NCLEX NEURO 500 QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
(QUESTIONS FROM DIFFERENT EXAM VERSIONS )
The nurse caring for an older adult client understands that which of the
following can increase disorientation in this client? *Select all that
apply.* - ANSWER-*1. Sedatives*
*2. Anesthesia*
*3. Analgesics*
4. Ambulation
5. Frequent visitors
*6. Physical restraints*
*rationale* Using sedatives, anesthesia, analgesics, physical
restraints, and tranquilizers can increase disorientation in the older
adult client. Ambulation and frequent visitors can assist in orientation
of the client due to the stimulation these activities provide..
A nurse is assisting with caring for a client after a craniotomy. The
nurse plans to position the client in a: - ANSWER-1. Prone position
2. Supine position
*3. Semi-Fowler's position*
4. Dorsal recumbent position
*rationale* After a craniotomy, the head of the bed is elevated 30 to 45
degrees (semi-Fowler's to Fowler's position), and the client's head is
maintained in a midline, neutral position to facilitate venous drainage.
Options 1, 2, and 4 are incorrect positions.
,A nurse is turning a postoperative client who had extensive back
surgery yesterday. What turning intervention or position would be
best for repositioning this client? - ANSWER-*1. Logrolling*
2. Semi-Fowler's
3. Sims' (semi-prone)
4. 30-degree lateral (side-lying)
*rationale* Logrolling is used to maintain neck and spinal alignment
after injury or surgery. A minimum of three to four staff members is
recommended to prevent injury to the client, and a draw or pull sheet
is also suggested. Options 2, 3, and 4 do not maintain proper spinal
alignment and could be harmful.
The nurse is caring for a client after a supratentorial craniotomy in
which a large tumor was removed from the left side. Choose the
positions in which the nurse can safely place the client. *Select all
that apply.* - ANSWER-1. On the left side
2. With the neck flexed
3. Supine on the left side
4. With extreme hip flexion
*5. In a semi-Fowler's position*
*6. With the head in a midline position*
*rationale* Clients who have undergone supratentorial surgery should
have the head of the bed elevated 30 degrees to promote venous
drainage from the head. The client is positioned to avoid extreme hip
or neck flexion, and the head is maintained in a midline, neutral
position. If a large tumor has been removed, the client should be
,placed on the nonoperative side to prevent the displacement of the
cranial contents.
A client is having a lumbar puncture (LP) performed. The nurse would
place the client in which position for the procedure? - ANSWER-1.
Supine, in semi-Fowler's
2. Prone, in slight Trendelenburg's
3. Prone, with a pillow under the abdomen
*4. Side-lying, with legs pulled up and head bent down onto the chest*
*rationale* The client undergoing LP is positioned lying on the side,
with the legs pulled up to the abdomen and the head bent down onto
the chest. This position helps open the spaces between the vertebrae.
A client has just undergone computed tomography (CT) scanning
with a contrast medium. The nurse determines that the client
understands postprocedure care if the client verbalizes that he or she
will: - ANSWER-*1. Drink extra fluids for the day.*
2. Hold medications for at least 4 hours.
3. Eat lightly for the remainder of the day.
4. Rest quietly for the remainder of the day.
*rationale* After CT scanning, the client may resume all usual
activities. The client should be encouraged to take in extra fluids to
replace those lost with diuresis from the contrast dye. Options 2, 3,
and 4 are unnecessary.
A nurse is caring for a client with increased intracranial pressure
, (ICP). The nurse should monitor for which of the following trends in
vital signs that would occur if ICP is rising? - ANSWER-*1. Increasing
temperature, decreasing pulse, decreasing respirations, increasing
blood pressure (BP)*
2. Decreasing temperature, decreasing pulse, increasing
respirations, decreasing BP
3. Decreasing temperature, increasing pulse, decreasing
respirations, increasing BP
4. Increasing temperature, increasing pulse, increasing
respirations, decreasing BP
*rationale* A change in vital signs may be a late sign of increased ICP.
Trends include increasing temperature and blood pressure and
decreasing pulse and respirations. Respiratory irregularities may also
arise.
A nurse is positioning the client with increased intracranial pressure
(ICP). Which position should the nurse avoid? - ANSWER-1. Head
midline
*2. Head turned to the side*
3. Neck in neutral position
4. Head of bed elevated 30 to 45 degrees
*rationale* The head of the client with increased ICP should be
positioned so that the head is in a neutral, midline position. The nurse
should avoid flexing or extending the neck or turning the head side to
side. The head of the bed should be raised to 30 to 45 degrees. Use of
proper positions promotes venous drainage from the cranium to keep
ICP down.
(QUESTIONS FROM DIFFERENT EXAM VERSIONS )
The nurse caring for an older adult client understands that which of the
following can increase disorientation in this client? *Select all that
apply.* - ANSWER-*1. Sedatives*
*2. Anesthesia*
*3. Analgesics*
4. Ambulation
5. Frequent visitors
*6. Physical restraints*
*rationale* Using sedatives, anesthesia, analgesics, physical
restraints, and tranquilizers can increase disorientation in the older
adult client. Ambulation and frequent visitors can assist in orientation
of the client due to the stimulation these activities provide..
A nurse is assisting with caring for a client after a craniotomy. The
nurse plans to position the client in a: - ANSWER-1. Prone position
2. Supine position
*3. Semi-Fowler's position*
4. Dorsal recumbent position
*rationale* After a craniotomy, the head of the bed is elevated 30 to 45
degrees (semi-Fowler's to Fowler's position), and the client's head is
maintained in a midline, neutral position to facilitate venous drainage.
Options 1, 2, and 4 are incorrect positions.
,A nurse is turning a postoperative client who had extensive back
surgery yesterday. What turning intervention or position would be
best for repositioning this client? - ANSWER-*1. Logrolling*
2. Semi-Fowler's
3. Sims' (semi-prone)
4. 30-degree lateral (side-lying)
*rationale* Logrolling is used to maintain neck and spinal alignment
after injury or surgery. A minimum of three to four staff members is
recommended to prevent injury to the client, and a draw or pull sheet
is also suggested. Options 2, 3, and 4 do not maintain proper spinal
alignment and could be harmful.
The nurse is caring for a client after a supratentorial craniotomy in
which a large tumor was removed from the left side. Choose the
positions in which the nurse can safely place the client. *Select all
that apply.* - ANSWER-1. On the left side
2. With the neck flexed
3. Supine on the left side
4. With extreme hip flexion
*5. In a semi-Fowler's position*
*6. With the head in a midline position*
*rationale* Clients who have undergone supratentorial surgery should
have the head of the bed elevated 30 degrees to promote venous
drainage from the head. The client is positioned to avoid extreme hip
or neck flexion, and the head is maintained in a midline, neutral
position. If a large tumor has been removed, the client should be
,placed on the nonoperative side to prevent the displacement of the
cranial contents.
A client is having a lumbar puncture (LP) performed. The nurse would
place the client in which position for the procedure? - ANSWER-1.
Supine, in semi-Fowler's
2. Prone, in slight Trendelenburg's
3. Prone, with a pillow under the abdomen
*4. Side-lying, with legs pulled up and head bent down onto the chest*
*rationale* The client undergoing LP is positioned lying on the side,
with the legs pulled up to the abdomen and the head bent down onto
the chest. This position helps open the spaces between the vertebrae.
A client has just undergone computed tomography (CT) scanning
with a contrast medium. The nurse determines that the client
understands postprocedure care if the client verbalizes that he or she
will: - ANSWER-*1. Drink extra fluids for the day.*
2. Hold medications for at least 4 hours.
3. Eat lightly for the remainder of the day.
4. Rest quietly for the remainder of the day.
*rationale* After CT scanning, the client may resume all usual
activities. The client should be encouraged to take in extra fluids to
replace those lost with diuresis from the contrast dye. Options 2, 3,
and 4 are unnecessary.
A nurse is caring for a client with increased intracranial pressure
, (ICP). The nurse should monitor for which of the following trends in
vital signs that would occur if ICP is rising? - ANSWER-*1. Increasing
temperature, decreasing pulse, decreasing respirations, increasing
blood pressure (BP)*
2. Decreasing temperature, decreasing pulse, increasing
respirations, decreasing BP
3. Decreasing temperature, increasing pulse, decreasing
respirations, increasing BP
4. Increasing temperature, increasing pulse, increasing
respirations, decreasing BP
*rationale* A change in vital signs may be a late sign of increased ICP.
Trends include increasing temperature and blood pressure and
decreasing pulse and respirations. Respiratory irregularities may also
arise.
A nurse is positioning the client with increased intracranial pressure
(ICP). Which position should the nurse avoid? - ANSWER-1. Head
midline
*2. Head turned to the side*
3. Neck in neutral position
4. Head of bed elevated 30 to 45 degrees
*rationale* The head of the client with increased ICP should be
positioned so that the head is in a neutral, midline position. The nurse
should avoid flexing or extending the neck or turning the head side to
side. The head of the bed should be raised to 30 to 45 degrees. Use of
proper positions promotes venous drainage from the cranium to keep
ICP down.
