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NCLEX-RN Exam Questions - Part 100
1. A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
A) Loss of ability to speak and communicate effectively
B) Aspiration and weight loss
C) Secondary infection resulting from poor oral hygiene
D) Drooling
2. A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
A) Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
B) Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
C) Potential for injury related to impaired mobility and seizures
D) Impaired verbal communication related to aphasia
3. A 32-year-old female client is being treated for Guillain- Barr syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
A) Complaints of a headache
B) Loss of superficial and deep tendon reflexes
C) Complaints of shortness of breath
D) Facial paralysis
4. A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
A) Reclining to control bleeding
B) Any position in which the client is comfortable
C) Side-lying, either left or right
D) Sitting with head support
5. A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
A) Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
B) Advise the client to discontinue the drug at the first sign of dizziness.
C) Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
D) Instruct the client in Valsalva - s maneuver to equalize middle ear pressure and to prevent hearing loss.
A) Loss of ability to speak and communicate effectively
B) Aspiration and weight loss
C) Secondary infection resulting from poor oral hygiene
D) Drooling
2. A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
A) Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
B) Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
C) Potential for injury related to impaired mobility and seizures
D) Impaired verbal communication related to aphasia
3. A 32-year-old female client is being treated for Guillain- Barr syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
A) Complaints of a headache
B) Loss of superficial and deep tendon reflexes
C) Complaints of shortness of breath
D) Facial paralysis
4. A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
A) Reclining to control bleeding
B) Any position in which the client is comfortable
C) Side-lying, either left or right
D) Sitting with head support
5. A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
A) Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
B) Advise the client to discontinue the drug at the first sign of dizziness.
C) Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
D) Instruct the client in Valsalva - s maneuver to equalize middle ear pressure and to prevent hearing loss.
1. Right Answer: B
Explanation: (A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the clients inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
2. Right Answer: A
Explanation: (A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
3. Right Answer: C
Explanation: (A) Headaches are not associated with Guillain-Barr syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.
4. Right Answer: D
Explanation: (A) A reclining position can cause a penetrating object to advance further into the eye. (B) Prevention of further injury is the priority, not comfort. (C) A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. (D) A sitting position with the head supported will prevent further injury while allowing injury care to take place.
5. Right Answer: A
Explanation: (A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.
Explanation: (A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the clients inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
2. Right Answer: A
Explanation: (A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
3. Right Answer: C
Explanation: (A) Headaches are not associated with Guillain-Barr syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.
4. Right Answer: D
Explanation: (A) A reclining position can cause a penetrating object to advance further into the eye. (B) Prevention of further injury is the priority, not comfort. (C) A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. (D) A sitting position with the head supported will prevent further injury while allowing injury care to take place.
5. Right Answer: A
Explanation: (A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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