NUR 210 (MED/SURG - Test 3) PRACTICE NCLEX STYLE QUESTIONS

NUR 210 (MED/SURG - Test 3) PRACTICE NCLEX STYLE QUESTIONS A school-age client loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 132/58 mmHg, and respiratory rate 28 and irregular. Based on this data, which conclusion by the nurse is the most appropriate? A) These vital signs indicate respiratory distress B) These vital signs indicate increased intracranial pressure C) These vital signs indicate cardiovascular disease D) These vital signs indicate that this child has a spinal cord injury **P-11** - AnswersB (These vital signs indicate increased intracranial pressure) The nurse is caring for a school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for increased intracranial pressure (IICP). The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met? A) "If our child has a bulging soft spot, we will call the doctor." B) "If our child develops an altered level of consciousness, we will notify the doctor." C) "If we notice our child's head is expanding, we will notify the doctor." D) "If our child vomits, we will call the doctor." **P-11** - AnswersB ("If our child develops an altered level of consciousness, we will notify the doctor.") The nurse selects the diagnosis of Risk of Infection for a child who sustained a brain injury during an automobile accident. Which nursing intervention would be appropriate to include in this client's plan of care related to this diagnosis? A) Teach the family the importance of using seat belts B) Change the client's dressings on a prescribed basis C) Refer the family to support services in the community D) Explain rules for visiting in the Intensive Care Unit **P-11** - AnswersB (Change the client's dressings on a prescribed basis) NUR 210 (MED/SURG - Test 3) PRACTICE NCLEX STYLE QUESTIONS While caring for a client with increased intracranial pressure (IICP), a family member asks to assist. Which interventions are appropriate for the nurse to teach the family member regarding this client's care? (Select all that apply) A) Maintain head of the bed elevated to 30 degrees B) Position client in a supine position. C) Decrease stimuli D) Keep bedrails raised E) Keep the client in a stationary position **P-11** - AnswersA, C, & D (Maintain head of the bed elevated to 30 degrees) (Decrease stimuli) (Keep the client in a stationary position) The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP). Which assessment data indicates that the nurse is successful? A) Body temperature elevated 1 degree in 4 hours B) Absent gag reflex C) Pupils equal and reactive to light D) Sluggish response to verbal stimuli **P-11** - AnswersC (Pupils equal and reactive to light) The nurse is caring for a pregnant client with a history of idiopathic intracranial hypertension (IIH) and optic neuritis. What should the nurse least assume regarding this client? A) The client will deliver her baby via cesarean birth B) Pregnancy-related weight gain should be kept to no more than 9 kg C) The client has been prescribed a medication to treat the IIH D) The second stage of labor should not be prolonged **P-11** - AnswersA (The client will deliver her baby via cesarean birth) NUR 210 (MED/SURG - Test 3) PRACTICE NCLEX STYLE QUESTIONS The nurse is planning care for a client who is experiencing increased intracranial pressure (IICP) secondary to a head injury sustained during a motor vehicle crash. Which intervention is a priority for this client? A) Ensuring adequate oxygenation B) Maintaining a calm environment C) Monitoring for nausea and vomiting D) Controlling pain **P-11** - AnswersA (Ensuring adequate oxygenation) Hydrocephalus results from an imbalance between production and absorption of which of the following? A) Blood B) Cerebrospinal fluid C) Oxygen D) Water **P-11** - AnswersB (Cerebrospinal fluid) When a nurse provides a client with the guidance to wear seat belts and avoid mobile device use while driving, this measure is intended to lower the risk of which of the following? A) Cerebral edema B) Head trauma C) Hydrocephalus D) Intracranial tumors **P-11** - AnswersB (Head trauma) Which events are associated with the loss of autoregulation? A) Both intracranial pressure and cerebral perfusion decrease B) Both intracranial pressure and cerebral perfusion increase C) Intracranial pressure decreases and cerebral perfusion increases D) Intracranial pressure increases and cerebral perfusion decreases NUR 210 (MED/SURG - Test 3) PRACTICE NCLEX STYLE QUESTIONS **P-11** - AnswersD (Intracranial pressure increases and cerebral perfusion decreases) The nurse observes a school-age client have an absence seizure. Which statement will the nurse likely include when documenting this seizure? A) "Reported experiencing tingling sensations but denied loss of consciousness." B) "Became unconscious, and all four extremities were jerking uncontrollably for 2 minutes." C) "Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes." D) "Sat very still and was unresponsive with a blank stare for 30 seconds." **P-11* - AnswersD ("Sat very still and was unresponsive with a blank stare for 30 seconds.") A preschool-age client with myoclonic seizures has been following a ketogenic diet for the last 6 months to reduce seizure activity and is complaining of left-sided lower abdominal pain. Which complication of the ketogenic diet should the nurse suspect the client is experiencing? A) Bowel obstruction B) Kidney stone C) Urinary tract infection D) Appendicitis **P-11** - AnswersB (Kidney stone) The nurse provides teaching about phenytoin (Dilantin) to the mother of a school-age client with a seizure disorder. Which statement made by the mother indicates that teaching has been effective? A) "I will give his medicine on an empty stomach so he will absorb it better." B) "I will check his gums and increase visits to the dentist." C) "I will use a carbonated beverage to dilute his medication." D) "I will allow him to chew the tablet." **P-11** - AnswersB