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Final Exam NCLEX Questions and correct answers new update for 2024 /
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A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15. - CORRECT ANSWER-AN...

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  • August 9, 2024
  • 47
  • 2024/2025
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Final Exam NCLEX Questions and correct answers new update for 2024
/ Final Exam NCLEX Questions and correct answers new update for
2024 / Final Exam NCLEX Questions and correct answers new update
for 2024
A patient with a head injury opens the eyes to verbal stimulation,
curses when stimulated, and does not respond to a verbal command
to move but attempts to remove a painful stimulus. The nurse records
the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15. - CORRECT ANSWER-ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal
response, and 5 for best motor response.


A patient who is suspected of having an epidural hematoma is
admitted to the emergency department. Which action will the nurse
plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy. - CORRECT ANSWER-
ANS: D
The principal treatment for epidural hematoma is rapid surgery to
remove the hematoma and prevent herniation. If intracranial pressure

,(ICP) is elevated after surgery, furosemide or high-dose barbiturate
therapy may be needed, but these will not be of benefit unless the
hematoma is removed. Minimal blood loss occurs with head injuries,
and transfusion is usually not necessary.


A patient who has bacterial meningitis is disoriented and anxious.
Which nursing action will be included in the plan of care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well-lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input. -
CORRECT ANSWER-ANS: A
Patients with meningitis and disorientation will be calmed by the
presence of someone familiar at the bedside. Restraints should be
avoided because they increase agitation and anxiety. The patient
requires frequent assessment for complications; the use of touch and
a soothing voice will decrease anxiety for most patients. The patient
will have photophobia, so the light should be dim.


When assessing a patient with bacterial meningitis, the nurse obtains
the following data. Which finding should be reported immediately to
the health care provider?


a. The patient has a positive Kernig's sign.
b. The patient complains of having a stiff neck.

,c. The patient's temperature is 101° F (38.3° C).
d. The patient's blood pressure is 86/42 mm Hg. - CORRECT ANSWER-
ANS: D
Shock is a serious complication of meningitis, and the patient's low
blood pressure indicates the need for interventions such as fluids or
vasopressors. Nuchal rigidity and a positive Kernig's sign are expected
with bacterial meningitis. The nurse should intervene to lower the
temperature, but this is not as life threatening as the hypotension.


Which assessment finding in a patient who was admitted the previous
day with a basilar skull fracture is most important to report to the
health care provider?
a. Bruising under both eyes
b. Complaint of severe headache
c. Large ecchymosis behind one ear
d. Temperature of 101.5° F (38.6° C) - CORRECT ANSWER-ANS: D
Patients who have basilar skull fractures are at risk for meningitis, so
the elevated temperature should be reported to the health care
provider. The other findings are typical of a patient with a basilar skull
fracture.


An unconscious patient with a traumatic head injury has a blood
pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg.
The nurse will calculate the cerebral perfusion pressure as
____________________. - CORRECT ANSWER-ANS:
72 mm Hg

, The formula for calculation of cerebral perfusion pressure is [(Systolic
pressure + Diastolic blood pressure 2)/3] = intracranial pressure.


Which laboratory data would reflect early signs of renal tubular
damage?
A. Decreased hemoglobin level
B. Increased serum sodium level
C. Increased serum calcium level
D. Decreased urine specific gravity - CORRECT ANSWER-ANS: D
A decrease in urine specific gravity indicates a loss of urine-
concentrating ability and is
the earliest sign of renal tubular damage.


Which laboratory data alteration would the nurse expect to see
manifested in a client
with renal failure?


A. Hypokalemia and metabolic acidosis
B. Hyperkalemia and metabolic alkalosis
C. Hyperphosphatemia and hypocalcemia
D. Hypophosphatemia and hypercalcemia - CORRECT ANSWER-ANS: C

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