CVA NCLEX real Actual EXAM
CVA NCLEX real Actual EXAM Complete
Verified Questions And Correct Detailed
Answers with Rationales Graded A+
Guaranteed Pass
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial
pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure
(CPP) of this patient indicates
a. high blood flow to the brain.
b. normal intracranial pressure (ICP).
c. impaired brain blood flow.
A+ TEST BANK 1
, CVA NCLEX real Actual EXAM
d. adequate cerebral perfusion. –
Correct Answer :Correct Answer: C
Rationale:
The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the
level of ischemia and neuronal death. The patient has low cerebral blood
flow/perfusion. Normal ICP is 0 to 15 mm Hg.
Cognitive Level: Application Text Reference: p. 1468
Nursing Process: Assessment NCLEX: Physiological Integrity
When caring for a patient who has had a head injury, which assessment
information is of most concern to the nurse?
a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient's apical pulse is slightly irregular. –
Correct Answer :Correct Answer: B
Rationale:
The change in level of consciousness (LOC) is an indicator of increased ICP and
suggests that action by the nurse is needed to prevent complications. The change
in BP should be monitored but is not an indicator of a need for immediate nursing
action. Headache is not unusual in a patient after a head injury. A slightly irregular
apical pulse is not unusual.
A+ TEST BANK 2
, CVA NCLEX real Actual EXAM
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Assessment NCLEX: Physiological Integrity
When the nurse applies a painful stimulus to the nailbeds of an unconscious
patient, the patient responds with internal rotation, adduction, and flexion of the
arms. The nurse documents this as
a. decorticate posturing.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal. –
Correct Answer :Correct Answer: A
Rationale:
Internal rotation, adduction, and flexion of the arms in an unconscious patient is
documented as decorticate posturing. Extension of the arms and legs is
decerebrate posturing. Because the flexion is general, it does not indicate
localization of pain or flexion withdrawal.
Cognitive Level: Comprehension Text Reference: p. 1472
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L
(115 mmol/L), a decreasing level of consciousness (LOC) and complains of a
A+ TEST BANK 3
, CVA NCLEX real Actual EXAM
headache. All of the following orders have been received. Which one should the
nurse accomplish first?
a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send patient to radiology for computed tomography (CT) of the head. –
Correct Answer :
Correct Answer: B
Rationale:
The patient's low sodium indicates that hyponatremia may be causing the cerebral
edema, and the nurse's first action should be to correct the low sodium level.
Acetaminophen (Tylenol) will have minimal effect on the headache because it is
caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT
scan may add some useful information, but the low sodium level may lead to
seizures unless it is addressed quickly.
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Implementation NCLEX: Physiological Integrity
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation
is used for a patient with a head injury. To evaluate the effectiveness of the
therapy, the nurse should
a. monitor oxygen saturation.
A+ TEST BANK 4
CVA NCLEX real Actual EXAM Complete
Verified Questions And Correct Detailed
Answers with Rationales Graded A+
Guaranteed Pass
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial
pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure
(CPP) of this patient indicates
a. high blood flow to the brain.
b. normal intracranial pressure (ICP).
c. impaired brain blood flow.
A+ TEST BANK 1
, CVA NCLEX real Actual EXAM
d. adequate cerebral perfusion. –
Correct Answer :Correct Answer: C
Rationale:
The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the
level of ischemia and neuronal death. The patient has low cerebral blood
flow/perfusion. Normal ICP is 0 to 15 mm Hg.
Cognitive Level: Application Text Reference: p. 1468
Nursing Process: Assessment NCLEX: Physiological Integrity
When caring for a patient who has had a head injury, which assessment
information is of most concern to the nurse?
a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient's apical pulse is slightly irregular. –
Correct Answer :Correct Answer: B
Rationale:
The change in level of consciousness (LOC) is an indicator of increased ICP and
suggests that action by the nurse is needed to prevent complications. The change
in BP should be monitored but is not an indicator of a need for immediate nursing
action. Headache is not unusual in a patient after a head injury. A slightly irregular
apical pulse is not unusual.
A+ TEST BANK 2
, CVA NCLEX real Actual EXAM
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Assessment NCLEX: Physiological Integrity
When the nurse applies a painful stimulus to the nailbeds of an unconscious
patient, the patient responds with internal rotation, adduction, and flexion of the
arms. The nurse documents this as
a. decorticate posturing.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal. –
Correct Answer :Correct Answer: A
Rationale:
Internal rotation, adduction, and flexion of the arms in an unconscious patient is
documented as decorticate posturing. Extension of the arms and legs is
decerebrate posturing. Because the flexion is general, it does not indicate
localization of pain or flexion withdrawal.
Cognitive Level: Comprehension Text Reference: p. 1472
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L
(115 mmol/L), a decreasing level of consciousness (LOC) and complains of a
A+ TEST BANK 3
, CVA NCLEX real Actual EXAM
headache. All of the following orders have been received. Which one should the
nurse accomplish first?
a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send patient to radiology for computed tomography (CT) of the head. –
Correct Answer :
Correct Answer: B
Rationale:
The patient's low sodium indicates that hyponatremia may be causing the cerebral
edema, and the nurse's first action should be to correct the low sodium level.
Acetaminophen (Tylenol) will have minimal effect on the headache because it is
caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT
scan may add some useful information, but the low sodium level may lead to
seizures unless it is addressed quickly.
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Implementation NCLEX: Physiological Integrity
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation
is used for a patient with a head injury. To evaluate the effectiveness of the
therapy, the nurse should
a. monitor oxygen saturation.
A+ TEST BANK 4
