uworld NCLEX Questions LATEST VERSION [QUESTIONS AND
ANSWERS] WITH PRACTICE EXAM DETAILED AND VERIFIED
FOR GUARANTEED PASS- LATEST UPDATE 2025 GRADED A
A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur. - CORRECT ANSWER The
nurse is caring for the client with increased intracranial pressure. The nurse would note
which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood
pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood
pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood
pressure
2, 3, 4
The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and
monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of
normal indicates increased ICP, and the nurse should notify the HCP. Coughing and
range of motion exercises will increase ICP and should be avoided in the early
postoperative stage. - CORRECT ANSWER The nurse has established a goal to
maintain intracranial pressure (ICP) within the normal range for a client who had a
craniotomy 12 hours ago. What should the nurse do? Select all that apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.
3
The clear drainage must be analyzed to determine whether it is nasal drainage or CSF.
The nurse should not give the client tissues because it is important to know how much
leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is
inappropriate to tilt the head back, which would allow the fluid to drain down the throat
and not be collected for a sample. It is inappropriate to administer an antihistamine
because the drainage may not be from postnasal drip. - CORRECT ANSWER What
, should the nurse do first when a client with a head injury begins to have clear drainage
from the nose?
1. Compress the nares
2. Tilt the head back
3. Collect the drainage
4. Administer an antihistamine for postnasal drip
4
Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull
fractures. CSF can be distinguished from other body fluids because the drainage will
separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose. - CORRECT ANSWER A client has
clear fluid leaking from the nose following a basilar skull fracture. Which finding would
alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly blood in appearance and has a pH of 6
3. Fluid clumps together on the dressing and had a pH of 7
Fluid separates into concentric rings and tests positive for glucose.
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. - CORRECT
ANSWER The 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.
4
Homonymous hemianopsia is loss of half of the visual field. The client with
homonymous hemianopsia should have objects placed in the intact field of vision, and
the nurse also should approach the client from the intact side. The nurse instructs the
client to scan the environment to overcome the visual deficit and does client teaching
from within the intact field of vision. The nurse encourages the use of personal
ANSWERS] WITH PRACTICE EXAM DETAILED AND VERIFIED
FOR GUARANTEED PASS- LATEST UPDATE 2025 GRADED A
A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur. - CORRECT ANSWER The
nurse is caring for the client with increased intracranial pressure. The nurse would note
which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood
pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood
pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood
pressure
2, 3, 4
The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and
monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of
normal indicates increased ICP, and the nurse should notify the HCP. Coughing and
range of motion exercises will increase ICP and should be avoided in the early
postoperative stage. - CORRECT ANSWER The nurse has established a goal to
maintain intracranial pressure (ICP) within the normal range for a client who had a
craniotomy 12 hours ago. What should the nurse do? Select all that apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.
3
The clear drainage must be analyzed to determine whether it is nasal drainage or CSF.
The nurse should not give the client tissues because it is important to know how much
leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is
inappropriate to tilt the head back, which would allow the fluid to drain down the throat
and not be collected for a sample. It is inappropriate to administer an antihistamine
because the drainage may not be from postnasal drip. - CORRECT ANSWER What
, should the nurse do first when a client with a head injury begins to have clear drainage
from the nose?
1. Compress the nares
2. Tilt the head back
3. Collect the drainage
4. Administer an antihistamine for postnasal drip
4
Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull
fractures. CSF can be distinguished from other body fluids because the drainage will
separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose. - CORRECT ANSWER A client has
clear fluid leaking from the nose following a basilar skull fracture. Which finding would
alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly blood in appearance and has a pH of 6
3. Fluid clumps together on the dressing and had a pH of 7
Fluid separates into concentric rings and tests positive for glucose.
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. - CORRECT
ANSWER The 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.
4
Homonymous hemianopsia is loss of half of the visual field. The client with
homonymous hemianopsia should have objects placed in the intact field of vision, and
the nurse also should approach the client from the intact side. The nurse instructs the
client to scan the environment to overcome the visual deficit and does client teaching
from within the intact field of vision. The nurse encourages the use of personal
