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NCLEX-RN Exam Questions - Part 139
1. An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
A) Has a sudden and severe increase in intracranial pressure
B) Has sustained an internal injury in addition to the head injury
C) Is beginning to experience a dangerously high level of anxiety
D) Is having intracranial bleeding
2. The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
A) Call the doctor immediately
B) Help her to blow her nose carefully
C) Test the discharge for sugar
D) Turn her to her side
3. A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
A) Evidence of perineal irritation
B) Pulse fell from 102 to 96
C) Pulse increased from 96 to 102
D) Temperature rose to 102_F rectally
4. The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig - s sign. The nurse expects her to react to discomfort if she:
A) Dorsiflexes her ankle
B) Flexes her spine
C) Plantiflexes her wrist
D) Turns her head to the side
5. The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
A) Constipation
B) Hypothermia
C) Seizure
D) Sunken fontanelles
A) Has a sudden and severe increase in intracranial pressure
B) Has sustained an internal injury in addition to the head injury
C) Is beginning to experience a dangerously high level of anxiety
D) Is having intracranial bleeding
2. The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
A) Call the doctor immediately
B) Help her to blow her nose carefully
C) Test the discharge for sugar
D) Turn her to her side
3. A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
A) Evidence of perineal irritation
B) Pulse fell from 102 to 96
C) Pulse increased from 96 to 102
D) Temperature rose to 102_F rectally
4. The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig - s sign. The nurse expects her to react to discomfort if she:
A) Dorsiflexes her ankle
B) Flexes her spine
C) Plantiflexes her wrist
D) Turns her head to the side
5. The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
A) Constipation
B) Hypothermia
C) Seizure
D) Sunken fontanelles
1. Right Answer: B
Explanation: (A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.
2. Right Answer: C
Explanation: (A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.
3. Right Answer: D
Explanation: (A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
4. Right Answer: B
Explanation: (A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.
5. Right Answer: C
Explanation: (A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles.
Explanation: (A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.
2. Right Answer: C
Explanation: (A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.
3. Right Answer: D
Explanation: (A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
4. Right Answer: B
Explanation: (A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.
5. Right Answer: C
Explanation: (A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles.
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