NCLEX-PN
PN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?
Correct Answer: B
Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.
Question 2 of 5
The nurse is caring for a client who had a seizure 10 minutes ago. The client is now confused and reports a headache. Which of the following phases of seizure activity should the nurse recognize the client is experiencing?
Correct Answer: C
Rationale: The postictal phase follows a seizure, characterized by confusion and headache as the brain recovers. Ictal is the seizure itself, aural involves pre-seizure sensations, and prodromal is vague premonitory symptoms.
Question 3 of 5
The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?
Correct Answer: A
Rationale: The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients.
Question 4 of 5
The nurse is caring for an adult who has atrial fibrillation and osteoporosis. Atenolol is prescribed. The nurse should expect that this medication was prescribed to:
Correct Answer: D
Rationale: Atenolol, a beta-blocker, is used in atrial fibrillation to control heart rate, reducing rapid ventricular response.
Question 5 of 5
The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting?
Correct Answer: A
Rationale: A 2-month-old cannot roll, and lethargy after a fall suggests possible non-accidental head trauma, requiring abuse investigation. Bluish buttock marks may be Mongolian spots (benign), and splatter burns are consistent with an accident.