Uworld NCLEX Questions and Answers
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. - ansThe 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.
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 - ansThe 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.
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) - ansThe 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
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. - ansThe 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.
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 - ansThe 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.
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) - ansThe 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
