NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
A client with a neurological disorder.
Question 1 of 5
Which of the following nursing assessments will be MOST helpful in determining subtle changes in the client's level of consciousness?
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates increased intracranial pressure (2) correct-Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client
Extract:
A client with signs of increased intracranial pressure (ICP).
Question 2 of 5
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse would include which of the following?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15 to 30° to promote venous drainage (4) correct-assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration
Extract:
Question 3 of 5
Following a CT scan with contrast medium, the nurse should give attention to:
Correct Answer: B
Rationale: Forcing fluids promotes excretion of contrast medium, reducing risk of renal toxicity. Bed rest and hemorrhage monitoring are not typically required.
Question 4 of 5
A woman has been recently diagnosed with systemic lupus and shares with the nurse, 'I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy since I have lupus.'
Correct Answer: B
Rationale: The nurse should assess the duration of remission, as women with systemic lupus erythematosus (SLE) should be in remission for at least 5 months before conceiving to minimize risks of maternal and fetal complications. Pregnancy does not typically improve SLE symptoms, gestation length is unaffected, and early pregnancy post-diagnosis is not recommended.
Question 5 of 5
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
Correct Answer: D
Rationale: A middle-aged client receiving radiation for throat cancer. Radiation therapy, particularly to the abdomen or pelvis, can disrupt the gut microbiota and increase the risk of C. difficile infection, especially if the client is also receiving antibiotics or has a weakened immune system.