NCLEX-RN Practice Questions Set 3 (75 Questions)A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?
o A. The NA assist...
nclex rn practice questions set 3 75 questions 1 1 question a patient with parkinson’s disease has a nursing diagnosis of impaired physical mobility related to neuromuscular impairment you observ
Written for
NCLEX-RN Practice Questions Set 3
All documents for this subject (3)
Seller
Follow
RubricNurse
Reviews received
Content preview
NCLEX-RN Practice Questions Set 3
(75 Questions)
1. 1. Question
A patient with Parkinson’s disease has a nursing diagnosis of
Impaired Physical Mobility related to neuromuscular impairment.
You observe a nursing assistant performing all of these actions.
For which action must you intervene?
o A. The NA assists the patient to ambulate to the
bathroom and back to bed.
o B. The NA reminds the patient not to look at his feet
when he is walking.
o C. The NA performs the patient’s complete bath
and oral care.
o D. The NA sets up the patient’s tray and encourages the
patient to feed himself.
Correct Answer: C. The NA performs the patient’s
complete bath and oral care.
The nursing assistant should assist the patient with morning care
as needed, but the goal is to keep this patient as independent
and mobile as possible.
Option A: Assisting the patient to ambulate prevents
incidences of fall and injury.
Option B: Reminding the patient not to look at his
feet while walking maintains the client’s independence
while keeping him safe.
Option D: Encouraging the patient to feed himself is
an appropriate goal of maintaining independence.
2. 2. Question
The nurse is preparing to discharge a patient with chronic low
back pain. Which statement by the patient indicates that
additional teaching is necessary?
, A. “I will avoid exercise because the pain gets
worse.”
B. “I will use heat or ice to help control the pain.”
C. “I will not wear high-heeled shoes at home or work.”
D. “I will purchase a firm mattress to replace my old
one.”
Correct Answer: A. “I will avoid exercise because the pain
gets worse.”
Exercises are used to strengthen the back, relieve pressure on
compressed nerves and protect the back from re-injury. Doing
exercises to strengthen the lower back can help alleviate and
prevent lower back pain. It can also strengthen the core, leg, and
arm muscles. According to researchers, exercise also increases
blood flow to the lower back area, which may reduce stiffness
and speed up the healing process.
Option B: Ice and heat application are appropriate
interventions for back pain. Applying ice or a reusable
gel pack constricts blood vessels and reduces swelling
around the injury. This is particularly useful for
conditions, like a sprained ankle, that cause significant
swelling. Heat has the opposite effect, increasing
blood flow to the area. This relaxes muscle fibers,
which can help when the client experiences spasms or
stiffness.
Option C: People with chronic back pain should avoid
wearing high-heeled shoes at all times. The normal s-
curve of the spine acts as a cushion or spring,
reducing stress on the vertebrae. When wearing high
heels, the shape of the spine is altered and the client
doesn’t get that same shock absorption as she walks,
which, over time, can lead to uneven wear on the
cartilage discs, joints and ligaments of the back.
Option D: A firm mattress prevents lower back pain.
Sleeping on a mattress that is too firm can cause
aches and pains on pressure points. A medium-firm
mattress may be more comfortable because it allows
the shoulder and hips to sink in slightly. Patients who
, want a firmer mattress for back support can get one
with thicker padding for greater comfort.
3. 3. Question
A patient with a spinal cord injury (SCI) complains about a severe
throbbing headache that suddenly started a short time ago.
Assessment of the patient reveals increased blood pressure
(168/94) and decreased heart rate (48/minute), diaphoresis, and
flushing of the face and neck. What action should you take first?
A. Administer the ordered acetaminophen (Tylenol).
B. Check the Foley tubing for kinks or obstruction.
C. Adjust the temperature in the patient’s room.
D. Notify the physician about the change in status.
Correct Answer: B. Check the Foley tubing for kinks or
obstruction.
These signs and symptoms are characteristic of autonomic
dysreflexia, a neurologic emergency that must be promptly
treated to prevent a hypertensive stroke. The cause of this
syndrome is noxious stimuli, most often a distended bladder or
constipation, so checking for poor catheter drainage, bladder
distention, or fecal impaction is the first action that should be
taken.
Option C: Adjusting the room temperature may be
helpful, since too cool a temperature in the room may
contribute to the problem.
Option A: Tylenol will not decrease the autonomic
dysreflexia that is causing the patient’s headache.
Option D: Notification of the physician may be
necessary if nursing actions do not resolve symptoms.
4. 4. Question
Which patient should you, as charge nurse, assign to a new
graduate RN who is orienting to the neurologic unit?
, A. A 28-year-old newly admitted patient with spinal cord
injury.
B. A 67-year-old patient with stroke 3 days ago
and left-sided weakness.
C. An 85-year-old dementia patient to be transferred to
long-term care today.
D. A 54-year-old patient with Parkinson’s who needs
assistance with bathing.
Correct Answer: B. A 67-year-old patient with stroke 3
days ago and left-sided weakness.
The new graduate RN who is oriented to the unit should be
assigned stable, non-complex patients, such as the patient with
stroke.
Option A: The newly admitted SCI should be assigned
to experienced nurses. Most cases of SCI take place
when trauma breaks and squeezes the vertebrae, or
the bones of the back. This, in turn, damages the
axons—the long nerve cell “wires” that pass through
vertebrae, carrying signals between the brain and the
rest of the body. The axons might be crushed or
completely severed by this damage. Someone with
injury to only a few axons might be able to recover
completely from their injury. On the other hand, a
person with damage to all axons will most likely be
paralyzed in the areas below the injury.
Option C: A patient for transfer should be assigned to
a nurse who has experience in the process of
transferring patients.
Option D: The patient with Parkinson’s disease needs
assistance with bathing, which is best delegated to the
nursing assistant.
5. 5. Question
A patient with a spinal cord injury at level C3-4 is being cared for
in the ED. What is the priority assessment?
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller RubricNurse. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $15.00. You're not tied to anything after your purchase.
