NCLEX-RN Practice Quiz Test Bank #3 (75 Questions)
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Course
NCLEX Fundamental
Institution
NCLEX Fundamental
NCLEX-RN Practice Quiz Test Bank #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?...
NCLEX-RN Practice Quiz Test Bank #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.
Incorrect
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.”
Incorrect
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.
Incorrect
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.
Incorrect
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?
A. Determine the level at which the patient has intact sensation.
B. Assess the level at which the patient has retained mobility.
C. Check blood pressure and pulse for signs of spinal shock.
D. Monitor respiratory effort and oxygen saturation level.
Incorrect
Correct Answer: D. Monitor respiratory effort and oxygen
saturation level.
The first priority for the patient with an SCI is assessing respiratory
patterns and ensuring an adequate airway. The patient with a high
cervical injury is at risk for respiratory compromise because the spinal
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