NCLEX PAST QUESTIONS
LIVING SPRING INSTITUTE
PLEASE MEMORIZE & MASTER
Living Spring
MEDICAL-SURGICAL NURSING NOTE
What is the nursing priority for a patient with epiglottitis?
A. administer steroids
B. assist in endotracheal intubation
C. assist in tracheostomy
D. apply warm moist pack
The correct answer is C. Epiglottitis is an emergency situation requiring immediate
intervention: the inflamed epiglottis is blocking the entrance to the trachea, therefore
clearing the patient’s AIRWAY is the priority nursing action (eliminate options A and D).
Option C is better than Option B; endotracheal intubation will be difficult because the
inflamed epiglottis will not permit the insertion of a laryngoscope.
The following are clinical manifestations of nontoxic goiter (hypothyroidism), EXCEPT:
A. dry skin
B. lethargy
C. insomnia
D. sensitivity to cold
The correct answer is C. Hypothyroidism causes a decrease in thyroid hormones, which in
turn causes decreased metabolism. Options A, B and D are all consistent with decreased
metabolism. Option C is a symptom of increased metabolism found in hyperthyroidism.
ƒ Thyroid gland secretions (T3 and T4) are metabolic hormones
Thyroid hormones cause increased metabolism: CNS stimulation, increased vital signs,
and increased GI motility (diarrhea)
HYPOTHYROIDISM HYPERTHYROIDISM
All b od y sy stems are DECREASED All b od y sy stems are INC REA S ED
e x c e p t W E I G H T a nd M E N ST R U A T I O N ! e x c e p t W E I GHT a nd M E NST R UAT I ON!
decreased CNS: drowsiness, memory increased CNS: tremors, insomnia
problems (forgetfulness)
decreased v/s: hypotension, bradycardia, increased v/s: hypertension, tachycardia,
bradypnea, low body temp tachypnea, fever
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,LIVING SPRING INSTITUTE
decreased GI motility: constipation increased GI motility: diarrhea
decreased appetite (anorexia) but with increased appetite (hyperphagia) but with
WEIGHT GAIN WEIGHT LOSS [high metabolism causes
[low metabolism causes decreased burning of increased burning of fats and carbs]
fats and carbs]
This leads to increased serum cholesterol
atherosclerosis (hardening of arteries due to
cholesterol deposits)
Because of increased cholesterol, hypothyroid
patients are prone to hypertension, myocardial
infarction, CHF and stroke
decreased metabolism causes decreased increased metabolism causes increased
perspiration perspiration
DRY SKIN and COLD INTOLERANCE MOIST SKIN and HEAT INTOLERANCE
Menorrhagia (excessive bleeding during Amenorrhea (absence of menstruation)
menstruation)
Pathognomic sign: EXOPHTHALMOS (bulging
eyeballs)
ƒ NursingManagement for hypothyroidism: ƒ Nursing Management for hyperthyroidism:
Low calorie diet High calorie diet
Warm environment Cool environment
What is the best way to prevent the spread of STDs?
A. Use condoms
B. Monogamous relationship
C. Abstinence
D. Practice Safe Sex
The correct answer is B. TEST-TAKING TIP: Pick the conservative answer. Remember
the Board of Nursing is composed of older women with traditional values who do not
approve of promiscuity (implied in options A and D). Telling the patient to abstain from
sex (Option C) is not an acceptable response from the nurse.
LIVING SPRING INSTITUTE
,LIVING SPRING INSTITUTE
What is the nursing priority if the client is suffering from 1st, 2nd, 3rd or 4th degree
burns?
A. fluid and electrolyte balance
B. infection
C. pain
D. airway
The correct answer is B. Infection is a priority for all types of burns. Airway is a priority
only for burns to the face and neck. Pain is a second priority for 1st and 2nd degree
burns. Fluid and electrolyte balance is a second priority for 3rd and 4th degree burns
[no pain because nerve endings are damaged].
What is a normal physical finding of the thyroid gland?
A. nodular consistency
B. asymmetry
C. tenderness
D. palpable upon swallowing
The correct answer is A. The thyroid gland is symmetrical, non-tender, and palpable
only if the patient has goiter. The palpable mass on the neck is the thyroid cartilage. It
is present in both males and females but is larger in males; it develops during puberty
What food is most appropriate for a toddler?
A. hotdog
B. grapes
C. milk
D. spaghetti
The correct answer is D. Toddlers need a high-carb diet to sustain their active play
lifestyle. Toddlers are also at risk for aspiration, therefore eliminate foods that are
choking hazards (options A and B). Milk is not the best food for toddlers because of its
low IRON content; Milk is the primary cause of Iron-deficiency Anemia in children.
TEST-TAKING TIP: `Di ba may hotdog ang spaghetti? No, no, no… DO NOT ADD
DETAILS TO THE QUESTION. Do not justify a wrong answer.
LIVING SPRING INSTITUTE
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What would the nurse include in the teaching plan for a paraplegic client?
A. self-catheterization
B. assisted coughing
C. adapted feeding techniques
D. compensatory swallowing
The correct answer is A. A paraplegic patient has lower extremity paralysis (paralyzed
bladder and bowel). Therefore the nursing priority is ELIMINATION.
Review:
Monoplegia -- 1 limb paralysis
Hemiplegia -- Right or Left side paralysis
Paraplegia – Lower extremity paralysis (note: there is no such thing as upper extremity
paralysis)
Quadriplegia/Tetraplegia – Paralysis from the neck down. The priority for a
quadriplegic patient is AIRWAY.
NERVOUS SYSTEM
ƒ CNS: brain and spinal cord
ƒ PNS: 12 cranial nerves + 31 spinal nerves
8 cervical nerves (C1 to C8)
12 thoracic nerves (T1 to T12)
5 lumbar nerves (L1 to L5)
5 sacral nerves (S1 to S5)
1 coccygeal nerve (Co)
ƒ The spinal cord terminates at L1 to L2, therefore a LUMBAR TAP is performed at L3 ,L4 or L5
(no risk of paralysis from spinal cord damage)
AUTONOMIC NERVOUS SYSTEM
S y mpa t he t i c Ne rv ous S y s t e m (S NS ) P a ra s y mpa t he t i c Ne rv ous S y s t e m
(P NS )
ƒ “Fight” or aggression response ƒ “Flight” or withdrawal response
ƒ Also termed adrenergic or parasympatholytic ƒ Also termed cholinergic or sympatholytic
response response
ƒ The neurotransmitter for the SNS is ƒ The neurotransmitter for the PNS is
norepinephrine acetylcholine (Ach)
A l l body ac t i v i t i es are INC REA S ED A l l body ac t i v i t i es are DEC REA S ED
except GIT! except GIT!
increased blood flow to brain, heart and normalized blood flow to vital organs
skeletal muscles: These are the most important organs
during times of stress
increased BP, increased heart rate: decreased BP, decreased heart rate
To maintain perfusion to vital organs
bronchodilation and increased RR: bronchoconstriction, decreased RR
To increase oxygen intake
urinary retention FLUID VOLUME EXCESS urinary frequency FLUID VOLUME
Fluids are withheld by the body to maintain circulating DEFICIT
volume
LIVING SPRING INSTITUTE
LIVING SPRING INSTITUTE
PLEASE MEMORIZE & MASTER
Living Spring
MEDICAL-SURGICAL NURSING NOTE
What is the nursing priority for a patient with epiglottitis?
A. administer steroids
B. assist in endotracheal intubation
C. assist in tracheostomy
D. apply warm moist pack
The correct answer is C. Epiglottitis is an emergency situation requiring immediate
intervention: the inflamed epiglottis is blocking the entrance to the trachea, therefore
clearing the patient’s AIRWAY is the priority nursing action (eliminate options A and D).
Option C is better than Option B; endotracheal intubation will be difficult because the
inflamed epiglottis will not permit the insertion of a laryngoscope.
The following are clinical manifestations of nontoxic goiter (hypothyroidism), EXCEPT:
A. dry skin
B. lethargy
C. insomnia
D. sensitivity to cold
The correct answer is C. Hypothyroidism causes a decrease in thyroid hormones, which in
turn causes decreased metabolism. Options A, B and D are all consistent with decreased
metabolism. Option C is a symptom of increased metabolism found in hyperthyroidism.
ƒ Thyroid gland secretions (T3 and T4) are metabolic hormones
Thyroid hormones cause increased metabolism: CNS stimulation, increased vital signs,
and increased GI motility (diarrhea)
HYPOTHYROIDISM HYPERTHYROIDISM
All b od y sy stems are DECREASED All b od y sy stems are INC REA S ED
e x c e p t W E I G H T a nd M E N ST R U A T I O N ! e x c e p t W E I GHT a nd M E NST R UAT I ON!
decreased CNS: drowsiness, memory increased CNS: tremors, insomnia
problems (forgetfulness)
decreased v/s: hypotension, bradycardia, increased v/s: hypertension, tachycardia,
bradypnea, low body temp tachypnea, fever
LIVING SPRING INSTITUTE
,LIVING SPRING INSTITUTE
decreased GI motility: constipation increased GI motility: diarrhea
decreased appetite (anorexia) but with increased appetite (hyperphagia) but with
WEIGHT GAIN WEIGHT LOSS [high metabolism causes
[low metabolism causes decreased burning of increased burning of fats and carbs]
fats and carbs]
This leads to increased serum cholesterol
atherosclerosis (hardening of arteries due to
cholesterol deposits)
Because of increased cholesterol, hypothyroid
patients are prone to hypertension, myocardial
infarction, CHF and stroke
decreased metabolism causes decreased increased metabolism causes increased
perspiration perspiration
DRY SKIN and COLD INTOLERANCE MOIST SKIN and HEAT INTOLERANCE
Menorrhagia (excessive bleeding during Amenorrhea (absence of menstruation)
menstruation)
Pathognomic sign: EXOPHTHALMOS (bulging
eyeballs)
ƒ NursingManagement for hypothyroidism: ƒ Nursing Management for hyperthyroidism:
Low calorie diet High calorie diet
Warm environment Cool environment
What is the best way to prevent the spread of STDs?
A. Use condoms
B. Monogamous relationship
C. Abstinence
D. Practice Safe Sex
The correct answer is B. TEST-TAKING TIP: Pick the conservative answer. Remember
the Board of Nursing is composed of older women with traditional values who do not
approve of promiscuity (implied in options A and D). Telling the patient to abstain from
sex (Option C) is not an acceptable response from the nurse.
LIVING SPRING INSTITUTE
,LIVING SPRING INSTITUTE
What is the nursing priority if the client is suffering from 1st, 2nd, 3rd or 4th degree
burns?
A. fluid and electrolyte balance
B. infection
C. pain
D. airway
The correct answer is B. Infection is a priority for all types of burns. Airway is a priority
only for burns to the face and neck. Pain is a second priority for 1st and 2nd degree
burns. Fluid and electrolyte balance is a second priority for 3rd and 4th degree burns
[no pain because nerve endings are damaged].
What is a normal physical finding of the thyroid gland?
A. nodular consistency
B. asymmetry
C. tenderness
D. palpable upon swallowing
The correct answer is A. The thyroid gland is symmetrical, non-tender, and palpable
only if the patient has goiter. The palpable mass on the neck is the thyroid cartilage. It
is present in both males and females but is larger in males; it develops during puberty
What food is most appropriate for a toddler?
A. hotdog
B. grapes
C. milk
D. spaghetti
The correct answer is D. Toddlers need a high-carb diet to sustain their active play
lifestyle. Toddlers are also at risk for aspiration, therefore eliminate foods that are
choking hazards (options A and B). Milk is not the best food for toddlers because of its
low IRON content; Milk is the primary cause of Iron-deficiency Anemia in children.
TEST-TAKING TIP: `Di ba may hotdog ang spaghetti? No, no, no… DO NOT ADD
DETAILS TO THE QUESTION. Do not justify a wrong answer.
LIVING SPRING INSTITUTE
, LIVING SPRING INSTITUTE
What would the nurse include in the teaching plan for a paraplegic client?
A. self-catheterization
B. assisted coughing
C. adapted feeding techniques
D. compensatory swallowing
The correct answer is A. A paraplegic patient has lower extremity paralysis (paralyzed
bladder and bowel). Therefore the nursing priority is ELIMINATION.
Review:
Monoplegia -- 1 limb paralysis
Hemiplegia -- Right or Left side paralysis
Paraplegia – Lower extremity paralysis (note: there is no such thing as upper extremity
paralysis)
Quadriplegia/Tetraplegia – Paralysis from the neck down. The priority for a
quadriplegic patient is AIRWAY.
NERVOUS SYSTEM
ƒ CNS: brain and spinal cord
ƒ PNS: 12 cranial nerves + 31 spinal nerves
8 cervical nerves (C1 to C8)
12 thoracic nerves (T1 to T12)
5 lumbar nerves (L1 to L5)
5 sacral nerves (S1 to S5)
1 coccygeal nerve (Co)
ƒ The spinal cord terminates at L1 to L2, therefore a LUMBAR TAP is performed at L3 ,L4 or L5
(no risk of paralysis from spinal cord damage)
AUTONOMIC NERVOUS SYSTEM
S y mpa t he t i c Ne rv ous S y s t e m (S NS ) P a ra s y mpa t he t i c Ne rv ous S y s t e m
(P NS )
ƒ “Fight” or aggression response ƒ “Flight” or withdrawal response
ƒ Also termed adrenergic or parasympatholytic ƒ Also termed cholinergic or sympatholytic
response response
ƒ The neurotransmitter for the SNS is ƒ The neurotransmitter for the PNS is
norepinephrine acetylcholine (Ach)
A l l body ac t i v i t i es are INC REA S ED A l l body ac t i v i t i es are DEC REA S ED
except GIT! except GIT!
increased blood flow to brain, heart and normalized blood flow to vital organs
skeletal muscles: These are the most important organs
during times of stress
increased BP, increased heart rate: decreased BP, decreased heart rate
To maintain perfusion to vital organs
bronchodilation and increased RR: bronchoconstriction, decreased RR
To increase oxygen intake
urinary retention FLUID VOLUME EXCESS urinary frequency FLUID VOLUME
Fluids are withheld by the body to maintain circulating DEFICIT
volume
LIVING SPRING INSTITUTE
