NCLEX Prep

A health care provider prescribed a diagnostic workup for a client who may have myasthenia gravis. Which initial objective would the nurse establish with the client? -"The client will adhere to the teaching plan." -"The client will achieve psychologic adjustment." -"The client will maintain present muscle strength." -"The client will prepare for a possible myasthenic crisis"

"The client will maintain present muscle strength."

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give? -"You developed an infection that requires antibiotics." -"This is a highly contagious infection requiring isolation." -"An infection you had before beginning treatment has flared up." -Your infection occurred because of exposure to a health care facility."

"Your infection occurred because of exposure to a health care facility."

which statement indicates the nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)? -it is most common in women -It is manifested by intense bilateral pain -It is caused by an overactive hypothalamus -it is associated with headaches of long duration

It is caused by an overactive hypothalamus

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? select all that apply. -emptying the drainage system when full -keeping the drainage system at heart level -notifying the health care provider of drainage greater than 50 mL/h -marking the time on the drainage unit every shifft -laying the drainage system on its side during transport

Marking the time on the drainage unit every shift

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse administers oxygen? -To prevent dyspnea -To prevent cyanosis -To increase oxygen concentration to heart cells -To increase oxygen tension in the circulating blood

To increase concentration to heart cells

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? select all that apply -Type of employment -presence of ear pain -history of tobacco use -oral hygiene practices -amount of alcohol intake

all of the above

Which assessment would the nurse use to assess the client's trigeminal nerve function? -corneal sensation -facial expressions -ocular muscle movement -shrugging of the shoulders

corneal sensation

initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene? -spinal shock -brain herniation -hypovolemic shock -increased intracranial pressure

increased intracranial pressure

Which condition in a client with a brain injury is contraindicated for magnetic resonance imaging (MRI) with contrast? -Renal failure -claustrophobia -metal aneurysm clips -soft tissue imaging needs

metal aneurysm clips

Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? -Glottis -Paranasal sinus -Palatine tonsils -Eustachian tubes

Eustachian tubes

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis? -Hilum -Carina -Alveoli -Epiglottis

Carina

Which function of the limbic system is accurate? -Influence emotional behavior -Regulate autonomic functions -Facilitate automatic movements -Relay sensory and motor inputs for cerebrum

Influence emotional behavior

When assessing a client with a diagnosed "brain attack" (cerebrovascular accident [CVA]), the nurse evaluated the baseline vital signs of pulse rate of 78 beats per minute (bpm) and a blood pressure (BP) of 120/80 mmHg. Which changes in the baseline vital signs indicate an increasing intracranial pressure (ICP)? -pulse 50 bpm and BP 140/60 mmHg -Pulse 56 bpm and BP 130/110 mmHg -Pulse 60 bpm and BP 126/96 mmHg -Pulse 120 bpm and BP 80/60 mmHg

Pulse 50 bpm and BP 140/60 mm Hg