NUR 400 Final Exam NCLEX Style Ques ons and answers
newest RATED A+ 2025/2026
Which nursing interven on takes priority when assessing the neurological health of a pa ent
who has just been admi ed with a suspected stroke?
a. Assessing pa ent for injury (wounds, bruising, bone breaks)
b. Performing a comprehensive neurological assessment
c. Administering ssue plasminogen ac vator (tPA)
d. Obtaining a detailed medical history
b. Performing a comprehensive neurological assessment
Ra onale:
Assessing the client for injury (op on A) is important in the overall assessment of a client, but it
is not the priority. Neurological assessment takes precedence because mely iden fica on of
neurological deficits is crucial for determining the type and severity of the stroke and guiding
subsequent interven ons.
Administering ssue plasminogen ac vator (tPA) (op on C) is a me-sensi ve interven on for
ischemic strokes, but it should only be ini ated a+er a comprehensive neurological assessment
and confirma on of eligibility criteria. Administering tPA without proper assessment may pose
risks to the client.
Obtaining a detailed medical history (op on D) is essen al in understanding the client's risk
factors and medical background, but it is not the priority interven on upon admission of a client
with a suspected stroke.
Performing a comprehensive neurological assessment (op on B) is the priority because it allows
for the mely iden fica on of neurological deficits, such as asymmetry in strength, sensa on,
coordina on, and changes in level of consciousness. This assessment guides further diagnos c
tes ng, treatment decisions, and interven ons to promote op mal outcomes for the client.
An 86 year old pa ent with a history of hypertension comes to the Emergency Department
confused and complaining of a severe headache. The nurse is concerned that the pa ent is
having a stroke. Which ac on does the nurse take first?
,a. Obtain a full set of vitals
b. Perform a Mini Mental Status Exam
c. Assess the pa ent using the Glasgow Coma Scale
d. Ask the pa ent to smile, speak their name, and then hold out their arms
d. Ask the pa ent to smile, speak their name, and then hold out their arms
Ra onale:
To assess for a stroke the nurse should determine if the pa ent is experiencing face paralysis
using the "FAST" technique:
F > facial drooping and uneven smile
A > arm weakness, inability to li+ both arms
S > speech difficulty, inability to repeat a simple sentence
T > me, seek immediate care or interven on.
Although vital signs can be useful, they do not give a more focused assessment regarding brain
insult. Vital signs can be obtained a+er the FAST technique is used. The Mini Mental Status
Exam is used to assess cogni ve impairment, so it would not be useful in determining the status
of the pa ent at this me. The Glasgow Coma Scale is used to determine level of consciousness
and is not appropriate as an ini al assessment because the client is currently conscious.
AD
A nurse is assessing the neurological status of a pa ent who has been admi ed following a
motor vehicle accident. Which assessment finding should the nurse priori ze as an indica on of
poten al increased intracranial pressure (ICP)?
a. Dilated pupils with sluggish response to light
b. Unequal movement of extremi es
c. Decreased blood pressure with increased heart rate
d. Increased respiratory rate with shallow breathing
a. Dilated pupils with sluggish response to light
Ra onale:
,The correct answer is A because dilated pupils with sluggish response to light as an indica on of
poten al increased intracranial pressure (ICP). Pupillary changes, par cularly dila on with
sluggish or non-reac ve response to light, can be a significant neurological sign sugges ve of
increased pressure within the skull. This requires immediate medical a en on and can result in
death.
B) While unequal movement of extremi es can be indica ve of neurological compromise, it is
not as specific to increased intracranial pressure.
C) While decreased blood pressure with increased heart rate is a sign of worsening intracranial
pressure, it's not as immediate and specific as dilated pupils with sluggish response to light.
D) Increased respiratory rate with shallow breathing may indicate respiratory distress or
dysfunc on rather than increased intracranial pressure. While respiratory changes can occur in
response to neurological compromise, they are not as specific to increased ICP as dilated pupils
with sluggish response to light.
A nurse is conduc ng a neurological assessment on a pa ent who has been admi ed with a
head injury. Which assessment finding should the nurse priori ze as indica ve of a poten al
neurological complica on?
a. Unequal pupil size
b. Decreased bowel sounds
c. Elevated blood pressure
d. Increased respiratory rate
a. Unequal pupil size
Ra onale:
A) Unequal pupil is indica ve of anisocoria, which can be a sign of increased intracranial
pressure (ICP) or neurological damage. Unequal pupil size may suggest a dysfunc on of the
oculomotor nerve (cranial nerve III) or other neurological structures. Monitoring pupil size and
reac vity is crucial in assessing neurological status, especially in clients with head injuries.
B) While decreased bowel sounds may indicate gastrointes nal dysfunc on, it is not directly
related to neurological complica ons in a client with a head injury. Bowel sounds are more
indica ve of gastrointes nal mo lity and func on rather than neurological status.
C) Elevated blood pressure can occur due to various factors such as pain, stress, or physiological
responses to injury. While monitoring blood pressure is important in overall assessment, it is
not specifically indica ve of neurological complica ons related to a head injury.
, D) An increased respiratory rate can be a response to pain, anxiety, or other physiological
factors. While changes in respiratory rate may be observed in clients with neurological issues
such as brainstem dysfunc on, it is not a specific finding that directly indicates neurological
complica ons in a client with a head injury.
A+er comple ng a procedure that required the donning of PPE consis ng of a gown, an N95
respirator, a face shield, and gloves, which of the following should the nurse remove first when
removing PPE separately?
a. Gloves
b. Gown
c. Face shield
d. N95 respirator
a. Gloves
Ra onale:
Gloves are considered the most contaminated and should be removed first, followed by
face/eye protec on, gown, and then mask/respirator. The back of the gown and its es are
considered not contaminated, so this is not the first item that should be removed a+er
comple ng a procedure. The ear and head pieces of a face shield are rarely contaminated and
because this is the area that the nurse will grasp to remove the face shield, this is not the first
item that should be removed. The N95 respirator should be removed last because the pa ent
has an airborne disease, requiring a respirator and the nurse should keep this on un l they are
outside of the room and the door to the pa ent's room is closed.
We have an expert-wri+en solu on to this problem!
The nurse manager is evalua ng current infec on control data for the intensive care unit. The
nurse manager examines the infec on chain for possible solu on. What is the correct order of
the chain of infec on?
a. Suscep ble Host > Infec ous Agent/Pathogen > Reservoir/Source for Pathogen Growth >
Mode of Transmission > Portal of Entry to a Host > Portal of Exit from the Reservoir
newest RATED A+ 2025/2026
Which nursing interven on takes priority when assessing the neurological health of a pa ent
who has just been admi ed with a suspected stroke?
a. Assessing pa ent for injury (wounds, bruising, bone breaks)
b. Performing a comprehensive neurological assessment
c. Administering ssue plasminogen ac vator (tPA)
d. Obtaining a detailed medical history
b. Performing a comprehensive neurological assessment
Ra onale:
Assessing the client for injury (op on A) is important in the overall assessment of a client, but it
is not the priority. Neurological assessment takes precedence because mely iden fica on of
neurological deficits is crucial for determining the type and severity of the stroke and guiding
subsequent interven ons.
Administering ssue plasminogen ac vator (tPA) (op on C) is a me-sensi ve interven on for
ischemic strokes, but it should only be ini ated a+er a comprehensive neurological assessment
and confirma on of eligibility criteria. Administering tPA without proper assessment may pose
risks to the client.
Obtaining a detailed medical history (op on D) is essen al in understanding the client's risk
factors and medical background, but it is not the priority interven on upon admission of a client
with a suspected stroke.
Performing a comprehensive neurological assessment (op on B) is the priority because it allows
for the mely iden fica on of neurological deficits, such as asymmetry in strength, sensa on,
coordina on, and changes in level of consciousness. This assessment guides further diagnos c
tes ng, treatment decisions, and interven ons to promote op mal outcomes for the client.
An 86 year old pa ent with a history of hypertension comes to the Emergency Department
confused and complaining of a severe headache. The nurse is concerned that the pa ent is
having a stroke. Which ac on does the nurse take first?
,a. Obtain a full set of vitals
b. Perform a Mini Mental Status Exam
c. Assess the pa ent using the Glasgow Coma Scale
d. Ask the pa ent to smile, speak their name, and then hold out their arms
d. Ask the pa ent to smile, speak their name, and then hold out their arms
Ra onale:
To assess for a stroke the nurse should determine if the pa ent is experiencing face paralysis
using the "FAST" technique:
F > facial drooping and uneven smile
A > arm weakness, inability to li+ both arms
S > speech difficulty, inability to repeat a simple sentence
T > me, seek immediate care or interven on.
Although vital signs can be useful, they do not give a more focused assessment regarding brain
insult. Vital signs can be obtained a+er the FAST technique is used. The Mini Mental Status
Exam is used to assess cogni ve impairment, so it would not be useful in determining the status
of the pa ent at this me. The Glasgow Coma Scale is used to determine level of consciousness
and is not appropriate as an ini al assessment because the client is currently conscious.
AD
A nurse is assessing the neurological status of a pa ent who has been admi ed following a
motor vehicle accident. Which assessment finding should the nurse priori ze as an indica on of
poten al increased intracranial pressure (ICP)?
a. Dilated pupils with sluggish response to light
b. Unequal movement of extremi es
c. Decreased blood pressure with increased heart rate
d. Increased respiratory rate with shallow breathing
a. Dilated pupils with sluggish response to light
Ra onale:
,The correct answer is A because dilated pupils with sluggish response to light as an indica on of
poten al increased intracranial pressure (ICP). Pupillary changes, par cularly dila on with
sluggish or non-reac ve response to light, can be a significant neurological sign sugges ve of
increased pressure within the skull. This requires immediate medical a en on and can result in
death.
B) While unequal movement of extremi es can be indica ve of neurological compromise, it is
not as specific to increased intracranial pressure.
C) While decreased blood pressure with increased heart rate is a sign of worsening intracranial
pressure, it's not as immediate and specific as dilated pupils with sluggish response to light.
D) Increased respiratory rate with shallow breathing may indicate respiratory distress or
dysfunc on rather than increased intracranial pressure. While respiratory changes can occur in
response to neurological compromise, they are not as specific to increased ICP as dilated pupils
with sluggish response to light.
A nurse is conduc ng a neurological assessment on a pa ent who has been admi ed with a
head injury. Which assessment finding should the nurse priori ze as indica ve of a poten al
neurological complica on?
a. Unequal pupil size
b. Decreased bowel sounds
c. Elevated blood pressure
d. Increased respiratory rate
a. Unequal pupil size
Ra onale:
A) Unequal pupil is indica ve of anisocoria, which can be a sign of increased intracranial
pressure (ICP) or neurological damage. Unequal pupil size may suggest a dysfunc on of the
oculomotor nerve (cranial nerve III) or other neurological structures. Monitoring pupil size and
reac vity is crucial in assessing neurological status, especially in clients with head injuries.
B) While decreased bowel sounds may indicate gastrointes nal dysfunc on, it is not directly
related to neurological complica ons in a client with a head injury. Bowel sounds are more
indica ve of gastrointes nal mo lity and func on rather than neurological status.
C) Elevated blood pressure can occur due to various factors such as pain, stress, or physiological
responses to injury. While monitoring blood pressure is important in overall assessment, it is
not specifically indica ve of neurological complica ons related to a head injury.
, D) An increased respiratory rate can be a response to pain, anxiety, or other physiological
factors. While changes in respiratory rate may be observed in clients with neurological issues
such as brainstem dysfunc on, it is not a specific finding that directly indicates neurological
complica ons in a client with a head injury.
A+er comple ng a procedure that required the donning of PPE consis ng of a gown, an N95
respirator, a face shield, and gloves, which of the following should the nurse remove first when
removing PPE separately?
a. Gloves
b. Gown
c. Face shield
d. N95 respirator
a. Gloves
Ra onale:
Gloves are considered the most contaminated and should be removed first, followed by
face/eye protec on, gown, and then mask/respirator. The back of the gown and its es are
considered not contaminated, so this is not the first item that should be removed a+er
comple ng a procedure. The ear and head pieces of a face shield are rarely contaminated and
because this is the area that the nurse will grasp to remove the face shield, this is not the first
item that should be removed. The N95 respirator should be removed last because the pa ent
has an airborne disease, requiring a respirator and the nurse should keep this on un l they are
outside of the room and the door to the pa ent's room is closed.
We have an expert-wri+en solu on to this problem!
The nurse manager is evalua ng current infec on control data for the intensive care unit. The
nurse manager examines the infec on chain for possible solu on. What is the correct order of
the chain of infec on?
a. Suscep ble Host > Infec ous Agent/Pathogen > Reservoir/Source for Pathogen Growth >
Mode of Transmission > Portal of Entry to a Host > Portal of Exit from the Reservoir
