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nclex questions 4100 EXAM 4 Questions With Complete Solutions
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nclex questions 4100 EXAM 4 Questions With Complete Solutions
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nclex questions 4100 EXAM 4 Questions With CompleteSolutions
A client admitted to the nursing unit from the hospital
emergency department has a C4 spinal cord injury. In
conducting the admission assessment, what is the nurse's priority
action?
1.Take the temperature.
2.Listen to breath sounds.
3.Observe for dyskinesias.
4.Assess extremity muscle strength. Correct Answer 2
Rationale:Because compromise of respiration is a leading cause
of death in cervical cord injury, respiratory assessment is the
highest priority. Assessment of temperature and strength can be
done after adequate oxygenation is ensured. Because dyskinesias
occur in cerebellar disorders, this is not as important a concern
as in cord-injured clients unless head injury is suspected.
A client arrives in the hospital emergency department with a
closed head injury to the right side of the head caused by an
assault with a baseball bat. The nurse assesses the client
neurologically, looking primarily for motor response deficits
that involve which area?
1.The left side of the body
2.The right side of the body
3.Both sides of the body equally
4.Cranial nerves only, such as speech and pupillary response
Correct Answer 1
,Rationale:Motor responses such as weakness and decreased
movement will be seen on the side of the body that is opposite
an area of head injury. Contralateral deficits result from
compression of the cortex of the brain or the pyramidal tracts.
Depending on the severity of the injury, the client may have a
variety of neurological deficits.
A client has a high level of carbon dioxide (CO2) in the
bloodstream, as measured by arterial blood gases. The nurse
anticipates that which underlying pathophysiology can occur as
a result of this elevated CO2?
1.It will cause arteriovenous shunting.
2.It will cause vasodilation of blood vessels in the brain.
3.It will cause blood vessels in the circle of Willis to collapse.
4.It will cause hyperresponsiveness of blood vessels in the brain.
Correct Answer 2
Rationale:CO2 is one of the metabolic end products that can
alter the tone of the blood vessels in the brain. High CO2 levels
cause vasodilation, which may cause headache, whereas low
CO2 levels cause vasoconstriction, which may cause
lightheadedness. The statements included in the other options
are incorrect effects.
A client has clear fluid leaking from the nose following a basilar
skull fracture. Which finding would alert the nurse that
cerebrospinal fluid is present?
1.Fluid is clear and tests negative for glucose.
2.Fluid is grossly bloody in appearance and has a pH of 6.
3.Fluid clumps together on the dressing and has a pH of 7.
,4.Fluid separates into concentric rings and tests positive for
glucose. Correct Answer 4
Rationale:Leakage of cerebrospinal fluid (CSF) from the ears or
nose may accompany basilar skull fracture. CSF can be
distinguished from other body fluids because the drainage will
separate into bloody and yellow concentric rings on dressing
material, called a halo sign. The fluid also tests positive for
glucose.
A client has suffered a head injury affecting the occipital lobe of
the brain. What is the focus of the nurse's immediate
assessment?
1.Taste
2.Smell
3.Vision
4.Hearing Correct Answer 3
Rationale:The occipital lobe is responsible for reception of
vision and contains visual association areas. This area of the
brain helps the individual to visually recognize and understand
the surroundings. The other senses listed are not a function of
the occipital lobe.
A client has suffered damage to Broca's area of the brain. Which
priority assessment should the nurse perform?
1.Speech
2.Hearing
3.Balance
4.Level of consciousness Correct Answer 1
, Rationale:Broca's area in the brain is responsible for the motor
aspects of speech, through coordination of the muscular activity
of the tongue, mouth, and larynx. The term assigned to damage
in this area is aphasia. The items listed in the other options are
not the responsibility of Broca's area.
A client is admitted to the hospital emergency department after
receiving a burn injury in a house fire. The skin on the client's
trunk is tan, dry, and hard. It is edematous but not very painful.
The nurse determines that this client's burn should be classified
as which type?
1.Superficial
2.Full-thickness
3.Deep partial-thickness
4.Partial-thickness superficial Correct Answer 2
Rationale:Full-thickness burns involve the epidermis, the full
dermis, and some of the subcutaneous fat layer. The burn
appears to be a tan or fawn color, with skin that is hard, dry, and
inelastic. Edema is severe, and the accumulated fluid
compresses tissue underneath because of eschar formation.
Some nerve endings have been damaged, and the area may be
insensitive to touch, with little or no pain.
A client is admitted with an exacerbation of multiple sclerosis.
The nurse is assessing the client for possible precipitating risk
factors. Which factor, if reported by the client, should the nurse
identify as being unrelated to the exacerbation?
1.Annual influenza vaccination
2.Ingestion of increased fruits and vegetables
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