NUR 330 Exam #4 NCLEX Questions – UPDATED Questions with 100% Verified Answers
NUR 330 Exam #4 NCLEX Questions – UPDATED
Questions with 100% Verified Answers
Science › Medicine › Nursing
Section 1: Client, Nurse, Seizure (Q1–Q13)
Question & Answer
Q1 The male client is sitting in the chair and his entire body is rigid with his arms and legs
contracting and relaxing. The client is not aware of what is going on and is making
guttural sounds. Which action should the nurse implement first? 1. Push aside any
furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the
client to the floor. Company. Kindle Edition.
A 4. The client should not remain in the chair during a seizure. He should be brought safely to the
floor so that he will have room to move the extremities.
Q2 The occupational health nurse is concerned about preventing occupation-related
acquired seizures. Which intervention should the nurse implement? 1. Ensure that
helmets are worn in appropriate areas. 2. Implement daily exercise programs for the
staff. 3. Provide healthy foods in the cafeteria. 4. Encourage employees to wear safety
glasses.
A 1. Head injury is one of the main reasons for epilepsy that can be prevented through occupational
safety precautions and highway safety programs.
Q3 The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure
disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to
take any routine antiseizure medication prior to the EEG. 2. Tell the client not to eat
anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake
for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort
during the procedure.
A 3. The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or
flashing lights may induce a seizure.
Q4 The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What
action should the nurse implement first? 1. Note the first thing the client does in the
seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent
of urine or stool. 4. Provide the client with privacy during the seizure.
A 1. Noticing the first thing the client does during a seizure provides information and clues as to the
location of the seizure in the brain. It is important to document whether the beginning of the seizure
was observed.
Q5 The client who just had a three (3)-minute seizure has no apparent injuries and is
oriented to name, place, and time but is very lethargic and just wants to sleep. Which
intervention should the nurse implement? 1. Perform a complete neurological
assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and
allow the client to sleep. 4. Interview the client to find out what caused the seizure.
A 3. During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest
quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.
Page 1 of 20
,NUR 330 Exam #4 NCLEX Questions – UPDATED Questions with 100% Verified Answers
Question & Answer
Q6 The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the
mouth of a client having a tonic-clonic seizure. Which action should the primary nurse
take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop
trying to insert anything in the mouth. 3. Take no action because the UAP is handling
the situation. 4. Notify the charge nurse of the situation immediately.
A 2. The nurse should tell the UAP to stop trying to insert anything in the mouth of the client
experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to
place anything in the clenched jaws of a client having a tonic-clonic seizure.
Q7 The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder.
Which statement indicates the client understands the discharge teaching concerning
this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin
level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any
seizures while on this medication."
A 1. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are
essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking
Dilantin.
Q8 The client is admitted to the intensive care department (ICD) experiencing status
epilepticus. Which collaborative intervention should the nurse anticipate? 1. Assess the
client's neurological status every hour. 2. Monitor the client's heart rhythm via
telemetry. 3. Administer an anticonvulsant medication by intravenous push. 4. Prepare
to administer a glucocorticosteroid orally.
A 3. Administering an anticonvulsant medication by intravenous push requires the nurse to have an
order or confer with another member of the health-care team.
Q9 The client has been newly diagnosed with epilepsy. Which discharge instructions should
be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take
tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have
anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have
someone in the car.
A 1. Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with
the health-care provider and in identifying activities that may trigger a seizure. 3. Over-the-counter
medications may contain ingredients that will interact with antiseizure medications or, in some
cases, as with use of stimulants, possibly cause a seizure. 4. Most of the anticonvulsant medications
have therapeutic serum levels that should be maintained, and regular checks of the serum levels
help to ensure the correct level.
Q10 Which statement by the female client indicates that the client understands factors that
may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2.
"My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in
stress management." 4. "I should wear dark glasses when I am out in the sun."
A 3. Tension states, such as anxiety and frustration, induce seizures in some clients, so stress
management may be helpful in preventing seizures.
Page 2 of 20
, NUR 330 Exam #4 NCLEX Questions – UPDATED Questions with 100% Verified Answers
Question & Answer
Q11 The nurse asks the male client with epilepsy if he has auras with his seizures. The client
says, "I don't know what you mean. What are auras?" Which statement by the nurse
would be the best response? 1. "Some people have a warning that the seizure is about
to start." 2. "Auras occur when you are physically and psychologically exhausted." 3.
"You're concerned that you do not have auras before your seizures?" 4. "Auras usually
cause you to be sleepy after you have a seizure."
A 1. An aura is a visual, auditory, or olfactory occurrence that takes place prior to a seizure and warns
the client a seizure is about to occur. The aura often allows time for the client to lie down on the
floor or find a safe place to have the seizure.
Q12 The nurse educator is presenting an in-service on seizures. Which disease process is the
leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease.
3. Cerebral vascular accident (stroke). 4. Brain atrophy due to aging.
A 3. A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure
associated with the stroke can lead to seizures.
Q13 Where do you usually find a pressure ulcer?
A Over a bony prominence
Section 2: Pressure, Ulcer, Ulcers (Q14–Q26)
Question & Answer
Q14 What are four predisposing factors for pressure ulcers?
A limited mobility poor nutrition comorbidities aging skin
Q15 What is the pathophysiology of a pressure ulcer creation?
A The external pressure is greater than the capillary pressure and clamps the capillaries shut. This
causes ischemia and tissue damage
Q16 Where are the 5 most common places to get a pressure ulcer? (hint: 3 on the back, 2 on
the sides)
A Back: Sacrum, Heels, Ischial Tuberosity Sides: Greater Trochanter, Lateral Malleoli
Q17 what are four ways you can prevent stress ulcers?
A -patient repositioning schedule -keep head of bed at lowest safe elevation to prevent shear (<30
degrees) -using pressure-reducing surfaces -assessing nutrition/providing supplementation
Q18 How often should people who are bed ridden be respositioned to prevent pressure
ulcers?
A every 2 hours
Q19 what is ideal for wound cleansing?
A saline
Q20 if the wound takes longer than this amount of time to heal on its own, you should
consider antibiotics.
A 2 weeks
Page 3 of 20
NUR 330 Exam #4 NCLEX Questions – UPDATED
Questions with 100% Verified Answers
Science › Medicine › Nursing
Section 1: Client, Nurse, Seizure (Q1–Q13)
Question & Answer
Q1 The male client is sitting in the chair and his entire body is rigid with his arms and legs
contracting and relaxing. The client is not aware of what is going on and is making
guttural sounds. Which action should the nurse implement first? 1. Push aside any
furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the
client to the floor. Company. Kindle Edition.
A 4. The client should not remain in the chair during a seizure. He should be brought safely to the
floor so that he will have room to move the extremities.
Q2 The occupational health nurse is concerned about preventing occupation-related
acquired seizures. Which intervention should the nurse implement? 1. Ensure that
helmets are worn in appropriate areas. 2. Implement daily exercise programs for the
staff. 3. Provide healthy foods in the cafeteria. 4. Encourage employees to wear safety
glasses.
A 1. Head injury is one of the main reasons for epilepsy that can be prevented through occupational
safety precautions and highway safety programs.
Q3 The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure
disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to
take any routine antiseizure medication prior to the EEG. 2. Tell the client not to eat
anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake
for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort
during the procedure.
A 3. The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or
flashing lights may induce a seizure.
Q4 The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What
action should the nurse implement first? 1. Note the first thing the client does in the
seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent
of urine or stool. 4. Provide the client with privacy during the seizure.
A 1. Noticing the first thing the client does during a seizure provides information and clues as to the
location of the seizure in the brain. It is important to document whether the beginning of the seizure
was observed.
Q5 The client who just had a three (3)-minute seizure has no apparent injuries and is
oriented to name, place, and time but is very lethargic and just wants to sleep. Which
intervention should the nurse implement? 1. Perform a complete neurological
assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and
allow the client to sleep. 4. Interview the client to find out what caused the seizure.
A 3. During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest
quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.
Page 1 of 20
,NUR 330 Exam #4 NCLEX Questions – UPDATED Questions with 100% Verified Answers
Question & Answer
Q6 The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the
mouth of a client having a tonic-clonic seizure. Which action should the primary nurse
take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop
trying to insert anything in the mouth. 3. Take no action because the UAP is handling
the situation. 4. Notify the charge nurse of the situation immediately.
A 2. The nurse should tell the UAP to stop trying to insert anything in the mouth of the client
experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to
place anything in the clenched jaws of a client having a tonic-clonic seizure.
Q7 The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder.
Which statement indicates the client understands the discharge teaching concerning
this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin
level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any
seizures while on this medication."
A 1. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are
essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking
Dilantin.
Q8 The client is admitted to the intensive care department (ICD) experiencing status
epilepticus. Which collaborative intervention should the nurse anticipate? 1. Assess the
client's neurological status every hour. 2. Monitor the client's heart rhythm via
telemetry. 3. Administer an anticonvulsant medication by intravenous push. 4. Prepare
to administer a glucocorticosteroid orally.
A 3. Administering an anticonvulsant medication by intravenous push requires the nurse to have an
order or confer with another member of the health-care team.
Q9 The client has been newly diagnosed with epilepsy. Which discharge instructions should
be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take
tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have
anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have
someone in the car.
A 1. Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with
the health-care provider and in identifying activities that may trigger a seizure. 3. Over-the-counter
medications may contain ingredients that will interact with antiseizure medications or, in some
cases, as with use of stimulants, possibly cause a seizure. 4. Most of the anticonvulsant medications
have therapeutic serum levels that should be maintained, and regular checks of the serum levels
help to ensure the correct level.
Q10 Which statement by the female client indicates that the client understands factors that
may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2.
"My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in
stress management." 4. "I should wear dark glasses when I am out in the sun."
A 3. Tension states, such as anxiety and frustration, induce seizures in some clients, so stress
management may be helpful in preventing seizures.
Page 2 of 20
, NUR 330 Exam #4 NCLEX Questions – UPDATED Questions with 100% Verified Answers
Question & Answer
Q11 The nurse asks the male client with epilepsy if he has auras with his seizures. The client
says, "I don't know what you mean. What are auras?" Which statement by the nurse
would be the best response? 1. "Some people have a warning that the seizure is about
to start." 2. "Auras occur when you are physically and psychologically exhausted." 3.
"You're concerned that you do not have auras before your seizures?" 4. "Auras usually
cause you to be sleepy after you have a seizure."
A 1. An aura is a visual, auditory, or olfactory occurrence that takes place prior to a seizure and warns
the client a seizure is about to occur. The aura often allows time for the client to lie down on the
floor or find a safe place to have the seizure.
Q12 The nurse educator is presenting an in-service on seizures. Which disease process is the
leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease.
3. Cerebral vascular accident (stroke). 4. Brain atrophy due to aging.
A 3. A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure
associated with the stroke can lead to seizures.
Q13 Where do you usually find a pressure ulcer?
A Over a bony prominence
Section 2: Pressure, Ulcer, Ulcers (Q14–Q26)
Question & Answer
Q14 What are four predisposing factors for pressure ulcers?
A limited mobility poor nutrition comorbidities aging skin
Q15 What is the pathophysiology of a pressure ulcer creation?
A The external pressure is greater than the capillary pressure and clamps the capillaries shut. This
causes ischemia and tissue damage
Q16 Where are the 5 most common places to get a pressure ulcer? (hint: 3 on the back, 2 on
the sides)
A Back: Sacrum, Heels, Ischial Tuberosity Sides: Greater Trochanter, Lateral Malleoli
Q17 what are four ways you can prevent stress ulcers?
A -patient repositioning schedule -keep head of bed at lowest safe elevation to prevent shear (<30
degrees) -using pressure-reducing surfaces -assessing nutrition/providing supplementation
Q18 How often should people who are bed ridden be respositioned to prevent pressure
ulcers?
A every 2 hours
Q19 what is ideal for wound cleansing?
A saline
Q20 if the wound takes longer than this amount of time to heal on its own, you should
consider antibiotics.
A 2 weeks
Page 3 of 20
