uworld NCLEX Questions with answers
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure
A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur. - -The nurse is caring for the
client with increased intracranial pressure. The nurse would note which trend in vital
signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing
blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing
blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing
blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing
blood pressure
-2, 3, 4
The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and
monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper
limits of normal indicates increased ICP, and the nurse should notify the HCP.
Coughing and range of motion exercises will increase ICP and should be avoided in
the early postoperative stage. - -The nurse has established a goal to maintain
intracranial pressure (ICP) within the normal range for a client who had a
craniotomy 12 hours ago. What should the nurse do? Select all that apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.
-3
The clear drainage must be analyzed to determine whether it is nasal drainage or
CSF. The nurse should not give the client tissues because it is important to know
how much leakage of CSF is occurring. Compressing the nares will obstruct the
drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to
drain down the throat and not be collected for a sample. It is inappropriate to
administer an antihistamine because the drainage may not be from postnasal drip. -
-What should the nurse do first when a client with a head injury begins to have clear
drainage from the nose?
1. Compress the nares
2. Tilt the head back
3. Collect the drainage
, 4. Administer an antihistamine for postnasal drip
-4
Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull
fractures. CSF can be distinguished from other body fluids because the drainage will
separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose. - -A client has clear fluid leaking from
the nose following a basilar skull fracture. Which finding would alert the nurse that
cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly blood in appearance and has a pH of 6
3. Fluid clumps together on the dressing and had a pH of 7
Fluid separates into concentric rings and tests positive for glucose.
-1, 2, 4
Hemiparesis is a weakness of one side of the body that may occur after a stroke. It
involves weakness of the face and tongue, arm, and leg on one side. These clients
are also aphasic: unable to discriminate words and letters. They are generally very
cautions and get anxious when attempting a new task. Complete bilateral paralysis
does not occur in hemiparesis. The client with right-sided hemiparesis has weakness
of the right arm and leg and needs assistance with feeding, bathing, and
ambulating. - -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.
1. The client is aphasic.
2. The client has weakness on the right side of the body.
3. The client has complete bilateral paralysis of the arms and legs.
4. The client has weakness on the right side of the face and tongue.
5. The client has lost the ability to move the right arm but is able to walk
independently
6. The client has lost the ability to ambulate independently, but is able to feed and
bathe himself or herself without assistance.
-4
Homonymous hemianopsia is loss of half of the visual field. The client with
homonymous hemianopsia should have objects placed in the intact field of vision,
and the nurse also should approach the client from the intact side. The nurse
instructs the client to scan the environment to overcome the visual deficit and does
client teaching from within the intact field of vision. The nurse encourages the use
of personal eyeglasses, if they are available. - -The nurse has instructed the family
of a client with stroke who has homonymous hemianopsia about measures to help
the client overcome the deficit. Which statement suggests that the family
understand the measures to use when caring for the client?
1. We need to discourage him from wearing eyeglasses.
2. We need to place objects in his impaired field of vision.
3. We need to approach him from the impaired field of vision.
4. We need to remind him to turn his head to scan the lost visual field.
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure
A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur. - -The nurse is caring for the
client with increased intracranial pressure. The nurse would note which trend in vital
signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing
blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing
blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing
blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing
blood pressure
-2, 3, 4
The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and
monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper
limits of normal indicates increased ICP, and the nurse should notify the HCP.
Coughing and range of motion exercises will increase ICP and should be avoided in
the early postoperative stage. - -The nurse has established a goal to maintain
intracranial pressure (ICP) within the normal range for a client who had a
craniotomy 12 hours ago. What should the nurse do? Select all that apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.
-3
The clear drainage must be analyzed to determine whether it is nasal drainage or
CSF. The nurse should not give the client tissues because it is important to know
how much leakage of CSF is occurring. Compressing the nares will obstruct the
drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to
drain down the throat and not be collected for a sample. It is inappropriate to
administer an antihistamine because the drainage may not be from postnasal drip. -
-What should the nurse do first when a client with a head injury begins to have clear
drainage from the nose?
1. Compress the nares
2. Tilt the head back
3. Collect the drainage
, 4. Administer an antihistamine for postnasal drip
-4
Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull
fractures. CSF can be distinguished from other body fluids because the drainage will
separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose. - -A client has clear fluid leaking from
the nose following a basilar skull fracture. Which finding would alert the nurse that
cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly blood in appearance and has a pH of 6
3. Fluid clumps together on the dressing and had a pH of 7
Fluid separates into concentric rings and tests positive for glucose.
-1, 2, 4
Hemiparesis is a weakness of one side of the body that may occur after a stroke. It
involves weakness of the face and tongue, arm, and leg on one side. These clients
are also aphasic: unable to discriminate words and letters. They are generally very
cautions and get anxious when attempting a new task. Complete bilateral paralysis
does not occur in hemiparesis. The client with right-sided hemiparesis has weakness
of the right arm and leg and needs assistance with feeding, bathing, and
ambulating. - -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.
1. The client is aphasic.
2. The client has weakness on the right side of the body.
3. The client has complete bilateral paralysis of the arms and legs.
4. The client has weakness on the right side of the face and tongue.
5. The client has lost the ability to move the right arm but is able to walk
independently
6. The client has lost the ability to ambulate independently, but is able to feed and
bathe himself or herself without assistance.
-4
Homonymous hemianopsia is loss of half of the visual field. The client with
homonymous hemianopsia should have objects placed in the intact field of vision,
and the nurse also should approach the client from the intact side. The nurse
instructs the client to scan the environment to overcome the visual deficit and does
client teaching from within the intact field of vision. The nurse encourages the use
of personal eyeglasses, if they are available. - -The nurse has instructed the family
of a client with stroke who has homonymous hemianopsia about measures to help
the client overcome the deficit. Which statement suggests that the family
understand the measures to use when caring for the client?
1. We need to discourage him from wearing eyeglasses.
2. We need to place objects in his impaired field of vision.
3. We need to approach him from the impaired field of vision.
4. We need to remind him to turn his head to scan the lost visual field.
