NUR 400 Final Exam NCLEX Style Questions and answers Newest RATED A+ 2025/2026 NEW!!

NUR 400 Final Exam NCLEX Style Questions and answers
Newest RATED A+ 2025/2026 NEW!!

Which nursing intervention takes priority when assessing the neurological health of a patient who
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




has just been admitted with a suspected stroke?
Il` Il` Il` Il` Il` Il` Il` Il`




a. Assessing patient for injury (wounds, bruising, bone breaks)
Il` Il` Il` Il` Il` Il` Il` Il`




b. Performing a comprehensive neurological assessment
Il` Il` Il` Il` Il`




c. Administering tissue plasminogen activator (tPA)
Il` Il` Il` Il` Il`




d. Obtaining a detailed medical history
Il` Il` Il` Il` Il`




b. Performing a comprehensive neurological assessment
Il` Il` Il` Il` Il`




Rationale:
Assessing the client for injury (option A) is important in the overall assessment of a client, but it is
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




not the priority. Neurological assessment takes precedence because timely identification of
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




neurological deficits is crucial for determining the type and severity of the stroke and guiding
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




subsequent interventions.
Il` Il`




Administering tissue plasminogen activator (tPA) (option C) is a time-sensitive intervention for Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




ischemic strokes, but it should only be initiated after a comprehensive neurological assessment
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




and confirmation of eligibility criteria. Administering tPA without proper assessment may pose
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




risks to the client.
Il` Il` Il` Il`




Obtaining a detailed medical history (option D) is essential in understanding the client's risk Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




factors and medical background, but it is not the priority intervention upon admission of a client
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




with a suspected stroke.
Il` Il` Il` Il`




Performing a comprehensive neurological assessment (option B) is the priority because it allows Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




for the timely identification of neurological deficits, such as asymmetry in strength, sensation,
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




coordination, and changes in level of consciousness. This assessment guides further diagnostic
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




testing, treatment decisions, and interventions to promote optimal outcomes for the client.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




An 86 year old patient with a history of hypertension comes to the Emergency Department
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




confused and complaining of a severe headache. The nurse is concerned that the patient is having
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




a stroke. Which action does the nurse take first?
Il` Il` Il` Il` Il` Il` Il` Il` Il`

,a. Obtain a full set of vitals
Il` Il` Il` Il` Il` Il`




b. Perform a Mini Mental Status Exam
Il` Il` Il` Il` Il` Il`




c. Assess the patient using the Glasgow Coma Scale
Il` Il` Il` Il` Il` Il` Il` Il`




d. Ask the patient to smile, speak their name, and then hold out their arms
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




d. Ask the patient to smile, speak their name, and then hold out their arms
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




Rationale:
To assess for a stroke the nurse should determine if the patient is experiencing face paralysis using
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




the "FAST" technique:
Il` Il` Il`




F > facial drooping and uneven smile
Il` Il` Il` Il` Il` Il`




A > arm weakness, inability to lift both arms
Il` Il` Il` Il` Il` Il` Il` Il`




S > speech difficulty, inability to repeat a simple sentence
Il` Il` Il` Il` Il` Il` Il` Il` Il`




T > time, seek immediate care or intervention.
Il` Il` Il` Il` Il` Il` Il`




Although vital signs can be useful, they do not give a more focused assessment regarding brain
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




insult. Vital signs can be obtained after the FAST technique is used. The Mini Mental Status Exam is
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




used to assess cognitive impairment, so it would not be useful in determining the status of the
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




patient at this time. The Glasgow Coma Scale is used to determine level of consciousness and is
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




not appropriate as an initial assessment because the client is currently conscious.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




A nurse is assessing the neurological status of a patient who has been admitted following a motor
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




vehicle accident. Which assessment finding should the nurse prioritize as an indication of
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




potential increased intracranial pressure (ICP)?
Il` Il` Il` Il` Il`




a. Dilated pupils with sluggish response to light
Il` Il` Il` Il` Il` Il` Il`




b. Unequal movement of extremities
Il` Il` Il` Il`




c. Decreased blood pressure with increased heart rate
Il` Il` Il` Il` Il` Il` Il`




d. Increased respiratory rate with shallow breathing
Il` Il` Il` Il` Il` Il`




a. Dilated pupils with sluggish response to light
Il` Il` Il` Il` Il` Il` Il`




Rationale:
The correct answer is A because dilated pupils with sluggish response to light as an indication of
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`

,potential increased intracranial pressure (ICP). Pupillary changes, particularly dilation with
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




sluggish or non-reactive response to light, can be a significant neurological sign suggestive of
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




increased pressure within the skull. This requires immediate medical attention and can result in
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




death.
Il`




B) While unequal movement of extremities can be indicative of neurological compromise, it is not
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




as specific to increased intracranial pressure.
Il` Il` Il` Il` Il` Il`




C) While decreased blood pressure with increased heart rate is a sign of worsening intracranial
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




pressure, it's not as immediate and specific as dilated pupils with sluggish response to light.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




D) Increased respiratory rate with shallow breathing may indicate respiratory distress or
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




dysfunction rather than increased intracranial pressure. While respiratory changes can occur in
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




response to neurological compromise, they are not as specific to increased ICP as dilated pupils
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




with sluggish response to light.
Il` Il` Il` Il` Il`




A nurse is conducting a neurological assessment on a patient who has been admitted with a head
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




injury. Which assessment finding should the nurse prioritize as indicative of a potential
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




neurological complication?
Il` Il`




a. Unequal pupil size
Il` Il` Il`




b. Decreased bowel sounds
Il` Il` Il`




c. Elevated blood pressure
Il` Il` Il`




d. Increased respiratory rate
Il` Il` Il`




a. Unequal pupil size
Il` Il` Il`




Rationale:
A) Unequal pupil is indicative of anisocoria, which can be a sign of increased intracranial pressure
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




(ICP) or neurological damage. Unequal pupil size may suggest a dysfunction of the oculomotor
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




nerve (cranial nerve III) or other neurological structures. Monitoring pupil size and reactivity is
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




crucial in assessing neurological status, especially in clients with head injuries.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




B) While decreased bowel sounds may indicate gastrointestinal dysfunction, it is not directly
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




related to neurological complications in a client with a head injury. Bowel sounds are more
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




indicative of gastrointestinal motility and function rather than neurological status.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




C) Elevated blood pressure can occur due to various factors such as pain, stress, or physiological
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




responses to injury. While monitoring blood pressure is important in overall assessment, it is not
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




specifically indicative of neurological complications related to a head injury.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




D) An increased respiratory rate can be a response to pain, anxiety, or other physiological factors.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`

, Il` While changes in respiratory rate may be observed in clients with neurological issues such as
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




Il` brainstem dysfunction, it is not a specific finding that directly indicates neurological complications
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




Il` in a client with a head injury.
Il` Il` Il` Il` Il` Il`




After completing a procedure that required the donning of PPE consisting of a gown, an N95
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




respirator, a face shield, and gloves, which of the following should the nurse remove first when
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




removing PPE separately?
Il` Il` Il`




a. GlovesIl`




b. Gown Il`




c. Face shield
Il` Il`




d. N95 respirator
Il` Il`




a. GlovesIl`




Rationale:
Gloves are considered the most contaminated and should be removed first, followed by face/eye
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




protection, gown, and then mask/respirator. The back of the gown and its ties are considered not
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




contaminated, so this is not the first item that should be removed after completing a procedure.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




The ear and head pieces of a face shield are rarely contaminated and because this is the area that
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




the nurse will grasp to remove the face shield, this is not the first item that should be removed.
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




The N95 respirator should be removed last because the patient has an airborne disease, requiring
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




a respirator and the nurse should keep this on until they are outside of the room and the door to
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




the patient's room is closed.
Il` Il` Il` Il` Il`




We have an expert-written solution to this problem!



The nurse manager is evaluating current infection control data for the intensive care unit. The
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




nurse manager examines the infection chain for possible solution. What is the correct order of the
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




chain of infection?
Il` Il` Il`




a. Susceptible Host > Infectious Agent/Pathogen > Reservoir/Source for Pathogen Growth > Mode
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`




of Transmission > Portal of Entry to a Host > Portal of Exit from the Reservoir
Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il` Il`