NUR 211 Unit 4 Practice Questions And
Correct Answers.
The nurse is assessing the motor and sensory function of an unconscious client, The nurse should use
which technique ti test the clients peripheral response to pain?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Sqeeezing the sternocleidomastoid muscle - Answer B. Nail bed pressure
The nurse is caring for the client with increased ICP. The nurse would note which trend in Vital signs if
the ICP is rising?
A. Increasing tempature, increasing pulse, increasing Respirations, decreasing Blood pressure.
B. Increasing tempature, decreasing pulse, decreasing respirations, increasing blood pressure.
C. Decreasing tempature, decreasing pulse, increasing respirations, decreasing blood pressure.
D. Decreasing tempature, increasing pulse, decreasing respirations, increasing blood pressure. - Answer
B. Increasing tempature, decreasing pulse, decreasing respirations, increasing blood pressure.
A client recovering from a head injury is participating in care. The nurse determines that the client
understands measures to prevent elevations in ICP if the nurse obserbes the client doing which activity?
A. Blowing the nose
B. Isometric exercises
C. Coughing vigorously
D. Exhaling during repositioning - Answer D. Exhaling during repositioning
A client has clear fluid leaking from the nose following a skull fracture. Which finding would alert the
nurse that CSF is present?
A. Fluid is clear and tests negative for glucose
B. Fluid is grossly bloody in appearance and has a pH of 6
C. Fluid clumps together on the dressing and has a pH of 7
, D. Fluid seperates into concentric ring and tests positive for glucose - Answer D. Fluid seperates into
concentric ring and tests positive for glucose
The nurse is caring for a client who begins to experience seizure activity while in bed. WHich actions
should the nurse take? (select all that apply)
A. loosening restrictive clothing
B. Restraining the clients limbs
C. Removing the pillow and rasing padded side rails
D. Positioning the client to the side, if possible, with head flexed forward
E. Keeping the curtain around the client and the room door open so when help arrives they can quickly
enter to assist - Answer A. loosening restrictive clothing
C. Removing the pillow and rasing padded side rails
D. Positioning the client to the side, if possible, with head flexed forward
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which
characteristics are associated with this condition? (select all that apply)
A. The client is aphasic
B. The client has weakness on the right side of the body
C. The client has complete bilateral paralysis the arm and legs
D. The client has weakness on the right side of the face and tongue
E. The client has lost the ability to move the right arm but is able to walk independently.
F. The client has lost the ability to ambulate independently but is able to feed and bathe himself or
herself without assistance. - Answer A. The client is aphasic
B. The client has weakness on the right side of the body
D. The client has weakness on the right side of the face and tongue
Rationale: Right sided paralysis and weakness deals with the left side of brain which also control
language and speech. Aphasia/aphasic is the inability to speak.
The nurse has instructed the family of a client wiht a stroke who has homonymous hemianopsia about
measure to help the client overcome the deficit. Which statement suggests that the family understands
the measures to use when caring for the client?
Correct Answers.
The nurse is assessing the motor and sensory function of an unconscious client, The nurse should use
which technique ti test the clients peripheral response to pain?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Sqeeezing the sternocleidomastoid muscle - Answer B. Nail bed pressure
The nurse is caring for the client with increased ICP. The nurse would note which trend in Vital signs if
the ICP is rising?
A. Increasing tempature, increasing pulse, increasing Respirations, decreasing Blood pressure.
B. Increasing tempature, decreasing pulse, decreasing respirations, increasing blood pressure.
C. Decreasing tempature, decreasing pulse, increasing respirations, decreasing blood pressure.
D. Decreasing tempature, increasing pulse, decreasing respirations, increasing blood pressure. - Answer
B. Increasing tempature, decreasing pulse, decreasing respirations, increasing blood pressure.
A client recovering from a head injury is participating in care. The nurse determines that the client
understands measures to prevent elevations in ICP if the nurse obserbes the client doing which activity?
A. Blowing the nose
B. Isometric exercises
C. Coughing vigorously
D. Exhaling during repositioning - Answer D. Exhaling during repositioning
A client has clear fluid leaking from the nose following a skull fracture. Which finding would alert the
nurse that CSF is present?
A. Fluid is clear and tests negative for glucose
B. Fluid is grossly bloody in appearance and has a pH of 6
C. Fluid clumps together on the dressing and has a pH of 7
, D. Fluid seperates into concentric ring and tests positive for glucose - Answer D. Fluid seperates into
concentric ring and tests positive for glucose
The nurse is caring for a client who begins to experience seizure activity while in bed. WHich actions
should the nurse take? (select all that apply)
A. loosening restrictive clothing
B. Restraining the clients limbs
C. Removing the pillow and rasing padded side rails
D. Positioning the client to the side, if possible, with head flexed forward
E. Keeping the curtain around the client and the room door open so when help arrives they can quickly
enter to assist - Answer A. loosening restrictive clothing
C. Removing the pillow and rasing padded side rails
D. Positioning the client to the side, if possible, with head flexed forward
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which
characteristics are associated with this condition? (select all that apply)
A. The client is aphasic
B. The client has weakness on the right side of the body
C. The client has complete bilateral paralysis the arm and legs
D. The client has weakness on the right side of the face and tongue
E. The client has lost the ability to move the right arm but is able to walk independently.
F. The client has lost the ability to ambulate independently but is able to feed and bathe himself or
herself without assistance. - Answer A. The client is aphasic
B. The client has weakness on the right side of the body
D. The client has weakness on the right side of the face and tongue
Rationale: Right sided paralysis and weakness deals with the left side of brain which also control
language and speech. Aphasia/aphasic is the inability to speak.
The nurse has instructed the family of a client wiht a stroke who has homonymous hemianopsia about
measure to help the client overcome the deficit. Which statement suggests that the family understands
the measures to use when caring for the client?
