterial meningitis (ie, other than meningococcal meningitis) usually do not require droplet precautions. (Option 1) Although assessment is a priority and meningeal signs should be checked, the nurse can only safely perform these assessments once droplet precautions are in place. (Options 2 and 4) A peripheral IV catheter should be inserted to provide fluids. Subsequently, preparation for lumbar puncture is needed. However, placing the client on isolation is a priority to protect the nurse and other clients and care providers. Educational objective: The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated.
A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? 1. Check for Kernig's and Brudzinski's signs 2. Establish IV access 3. Place the client on droplet precautions 4. Prepare the client for lumbar puncture
2 Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4). Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy. Educational objective: For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.
An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? 1. Administer IV antibiotics 2. Infuse bolus of IV normal saline 3. Prepare to assist with lumbar puncture 4. Transport client for head CT scan
3 Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. (Option 1) Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This child should be seen second. (Option 2) A low-grade fever is common after immunizations; this child can be seen last. (Option 4) Although infection and pain are important, this child can be seen third. Educational objective: The child with head trauma who is leaking cerebrospinal fluid (CSF) is at risk for meningitis and intracerebral bleeding. If the drainage is clear, a dextrose test is used to determine if the drainage is CSF. The nurse should assess for signs of bleeding (eg, change in level of consciousness) and infection (eg, increased temperature) and anticipate a CT scan and prophylactic antibiotics.
Four children are brought to the emergency department. Which child should be assessed first? 1. A 13-month-old who ingested an unknown quantity of children's multivitamins 2. A 15-month-old with a fever of 100.5 F (38.1 C) after being vaccinated 3. A 3-year-old with a forehead laceration and colorless nasal drainage 4. A 4-year-old with enlarged tonsillar lymph nodes who is crying in pain
1, 3, 5, 6 The Valsalva maneuver (straining during defecation) involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure (Option 1). The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease (Option 3). Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding (Option 5). The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery (Option 6). (Option 2) The otherwise healthy client recovering from reconstructive augmentation mammoplasty is not at risk for complications related to the Valsalva maneuver. (Option 4) The client recently diagnosed with pancreatic cancer is not at risk for complications related to the Valsalva maneuver. Educational objective: The Valsalva maneuver is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.
The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year-old man with a head injury sustained during a college football game 2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year-old man 2 weeks post myocardial infarction 4. 68-year-old woman recently diagnosed with pancreatic cancer 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery
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.
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. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the head of the bed 15 - 20 degrees. 3. Contact the HCP if ICP is >15 mmHg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of-motion exercises.
4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
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? 1. We need to discourage him from wearing eyeglasses. 2. We need to place objects in his impaired field of vision. 3. We need to approach him from the impaired field of vision. 4. We need to remind him to turn his head to scan the lost visual field.
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 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. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently 6. The client has lost the ability to ambulate independently, but is able to feed and bathe himself or herself without assistance.
2, 3, 5 A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. (Options 1 and 4) The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting (indicate high intracranial pressure) Sleepiness and/or confusion (indicate high intracranial pressure) Visual changes Weakness or numbness of part of the body Educational objective: Expected neurological changes with a concussion include brief loss of consciousness, retrograde amnesia, and headache. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days.
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. 1. Asymmetrical pupillary constriction 2. Brief loss of consciousness 3. Headache 4. Loss of vision 5. Retrograde amnesia
3 After a supratentorial surgery, the head is kept at a 30-45 degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.
The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1. Head of bed flat, head and neck midline. 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side
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 is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
1, 2, 5, 6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking the patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed. 2. Placing an airway at the bedside. 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent.
A client with a neurological injury (eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately. (Option 1) Autonomic dysreflexia (eg, throbbing headache, flushing, hypertension) is a life-threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher. This is not the priority assessment as this client's injury is at L3. This client likely has acute urinary retention and needs catheterization. (Option 2) Phenytoin toxicity commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus. These are expected symptoms and therefore are not a priority. (Option 3) A brain tumor can also cause increased intracranial pressure; clients report morning headache, nausea, and vomiting. Dexamethasone (Decadron) can be prescribed short-term to decrease the surrounding edema. A tumor usually grows more slowly than a possible hematoma and is therefore not the priority assessment. Educational objective: Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure.
The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating 2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL 4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL
3, 1, 4, 2 To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. 1. Maintain a patent airway. 2. Record the seizure activity observed. 3. Ease the client to the floor. 4. Obtain vital signs.
3 Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, this reastablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability 2. Vasoconstriction 3. Dissolved emboli 4. Prevention of hemorrhage
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.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1. Compress the nares 2. Tilt the head back 3. Collect the drainage 4. Administer an antihistamine for postnasal drip
