NURS 405: Med Surg II Presentation NCLEX UPDATED
ACTUAL Questions and CORRECT Answers
A nurse is caring for a client who was recently admitted A
to the emergency department following a head on MVA.
Client is unresponsive, has spontaneous respirations of Keep neck stabilized
22/min, and a laceration on his forehead that is bleeding.
Which of the following is the priority nursing action at this Rationale: the greatest risk to the client if permanent damage to the spinal cord if
time? a cervical injury does exist. The priority nursing intervention is to keep the neck
immobile until damage to the cervical spine can be ruled out
A) Keep neck stabilized
B) Insert NG tube
C) Monitor pulse and BP frequently
D) Establish IV access and start fluid replacement
A client has experienced a left-hemispheric stroke, which C
of the following would be an expected finding?
Inability to recognize familiar objects
A) Impulse control difficulty
B) Poor judgement Rationale: a client who experiences a left-hemispheric stroke will demonstrate the
C) Inability to recognize familiar objects inability to recognize familiar objects. This is also known as agnosia
D) Loss of depth perceptions
A nurse is caring for a client who a spinal cord injury who B
reports a severe headache and is sweating profusely. BP
is 220/110 with a heart rate of 54/min. Which of the Sit the client upright in bed
following actions should the nurse take first?
Rationale: The greatest risk to the client is experiencing a cerebrovascular
A) Notify provider accident (stroke) secondary to elevated blood pressure. The first action by the
B) Sit the client upright in bed nurse is to elevate the head of the bed until the client is in an upright position. This
C) Check the urinary catheter for blockage will lower the blood pressure secondary to postural hypotension.
D) Administer antihypertensive medications
A client is admitted for treatment of the syndrome of C
inappropriate antidiuretic hormone (SIADH). Which
nursing intervention is appropriate? Restricting fluids
A) Infusing I.V. fluids rapidly as ordered Rationale: To reduce water retention in a client with the SIADH, the nurse should
B) Encouraging increased oral intake restrict fluids. Administering fluids by any route would further increase the client's
C) Restricting fluids already heightened fluid load
D) Administering glucose-containing I.V. fluids as ordered
A client with hypothyroidism (myxedema) is receiving C
levothyroxine (Synthroid), 25 mcg P.O. daily. Which
finding should the nurse recognize as an adverse effect? Tachycardia
A) Dysuria Rationale: Levothyroxine, a synthetic thyroid hormone, is given to a client with
B) Leg cramps hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent
C) Tachycardia include tachycardia. The other options aren't associated with levothyroxine
D) Blurred vision
, Which outcome indicates that treatment of a client with A
diabetes insipidus has been effective?
Fluid intake is less than 2,500 ml/day.
A) Fluid intake is less than 2,500 ml/day.
B) Urine output measures more than 200 ml/hour. Rationale: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant
C) Blood pressure is 90/50 mm Hg. thirst, and an unusually high oral intake of fluids. Treatment with the appropriate
D) The heart rate is 126 beats/minute. drug should decrease both oral fluid intake and urine output. A urine output of
200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and
a heart rate of 126 beats/minute indicate compensation for the continued fluid
deficit, suggesting that treatment hasn't been effective
A client with Cushing's syndrome is admitted to the A
medical-surgical unit. During the admission assessment,
the nurse notes that the client is agitated and irritable, Depression
has poor memory, reports loss of appetite, and appears
disheveled. These findings are consistent with which Rationale: Agitation, irritability, poor memory, loss of appetite, and neglect of
problem? one's appearance may signal depression, which is common in clients with
Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not
A) Depression Cushing's syndrome. Although hypoglycemia can cause irritability, it also
B) Neuropathy produces increased appetite, rather than loss of appetite. Hyperthyroidism
C) Hypoglycemia typically causes such signs as goiter, nervousness, heat intolerance, and weight
D) Hyperthyroidism loss despite increased appetite
Which nursing diagnosis takes highest priority for a client D
with hyperthyroidism?
Imbalanced nutrition: Less than body requirements related to thyroid hormone
A) Risk for imbalanced nutrition: More than body excess
requirements related to thyroid hormone excess
B) Risk for impaired skin integrity related to edema, skin Rationale: In the client with hyperthyroidism, excessive thyroid hormone
fragility, and poor wound healing production leads to hypermetabolism and increased nutrient metabolism. These
C) Body image disturbance related to weight gain and conditions may result in a negative nitrogen balance, increased protein synthesis
edema and breakdown, decreased glucose tolerance, and fat mobilization and depletion.
D) Imbalanced nutrition: Less than body requirements This puts the client at risk for marked nutrient and calorie deficiency, making
related to thyroid hormone excess Imbalanced nutrition: Less than body requirements the most important nursing
diagnosis. Options B and C may be appropriate for a client with hypothyroidism,
which slows the metabolic rate
A client is admitted with the diagnosis of testicular cancer. A
Which of the following factors in the client's history would
be associated with the disease? Undescended testes
A) Undescended testes Rationale: A history of undescended testes or cryptorchidism is a known risk
B) Sexual relations at an early age factor. Sexual relations at an early age, epididymitis, and seminal vesiculitis are not
C) Epididymitis risk factors
D) Seminal vesiculitis
Which of the following are age-related changes affecting A
the male reproductive system?
Plasma testosterone levels decrease
A) Plasma testosterone levels decrease
B) Prostate secretion increases Rationale: Changes in gonadal function include a decline in plasma testosterone
C) Patency increases levels and reduced production of progesterone. The testes become smaller and
D) Testes become soft more firm
ACTUAL Questions and CORRECT Answers
A nurse is caring for a client who was recently admitted A
to the emergency department following a head on MVA.
Client is unresponsive, has spontaneous respirations of Keep neck stabilized
22/min, and a laceration on his forehead that is bleeding.
Which of the following is the priority nursing action at this Rationale: the greatest risk to the client if permanent damage to the spinal cord if
time? a cervical injury does exist. The priority nursing intervention is to keep the neck
immobile until damage to the cervical spine can be ruled out
A) Keep neck stabilized
B) Insert NG tube
C) Monitor pulse and BP frequently
D) Establish IV access and start fluid replacement
A client has experienced a left-hemispheric stroke, which C
of the following would be an expected finding?
Inability to recognize familiar objects
A) Impulse control difficulty
B) Poor judgement Rationale: a client who experiences a left-hemispheric stroke will demonstrate the
C) Inability to recognize familiar objects inability to recognize familiar objects. This is also known as agnosia
D) Loss of depth perceptions
A nurse is caring for a client who a spinal cord injury who B
reports a severe headache and is sweating profusely. BP
is 220/110 with a heart rate of 54/min. Which of the Sit the client upright in bed
following actions should the nurse take first?
Rationale: The greatest risk to the client is experiencing a cerebrovascular
A) Notify provider accident (stroke) secondary to elevated blood pressure. The first action by the
B) Sit the client upright in bed nurse is to elevate the head of the bed until the client is in an upright position. This
C) Check the urinary catheter for blockage will lower the blood pressure secondary to postural hypotension.
D) Administer antihypertensive medications
A client is admitted for treatment of the syndrome of C
inappropriate antidiuretic hormone (SIADH). Which
nursing intervention is appropriate? Restricting fluids
A) Infusing I.V. fluids rapidly as ordered Rationale: To reduce water retention in a client with the SIADH, the nurse should
B) Encouraging increased oral intake restrict fluids. Administering fluids by any route would further increase the client's
C) Restricting fluids already heightened fluid load
D) Administering glucose-containing I.V. fluids as ordered
A client with hypothyroidism (myxedema) is receiving C
levothyroxine (Synthroid), 25 mcg P.O. daily. Which
finding should the nurse recognize as an adverse effect? Tachycardia
A) Dysuria Rationale: Levothyroxine, a synthetic thyroid hormone, is given to a client with
B) Leg cramps hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent
C) Tachycardia include tachycardia. The other options aren't associated with levothyroxine
D) Blurred vision
, Which outcome indicates that treatment of a client with A
diabetes insipidus has been effective?
Fluid intake is less than 2,500 ml/day.
A) Fluid intake is less than 2,500 ml/day.
B) Urine output measures more than 200 ml/hour. Rationale: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant
C) Blood pressure is 90/50 mm Hg. thirst, and an unusually high oral intake of fluids. Treatment with the appropriate
D) The heart rate is 126 beats/minute. drug should decrease both oral fluid intake and urine output. A urine output of
200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and
a heart rate of 126 beats/minute indicate compensation for the continued fluid
deficit, suggesting that treatment hasn't been effective
A client with Cushing's syndrome is admitted to the A
medical-surgical unit. During the admission assessment,
the nurse notes that the client is agitated and irritable, Depression
has poor memory, reports loss of appetite, and appears
disheveled. These findings are consistent with which Rationale: Agitation, irritability, poor memory, loss of appetite, and neglect of
problem? one's appearance may signal depression, which is common in clients with
Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not
A) Depression Cushing's syndrome. Although hypoglycemia can cause irritability, it also
B) Neuropathy produces increased appetite, rather than loss of appetite. Hyperthyroidism
C) Hypoglycemia typically causes such signs as goiter, nervousness, heat intolerance, and weight
D) Hyperthyroidism loss despite increased appetite
Which nursing diagnosis takes highest priority for a client D
with hyperthyroidism?
Imbalanced nutrition: Less than body requirements related to thyroid hormone
A) Risk for imbalanced nutrition: More than body excess
requirements related to thyroid hormone excess
B) Risk for impaired skin integrity related to edema, skin Rationale: In the client with hyperthyroidism, excessive thyroid hormone
fragility, and poor wound healing production leads to hypermetabolism and increased nutrient metabolism. These
C) Body image disturbance related to weight gain and conditions may result in a negative nitrogen balance, increased protein synthesis
edema and breakdown, decreased glucose tolerance, and fat mobilization and depletion.
D) Imbalanced nutrition: Less than body requirements This puts the client at risk for marked nutrient and calorie deficiency, making
related to thyroid hormone excess Imbalanced nutrition: Less than body requirements the most important nursing
diagnosis. Options B and C may be appropriate for a client with hypothyroidism,
which slows the metabolic rate
A client is admitted with the diagnosis of testicular cancer. A
Which of the following factors in the client's history would
be associated with the disease? Undescended testes
A) Undescended testes Rationale: A history of undescended testes or cryptorchidism is a known risk
B) Sexual relations at an early age factor. Sexual relations at an early age, epididymitis, and seminal vesiculitis are not
C) Epididymitis risk factors
D) Seminal vesiculitis
Which of the following are age-related changes affecting A
the male reproductive system?
Plasma testosterone levels decrease
A) Plasma testosterone levels decrease
B) Prostate secretion increases Rationale: Changes in gonadal function include a decline in plasma testosterone
C) Patency increases levels and reduced production of progesterone. The testes become smaller and
D) Testes become soft more firm
