Exam 6 NCLEX Style Questions

D. Assist with hygiene as needed

A nurse is caring for a client who has Parkinson's disease and displays signs of bradykinesia. Which of the following is an appropriate action by the nurse? A. Allow client extra time for verbal responses to questions B. Complete passive ROM exercises C. Provide an alternate form of communication D. Assist with hygiene as needed

B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling F. Lack of facial expressions

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply) A. Decreased vision B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expressions

B. Infection -The nurse should monitor a client with a ventriculostomy for infection, which is a complication. Strict asepsis should be used to avoid this life-threatening condition, which may result in meningitis

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

A. Exposure to metal waste products D. Previous head injury E. History of herpes infection

A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? (Select all that apply) A. Exposure to metal waste products B. Long-term estrogen hormone therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection

C. "It is limited to brain tissue"

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? A "It can spread to breasts and kidneys" B. "It can develop in your gastrointestinal tract" C. "It is limited to brain tissue" D. "It probably started in another area of your body and spread to your brain"

C. Place a magnet over the implantable device when an aura occurs

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following information should be nurse include in the teaching? A. The use of a microwave to heat food is permitted B. Inform a provider to order only a MRI when a scan is needed C. Place a magnet over the implantable device when an aura occurs D. The use of ultrasound diathermy for pain management is recommended

D. Is there a pattern of headaches among family members?

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the clinical findings of migraine headaches? A. Do the headaches occur at the same time each day? B. Is your headache accompanied by profuse facial sweating? C. Do you have seasonal headaches? D. Is there a pattern of headaches among family members?

C. Avoid consuming alcoholic beverages

A nurse is teaching a client who has ALS about a new prescription for riluzole (Rilutek). Whihc of the following instructions should the nurse give the client? A. Take this medication immediately prior to eating B. Drink a glass of milk with the medication C. Avoid consuming alcoholic beverages D. Monitor your blood pressure daily

D. Assist with ADLs

A nurse working in a long-term care facility is planning care for a client in stage 5 of Alzheimer's disease. Which of the following interventions should be included in the plan of care? A. Use a gait belt for ambulation B. Thicken all liquids C. Provide protective undergarments D. Assist with ADLs

A. Changes in urine output

A patient with a fracture of the pelvis should be monitored for A. Changes in urine output B. Petechiae on the abdomen C. A palpable lump in the buttock D. Sudden increase in blood pressure

C. Decreased sensation distal to the fracture site

An indication of a neurovascular problem noted during assessment of the patient with a fracture us A. Exaggeration of strength with movement B. Increased redness and heat below the injury C. Decreased sensation distal to the fracture site D. Purulent drainage at the site of an open fracture

A. Hip flexion contractures

During the postoperative period, the nurse instructs the patient with an above the knee amputation that the residual limb should not be routinely elevated because this position promotes A. Hip flexion contractures B. Skin irritation and breakdown C. Clot formation at the incision site D. Increased risk of wound dehiscense

B. The patient is unable to move the lower extremities

In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? A. The patient experiences a single episode of emesis B. The patient is unable to move the lower extremities C. The patient is nauseated and has not voided in 4 hours D. The patient complains of pain at the bone graft donor site

A. Divorce B. Job loss C. Depression D. Role changes E. Loss of self-esteem

Social effects of a chronic neurologic disease include (Select all that apply) A. Divorce B. Job loss C. Depression D. Role changes E. Loss of self-esteem

A. Formation of callus

The nurse explains to a patient with a fracture of the distal shaft of the humerus who is returning for a 4 week checkup that healing is indicated by A. Formation of callus B. Complete bony union C. Hematoma at fracture site D. Presence of granulation tissue

D. Twisting his ankle while running bases during a baseball game

The nurse suspects an ankle sprain when a patient at the urgent care center relates A. Being hit by another soccer player during a game B. Having ankle pain after sprinting around the track C. Dropping a 10 lb weight on his lower leg at the health club D. Twisting his ankle while running bases during a baseball game

A. A 63 year old man who is a long-distance truck driver B. A 36 year old 6'2" in construction worker who weighs 260 lb D. A 30 year old male nurse who works on an orthopedic unit and smokes E. A 44 year old female chef with prior compression fracture of the spine

Which individuals would be at high risk for low back pain (Select all that apply) A. A 63 year old man who is a long-distance truck driver B. A 36 year old 6'2" in construction worker who weighs 260 lb C. A 28 year old female yoga instructor who is 5'6" and weigs 130lb D. A 30 year old male nurse who works on an orthopedic unit and smokes E. A 44 year old female chef with prior compression fracture of the spine

B. Stop smoking

You are teaching a patient with osteopenia. What is important to include in the teaching plan? A. Lose weight B. Stop smoking C. Eat a high protein diet D. Start swimming for exercise

D. Bearing weight on the affected leg for 6 weeks

In teaching a patient scheduled for a total ankle replacement, it is important to tell the patient that after surgery he should avoid A. Lifting heavy objects B. Sleeping on the back C. Abduction exercises of the affected ankle D. Bearing weight on the affected leg for 6 weeks

D. Assess the patient more closely, suspecting a disorder such as restless legs syndrome

The nurse finds that an 87 year old woman with Alzheimer's disease is continually rubbing, flexing, and kicking out her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The net step the nurse should take is to A Ask the physician for a daytime sedative for the patient B. Request soft restraints to prevent her from falling out of her bed C. Ask the physician for a nighttime sleep medications for the patient D. Assess the patient more closely, suspecting a disorder such as restless legs syndrome

D. This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function

The nurse is reinforcing teaching with a newly diagnosed patient with ALS. Which statement would be appropriate to include in the teaching? A. ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication B. Even though the symptoms you are experiencing are severe, most people recover with treatment C. You need to consider advance directives now, since you will lose cognitive function as the disease progresses D. This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function

A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils E. Headache

A nurse is completing an assessment of a client who has increased intracranial pressure. Which of the following are expected findings? (Select all that apply) A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP 15 mm/Hg E. Headache

A. Cluster headaches

A 50 year old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his left eye seems to swell and get teary when these headaches occur. Based on this history., you suspect he has A. Cluster headaches B. Tension headaches C. Migraine headaches D. Medication overuse headaches

C. Promoting physical exercise and a well-balanced diet

A 65 year old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is A. Searching the internet for educational videos B. Evaluating the home for environmental safety C. Promoting physical exercise and a well-balanced diet D. Designing an exercise program to strengthen and stretch specific muscles

C. I should take this medication as soon as I notice symptoms developing

A nurse in a client is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan (Zomig). Which of the following statements by the client indicates understanding of the teaching? A. This medication will relieve my symptoms by causing my blood vessels to dilate B. This medication should prevent the headache from occuring C. I should take this medication as soon as I notice symptoms developing D. I should take this medication to lower my sensitivity to food triggers

B. Salted cashews

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that may cause headaches. The nurse should recommend that the client avoid which of the following foods? A. Baked salmon B. Salted cashews C. Frozen strawberries D. Fresh asparagus

B. Client is experiencing altered sleep-wake cycle C. Headache occurs at approximately the same time of the day E. Nasal congestion and drainage occur

A nurse in a provider's office is obtaining a nursing history from a client who has cluster headaches. Which of the following are expected findings? (Select all that apply) A. Pain is bilateral across the posterior occipital area B. Client is experiencing altered sleep-wake cycle C. Headache occurs at approximately the same time of the day D. Client describes headache pain as dull and throbbing E. Nasal congestion and drainage occur

C. I will soak in a warm bath every day

A nurse instructs a client who has MG about home care and the risk factors that can exacerbate the disease. Which of the following client statements indicates a need for further teaching? A. I should take my medication 45 min before meals B. I have suction equipment at home in case I start to choke C. I will soak in a warm bath every day D. I ordered a medical identification bracelet to wear

B. E3+V4+M4=11 -The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following is the correct scoring by the nurse using the Scale that indicates the client has a moderate head injury? A. E2+V3+M5=10 B. E3+V4+M4=11 C. E4+V5+M6=15 D. E2+V2+M4=8

A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply) A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding F. Restrain the client

B. Implement droplet isolation precautions -When using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to place the client in droplet precaution isolation when meningitis is suspected to prevent spread of the disease to others

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet isolation precautions C. Initiate IV access D. Decrease bright lights

A. Place client in supine position C. Place hands behind the client's neck D. Bend client's head toward chest -The nurse should place the client in supine position when assessing for Brudzinski's sign - The nurse should place her hands behind the client's neck when assessing for Brudzinski's sign, in order to flex the client's neck -The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign; it is a positive if the client reports pain

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following are appropriate actions by the nurse when performing this technique? (Select all that apply) A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee

A. Areas of paresthesia B. Involuntary eye movements E. Ataxia

A nurse is beginning a physical assessment of a client who was recently diagnosed with multiple sclerosis (MS). Which of the following findings should the nurse expect? (Select all that apply) A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia

C. Incontinence D. Ineffective cough

A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with amyotrophic lateral sclerosis (ALS) approimately 1 year ago. Which of the following client findings should the nurse anticipate? (Select all that apply) A. Loss of sensation B. Fluctuations in blood pressure C. Incontinence D. Ineffective cough E. Loss of cognitive function

B. Assist client to eat meals while lying flat in bed C. Administer an opioid medication D. Encourage client to increase fluid intake -The prone position may relieve a headache following a lumbar puncture -Administering an opioid medication for a client's report of headache pain is an appropriate action by the nurse -Maintaining positive fluid balance may relieve a headache following a lumbar puncture

A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse? (Select all that apply) A. Use the Glasgow Coma Scale when assessing the client B. Assist client to eat meals while lying flat in bed C. Administer an opioid medication D. Encourage client to increase fluid intake E. Place client in a "cannonball" position

C. Provide a walker for ambulation

A nurse is caring for a client who displays signs of stage 3 Parkinson's disease. Which of the following actions should the nurse include in the plan of care? A. Recommend a community support group B. Integrate a daily exercise routine C. Provide a walker for ambulation D. Consultation with a dietitian

B. Place the client in a room close to the nurse's station

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? A. Keep the call light near the client B. Place the client in a room close to the nurse's station C. Encourage the client to ask for assistance D. Remind the client to walk with someone for support

B. Morphone sulfate 2mg IV bolus PRN every 2 hr for pain

A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethasone (Decadron) 30mg IV bolus BID B. Morphone sulfate 2mg IV bolus PRN every 2 hr for pain C. Ondansetron (Zofran) 4mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin (Dilantin) 100mg IV bolus TID

A. Apply lubricating eye drops D. Tape eyes closed at night

A nurse is caring for a client who has myasthenia gravis (MG) and has developed dropping eyelids. Which of the following actions should the nurse take? (Select all that apply) A. Apply lubricating eye drops B. Encourage use of sunglasses C. Support the head with pillows D. Tape eyes closed at night E. Provide for periods of rest during the day

A. Increased intracranial pressure C. Hydrocephalus E. Seizures

A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (Select all that apply) A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures

A. Keep the client in a side-lying position

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position B. Monitor the client's vital signs C. Reorient the client to the environment D. Check the client for injuries

A. "I think I may be pregnant" B. "I take Coumadin" D. "I am allergic to shrimp" -The client's statement of possible pregnancy should be reported to the provider because the contrast dye may place the fetus at risk -The client taking Coumadin should be reported to the provider due to the potential for bleeding following the angiogram -A client's report of allergy to shrimp, which is a shellfish, should be reported to the provider due to a potential allergic reaction to the contrast dye

A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply) A. "I think I may be pregnant" B. "I take Coumadin" C. "I take antihypertensive medication" D. "I am allergic to shrimp" E. "I am allergic to latex"

B. Record diet and fluid intake daily D. Add thickener to liquids E. Offer nutritional supplements between meals

A nurse is developing a plan of care for the nutritional needs of a client who has stage 4 Parkinson's disease. Which actions should the nurse include in the plan of care? (Select all that apply) A. Provide three large balanced meals daily B. Record diet and fluid intake daily C. Document weight every other week D. Add thickener to liquids E. Offer nutritional supplements between meals

A. Remove floor rugs C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (Select all that apply) A. Remove floor rugs B. Have door locks that can be easily opened C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

B. Provide an emesis basin at the bedside C. Administer antipyretic medication as prescribed D. Perform a skin assessment

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication as prescribed D. Perform a skin assessment E. Keep the head of the bed flat

A. Implement seizure precautions D. Turn off room lights and television E. Monitor for impaired extraocular movements

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following are appropriate nursing actions? (Select all that apply) A. Implement seizure precautions B. Perform neurological checks four times a day C. Administer morphine for the report of neck and generalized pain D. Turn off room lights and television E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently

C. Take the medication at the same time every day

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin). Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication B. Watch for receding gums when taking the medication C. Take the medication at the same time every day D. Provide a urine sample to determine therapeutic levels of the medication

B. "Try to stay awake most of the night prior to the procedure" -The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity.

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure" B. "Try to stay awake most of the night prior to the procedure" C. "The procedure will take approximately 15 minutes" D. "You will need to lie flat for 4 hours after the procedure"

C. This medication should help my husband's daily function

A nurse is providing teaching to the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil (Aricept). Which of the following statements by the partner indications the teaching is effective? A. This medications should increase my husband's appetite B. This medication should help my husband sleep better C. This medication should help my husband's daily function D. This medications should increase my husband's energy level

A. Rise slowly when standing

A nurse is reinforcing teaching with a client who has Parkinson's disease and has received a prescription for bromocriptine (Parlodel). Which of the following instructions should the nurse include in the teaching? A. Rise slowly when standing B. Increase carbohydrate intake C. Limit exposure to hear D. Report any skin discoloration

A. It is given to reduce swelling of the brain. C. You may notice weight gain E. It can cause you to retain fluids

A nurse is reviewing a prescription for dexamethasone (Decadron) with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (Select all that apply) A. It is given to reduce swelling of the brain. B. You will need to monitor for low blood sugar C. You may notice weight gain D. Tumor growth will be delayed E. It can cause you to retain fluids

D. Apply a cool cloth to the face during a headache

A nurse is reviewing discharge instructions with a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of the headache B. Increase physical activity when a headache is present C. Drink sugar-free beverages to prevent headaches D. Apply a cool cloth to the face during a headache

D. Have the client stand erect with eyes closed

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign? A. Stroke the lateral aspect of the sole of the foot B. Ask the client to blink his eyes C. Observe for facial drooping D. Have the client stand erect with eyes closed

B. Neisseria meningitidis -The nurse should plan to administer a vaccine against Neisseria meningitidis because it is recommended that college students living in close proximity be immunized against meningitis

A nurse is reviewing the health record of a student newly admitted to a university and living in a dormitory. The health record indicates the student requires follow-up immunizations. Which of the following organisms should the nurse plan to vaccinate the student against? A. Streptococcus pneumoniae B. Neisseria meningitidis C. Bartonella henselae D. Rickettsia rickettsii

A. Overwhelming fatigue should be avoided B. Caffeinated products should be removed from the diet C. Looking at flashing lights should be limited

A nurse is reviewing trigger factors that can cause seizures who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in the review? (Select all that apply) A. Overwhelming fatigue should be avoided B. Caffeinated products should be removed from the diet C. Looking at flashing lights should be limited D. Aerobic exercise may be performed E. Episodes of hypoventilation should be limited F. Use of aerosol hairspray is recommended

B. The chemotherapy before surgery will shrink the tumor

A patient has been diagnosed with osteosarcoma of the humerus. He shows an understanding of his treatment options when he states A. I accept that I have to lose my arm with surgery B. The chemotherapy before surgery will shrink the tumor C. This tumor is related to the melanoma I had 3 years ago D. I'm glad they can take out the cancer with such a small scar

D. Adequate alignment cannot be obtained by other nonsurgical methods

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when A. The patient is unable to tolerate prolonged immobilization B. The patient cannot tolerate the surgery of a closed reduction C. A temporary cast would be too unstable to provide normal mobility D. Adequate alignment cannot be obtained by other nonsurgical methods

D. Pain when passively extending the fingers

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences A. Increasing edema of the limb B. Muscle spasms of the lower arm C. Rebounding pulse at the fracture site D. Pain when passively extending the fingers

B. Replace the joint D. Improve or maintain ROM

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (Select all that apply) A. Fuse the joint B. Replace the joint C. Prevent further damage D. Improve or maintain ROM E. Decrease the amount of destruction in the koint

A. The beads are used to directly deliver antibiotics to the site of the infection D. The beads are an adjunct to debridement and oral and IV antibiotics for deep infections

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (Select all that apply) A. The beads are used to directly deliver antibiotics to the site of the infection B. There are no effective oral or IV antibiotics to treat most cases of bone infection C. This is the safest method of delivering long term antibiotic therapy for a bone infection D. The beads are an adjunct to debridement and oral and IV antibiotics for deep infections E. The ischemia and bone death that occurs with osteomyelitis are impenetrable to IV antibiotics

A. Rest frequently with the feet elevated

Before discharge from the same-day surgery unit, instruct the patient who has had a surgical correction of bilateral hallux valgus to A. Rest frequently with the feet elevated B. Soak the feet in warm water several times a day C. Expect the feet to be numb for the next few days D. Expect continued pain in the feet, since this is not uncomming

D. Promoting the use of cold and hot compresses and pain medications

The nurse's responsibility for a patient with a suspected disc herniation who is experiencing acute pain and muscle spasms is A. Encouraging total bed rest for several days B. Teaching the principles of back strengthening exercises C. Stressing the importance of straight leg raises to decrease pain D. Promoting the use of cold and hot compresses and pain medications