Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client would the nurse report immediately?
A. The client complains of feeling tired
B. The client complains of pain at the site of injury
C. The client vomits
D. The client complains of dizziness when getting out of bed for the first time
Answer: C. The client vomits
Rationale: The client with a closed head injury is at risk of developing increased ICP. This is evidenced by symptoms such as headache, dizziness, confusion, weakness, and vomiting. Options 1 and 2 are expected occurrences. Likewise, option 4 also is an expected occurrence. Option 3 may be an indication of increased ICP, requiring notification of the registered nurse and physician.
Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, knowing that pain at the site of injury is likely to occur. Next eliminate option 1 because it is likely that the client may feel tired following the trauma of a head injury. From the remaining options, recall that most clients experience some dizziness when getting out of bed following any traumatic event. This will direct you to option C. Review the signs of increased ICP if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 382-383.
2. An emergency room nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle accident. The nurse understands that the initial data collection should focus on which of the following?
A. Respiratory status
B. Apical pulse rate
C. Level of consciousness
D. Range-of-motion status of the lower extremities
Answer: A. Respiratory status
Rationale: The initial data collection focuses on ensuring that the client has an adequate airway and respiratory status. In rapid sequence, the client’s circulatory status is evaluated, followed by evaluation of the neurological status. Range of motion is not a priority. In fact, the extent of the injuries should be well established prior to assessing range of motion.
Test-Taking Strategy: In emergency situations, remember to use the ABCs—airway, breathing, and circulation. The correct answer will most often be the option that deals with the client’s airway. Respiratory status supports this action. Review initial care to the client following a head injury if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 194.
3. A nurse is caring for a client with a spinal cord injury. The nurse prepares to place high-top sneakers on the client’s feet to prevent the occurrence of:
A. Plantar flexion
B. Foot drop
C. Pressure ulcers
D. Deep vein thrombosis
Answer: B. Foot drop
Rationale: The most effective way to prevent foot drop is to use posterior splints or high-top sneakers. A foot board prevents plantar flexion but also places the client at greater risk for developing pressure ulcers of the feet. Pneumatic boots prevent deep vein thrombosis, but not foot drop.
Test-Taking Strategy: Use the process of elimination. Focus on each of the conditions identified in the options and the measures that will prevent each of these conditions. Options 3 and 4 can then be easily eliminated. From the remaining options, visualize high-top sneakers on the client. This should help direct you to option B. Review the measures that will prevent foot drop if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Neurological
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2127.
4. A Halo vest is applied to a client following a cervical spine fracture. The nurse provides instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further instructions?
A. “I will bend at the waist, keeping the Halo vest straight to pick up items.”
B. “I will use a walker for ambulating if I need to.”
C. “I will wear rubber-soled shoes for walking.”
D. “I will scan the room to see things.”
Answer: A. “I will bend at the waist, keeping the Halo vest straight to pick up items.”
Rationale: The client with a Halo vest should avoid bending at the waist, because the Halo vest is heavy and the client’s trunk is limited in flexibility. It is helpful for the client to scan the environment visually because the client’s peripheral vision is diminished from keeping the neck in a stationary position. Use of a walker and rubber-soled shoes may help prevent falls and injury, so these items are also helpful.
Test-Taking Strategy: Use the process of elimination. Note the key words need for further instructions. These words indicate a false response question and that you need to select the action that could put the client at risk for injury. Visualize each of the items or actions in the options to assist in identifying how injury could be prevented. Review client teaching points related to a Halo vest if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Adult Health/Neurological
Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1414.
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