Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
NCLEX2023
| Question | Answer |
|---|---|
| A client is color blind. The nurse understands that this client has a problem with | Cones provide daylight color vision, and their stimulation is interpreted as color. Rods are sensitive to low levels of illumination . The lens is responsible for focusing images. Aqueous humor is a clear watery fluid . |
| A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? | It is important to first explain where a client is to orient him or her to time, person, and place. |
| When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? | When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. |
| A nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 174/100 mm Hg. The client reports a severe, pounding headache. Which nursing intervention | client is exhibiting signs and symptomsautonomicdysreflexia, The nurse would immediately elevate the head of the bed to 90° legs in a dependent position any constrictive clothing should beloosened.assess for distended bladder and bowel impaction Morphin |
| pilocarpine | Pilocarpine is a medication used to reduce pressure inside the eye and treat dry mouth. As eye drops it is used to manage angle closure glaucoma until surgery can be performed |
| When administering pilocarpine | the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. |
| Conductive hearing loss results from | Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, |
| . In a functional hearing loss, | no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. |
| Sensorineural hearing loss | affects the inner ear and involves the cochlea and eighth cranial nerve. |
| Carotid endarterectomy | a surgical procedure to remove a build-up of fatty deposits (plaque), which cause narrowing of a carotid artery. |
| When reviewing the results of a client's lumbar puncture, a nurse notes a glucose level of 32 mg/dL (1.8 mmol/L). What does this result suggest to the nurse? | The normal glucose level for cerebral spinal fluid (CSF) ranges from 50-75 mg/dL (2.8-4.2 mmol/L). The client's reduced glucose level may indicate a condition such as bacterial meningitis. |
| The nurse determines that the client understands home care instructions after scleral buckling for a detached retina if the client says the activity should include: | During recovery, the client should be instructed to avoid abrupt or jarring head movements. Activities such as shampooing or brushing hair may be restricted. |
| A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score? | The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points. |
| A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? | To prevent straining at stool, which may cause a Valsalva maneuver that increases ICP, regular bowel program use of a stool softener. client at risk for increased ICP, prevent, not encourage, oral fluid intake and should elevate the head of the bed only |
| Atropine sulfate is contraindicated as a preoperative medication for which client? | Atropine is contraindicated in clients with glaucoma because it increases intraocular pressure. It is not contraindicated in clients with diabetes, pyelonephritis, or COPD. |
| When a client is recovering as expected from spinal anesthesia, the nurse should assess: | Return of sensation in the toes and legs marks recovery from spinal anesthesia. The client receiving spinal anesthesia is conscious, so level of consciousness does not need to be assessed. The client’s respiratory status is not affected |
| The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider? | A worsening headache is a clinical manifestation associated with a vasospasm. cerebral vasospasm is a serious complication of subarachnoid hemorrhage and is a leading cause of morbidity and mortality in those who survive the initial hemorrhage |
| The son of an older adult reports that his father just “stares off into space” more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make? | Blank looks, decreased attention span, positioning of the head toward sound, and smiling/nodding in agreement once attention is gained are all behaviors that indicate hearing loss |
| A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include | Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness. |
| A nurse is documenting client states having problems with balance, as well as fine and gross motor function. When collaborating with the health team, which area on the illustration of the brain would the nurse highlight as an area of concern? | The cerebellum is the portion of the brain that controls balance and fine and gross motor function. The cerebellum is located at the base of the skull and above the brain stem. |
| The nurse is teaching a young female about using oxcarbazepine to control seizures | An alternative or additional method of birth control must be used because oxcarbazepine reduces the effectiveness of oral contraceptives. |
Created by:
hobart3809