N-clex prep Q&A
To promote optimal cerebral tissue perfusion in the postoperative phase following
cranial surgery, the nurse should place the client with an incision in the anterior or
middle fossa, in which position? - (correct answer)Correct positioning of the client
following cranial surgery is important to avoid increased intracranial pressure and to
promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is
always followed. The client with an incision in the anterior or middle fossa should be
positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in
the posterior fossa or burr holes have been made, the client is positioned flat, or with
the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is
performed, the client should not be positioned to the operative side. Trendelenburg's
position is contraindicated in the postoperative phase following cranial surgery.
The nurse is working with a client who is demonstrating delusional thinking. The client
says to the nurse, "The leaders of a religious cult are being sent to assassinate me."
Which is the best response by the nurse? - (correct answer)The nurse who disagrees
with a client's delusions may make the client more defensive and cling to the delusions
even more firmly. It is most therapeutic for the nurse to empathize with the client's
experience. The nurse can also use the opportunity to try to explore further the meaning
of the experience for the client. The correct option presents reality to the client and then
focuses on the client's feelings. None of the other options provide this support
The nurse is assessing a dark-skinned client for signs of anemia. - (correct
answer)Changes in skin color can be difficult to assess in the dark-skinned client. Color
changes are most easily seen in areas of the body where the epidermis is thin and in
areas where pigmentation is not influenced by exposure to sunlight. The nurse should
assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the
dark-skinned client. Signs of anemia are less easily observed in the tongue and
earlobes.
A client with a potential for violence is exhibiting aggressive gestures, making belligerent
comments to the other clients, and is continuously pacing in the hallway. Which
comment by the nurse would be therapeutic at this time? - (correct answer)The
appropriate response is to ask the client what is causing the anger. This helps make the
client aware of the behavior and may assist the nurse in planning appropriate
interventions. Asking why is confrontational and could further escalate the client's
behavior.
, The family of a bedridden client with type 2 diabetes mellitus and chronic kidney
disease calls the nurse to report symptoms of headache, polydipsia, and increased
lethargy. Which most important question should the nurse ask the family to determine a
possible problem? - (correct answer)Hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) is an acute complication of type 2 diabetes mellitus leading to hyperglycemia
and dehydration. Headache, polydipsia, and increasing lethargy can be caused by the
dehydration.
The history assessment of a client diagnosed with schizophrenia confirms a routine that
includes smoking two packs of cigarettes and drinking 10 cups of coffee daily.
Considering the assessment data, the nurse recognizes which as placing the client at
most risk for injury? - (correct answer)Both caffeine and nicotine can inhibit the action of
psychotropic medications, which are commonly prescribed for schizophrenia. Although
each of the remaining options presents a risk for injury, ineffective medication therapy
presents the greatest risk for injury that currently affects this client.
systematic desensitization? - (correct answer)Systematic desensitization is a form of
therapy in which the client is introduced to short periods of exposure to the phobic
object while in a relaxed state. Gradually, over a period of time, exposure is increased
until the anxiety about or fear of the object or situation has ceased. Medication is
associated with pharmacological therapy. While stress management techniques and
self-help groups may be helpful, neither is the basis of this therapy
Which readings obtained from a client's pulmonary artery catheter suggest that the
client is in left-sided heart failure? - (correct answer)Normal PCWP ranges from 8 to 15
mm Hg. A PCWP of 20 mm Hg is elevated and corresponds to volume overload of the
left ventricle, such as occurs in heart failure. Options 1, 2, and 4 are normal values
The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a
dysfunctional affect. Which situation is congruent with inappropriate affect? - (correct
answer)An inappropriate affect refers to an emotional response to a situation that is
incongruent with the tone of the situation. A flat affect is manifested as an immobile
facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-
directed mumbling is marked when the client is unable to relate logically to the
To promote optimal cerebral tissue perfusion in the postoperative phase following
cranial surgery, the nurse should place the client with an incision in the anterior or
middle fossa, in which position? - (correct answer)Correct positioning of the client
following cranial surgery is important to avoid increased intracranial pressure and to
promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is
always followed. The client with an incision in the anterior or middle fossa should be
positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in
the posterior fossa or burr holes have been made, the client is positioned flat, or with
the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is
performed, the client should not be positioned to the operative side. Trendelenburg's
position is contraindicated in the postoperative phase following cranial surgery.
The nurse is working with a client who is demonstrating delusional thinking. The client
says to the nurse, "The leaders of a religious cult are being sent to assassinate me."
Which is the best response by the nurse? - (correct answer)The nurse who disagrees
with a client's delusions may make the client more defensive and cling to the delusions
even more firmly. It is most therapeutic for the nurse to empathize with the client's
experience. The nurse can also use the opportunity to try to explore further the meaning
of the experience for the client. The correct option presents reality to the client and then
focuses on the client's feelings. None of the other options provide this support
The nurse is assessing a dark-skinned client for signs of anemia. - (correct
answer)Changes in skin color can be difficult to assess in the dark-skinned client. Color
changes are most easily seen in areas of the body where the epidermis is thin and in
areas where pigmentation is not influenced by exposure to sunlight. The nurse should
assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the
dark-skinned client. Signs of anemia are less easily observed in the tongue and
earlobes.
A client with a potential for violence is exhibiting aggressive gestures, making belligerent
comments to the other clients, and is continuously pacing in the hallway. Which
comment by the nurse would be therapeutic at this time? - (correct answer)The
appropriate response is to ask the client what is causing the anger. This helps make the
client aware of the behavior and may assist the nurse in planning appropriate
interventions. Asking why is confrontational and could further escalate the client's
behavior.
, The family of a bedridden client with type 2 diabetes mellitus and chronic kidney
disease calls the nurse to report symptoms of headache, polydipsia, and increased
lethargy. Which most important question should the nurse ask the family to determine a
possible problem? - (correct answer)Hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) is an acute complication of type 2 diabetes mellitus leading to hyperglycemia
and dehydration. Headache, polydipsia, and increasing lethargy can be caused by the
dehydration.
The history assessment of a client diagnosed with schizophrenia confirms a routine that
includes smoking two packs of cigarettes and drinking 10 cups of coffee daily.
Considering the assessment data, the nurse recognizes which as placing the client at
most risk for injury? - (correct answer)Both caffeine and nicotine can inhibit the action of
psychotropic medications, which are commonly prescribed for schizophrenia. Although
each of the remaining options presents a risk for injury, ineffective medication therapy
presents the greatest risk for injury that currently affects this client.
systematic desensitization? - (correct answer)Systematic desensitization is a form of
therapy in which the client is introduced to short periods of exposure to the phobic
object while in a relaxed state. Gradually, over a period of time, exposure is increased
until the anxiety about or fear of the object or situation has ceased. Medication is
associated with pharmacological therapy. While stress management techniques and
self-help groups may be helpful, neither is the basis of this therapy
Which readings obtained from a client's pulmonary artery catheter suggest that the
client is in left-sided heart failure? - (correct answer)Normal PCWP ranges from 8 to 15
mm Hg. A PCWP of 20 mm Hg is elevated and corresponds to volume overload of the
left ventricle, such as occurs in heart failure. Options 1, 2, and 4 are normal values
The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a
dysfunctional affect. Which situation is congruent with inappropriate affect? - (correct
answer)An inappropriate affect refers to an emotional response to a situation that is
incongruent with the tone of the situation. A flat affect is manifested as an immobile
facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-
directed mumbling is marked when the client is unable to relate logically to the
