CVA NCLEX real Actual EXAM
CVA NCLEX real Actual EXAM 3 Complete
Verified Questions And Correct Detailed
Answers with Rationales Graded A+
Guaranteed Pass
1. If a male client experienced a cerebrovascular accident (CVA) that damaged the
hypothalamus, the nurse would anticipate that the client has problems with:
A. Body temperature control.
B. Balance and equilibrium.
C. Visual acuity.
D. Thinking and reasoning. –
Correct Answer :Answer: A. Body temperature control.
A+ TEST BANK 1
, CVA NCLEX real Actual EXAM
The body's thermostat is located in the hypothalamus; therefore, injury to that
area can cause problems of body temperature control.
2. A female client admitted to an acute care facility after a car accident develops
signs and symptoms of increased intracranial pressure (ICP). The client is intubated
and placed on mechanical ventilation to help reduce ICP. To prevent a further rise
in ICP caused by suctioning, the nurse anticipates administering which drug
endotracheally before suctioning?
A. Phenytoin (Dilantin)
B. Mannitol (Osmitrol)
C. Lidocaine (Xylocaine)
D. Furosemide (Lasix) –
Correct Answer :Answer: C. Lidocaine (Xylocaine)
Administering lidocaine via an endotracheal tube may minimize elevations in ICP
caused by suctioning.
3. After striking his head on a tree while falling from a ladder, a young man age 18
is admitted to the emergency department. He's unconscious and his pupils are
nonreactive. Which intervention would be the most dangerous for the client?
A. Give him a barbiturate.
B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
A+ TEST BANK 2
, CVA NCLEX real Actual EXAM
D. Elevate the head of his bed. –
Correct Answer :Answer: C. Perform a lumbar puncture.
The client's history and assessment suggest that he may have increased
intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done
because it can quickly decompress the central nervous system and, thereby, cause
additional damage.
4. When obtaining the health history from a male client with retinal detachment,
the nurse expects the client to report:
A. Light flashes and floaters in front of the eye.
B. A recent driving accident while changing lanes.
C. Headaches, nausea, and redness of the eyes.
D. Frequent episodes of double vision. –
Correct Answer :Answer: A. Light flashes and floaters in front of the eye.
The sudden appearance of light flashes and floaters in front of the affected eye is
characteristic of retinal detachment.
5. Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
A. Imbalanced nutrition: Less than body requirements
A+ TEST BANK 3
, CVA NCLEX real Actual EXAM
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury –
Correct Answer :Answer: B. Ineffective airway clearance
In Parkinson's crisis, dopamine-related symptoms are severely exacerbated,
virtually immobilizing the client. A client confined to bed during such a crisis is at
risk for aspiration and pneumonia. Also, excessive drooling increases the risk of
airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective
airway clearance takes highest priority. Although the other options also are
appropriate, they aren't immediately life-threatening.
6. To encourage adequate nutritional intake for a female client with Alzheimer's
disease, the nurse should:
A. Stay with the client and encourage him to eat.
B. Help the client fill out his menu.
C. Give the client privacy during meals.
D. Fill out the menu for the client. –
Correct Answer :Answer: A. Stay with the client and encourage him to eat.
Staying with the client and encouraging him to feed himself will ensure adequate
food intake. A client with Alzheimer's disease can forget how to eat.
A+ TEST BANK 4
CVA NCLEX real Actual EXAM 3 Complete
Verified Questions And Correct Detailed
Answers with Rationales Graded A+
Guaranteed Pass
1. If a male client experienced a cerebrovascular accident (CVA) that damaged the
hypothalamus, the nurse would anticipate that the client has problems with:
A. Body temperature control.
B. Balance and equilibrium.
C. Visual acuity.
D. Thinking and reasoning. –
Correct Answer :Answer: A. Body temperature control.
A+ TEST BANK 1
, CVA NCLEX real Actual EXAM
The body's thermostat is located in the hypothalamus; therefore, injury to that
area can cause problems of body temperature control.
2. A female client admitted to an acute care facility after a car accident develops
signs and symptoms of increased intracranial pressure (ICP). The client is intubated
and placed on mechanical ventilation to help reduce ICP. To prevent a further rise
in ICP caused by suctioning, the nurse anticipates administering which drug
endotracheally before suctioning?
A. Phenytoin (Dilantin)
B. Mannitol (Osmitrol)
C. Lidocaine (Xylocaine)
D. Furosemide (Lasix) –
Correct Answer :Answer: C. Lidocaine (Xylocaine)
Administering lidocaine via an endotracheal tube may minimize elevations in ICP
caused by suctioning.
3. After striking his head on a tree while falling from a ladder, a young man age 18
is admitted to the emergency department. He's unconscious and his pupils are
nonreactive. Which intervention would be the most dangerous for the client?
A. Give him a barbiturate.
B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
A+ TEST BANK 2
, CVA NCLEX real Actual EXAM
D. Elevate the head of his bed. –
Correct Answer :Answer: C. Perform a lumbar puncture.
The client's history and assessment suggest that he may have increased
intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done
because it can quickly decompress the central nervous system and, thereby, cause
additional damage.
4. When obtaining the health history from a male client with retinal detachment,
the nurse expects the client to report:
A. Light flashes and floaters in front of the eye.
B. A recent driving accident while changing lanes.
C. Headaches, nausea, and redness of the eyes.
D. Frequent episodes of double vision. –
Correct Answer :Answer: A. Light flashes and floaters in front of the eye.
The sudden appearance of light flashes and floaters in front of the affected eye is
characteristic of retinal detachment.
5. Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
A. Imbalanced nutrition: Less than body requirements
A+ TEST BANK 3
, CVA NCLEX real Actual EXAM
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury –
Correct Answer :Answer: B. Ineffective airway clearance
In Parkinson's crisis, dopamine-related symptoms are severely exacerbated,
virtually immobilizing the client. A client confined to bed during such a crisis is at
risk for aspiration and pneumonia. Also, excessive drooling increases the risk of
airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective
airway clearance takes highest priority. Although the other options also are
appropriate, they aren't immediately life-threatening.
6. To encourage adequate nutritional intake for a female client with Alzheimer's
disease, the nurse should:
A. Stay with the client and encourage him to eat.
B. Help the client fill out his menu.
C. Give the client privacy during meals.
D. Fill out the menu for the client. –
Correct Answer :Answer: A. Stay with the client and encourage him to eat.
Staying with the client and encouraging him to feed himself will ensure adequate
food intake. A client with Alzheimer's disease can forget how to eat.
A+ TEST BANK 4
