STUVIA 2024/2025
NCLEX Qs Module 9
A.
A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid
space. Brudzinski's sign is also indicative of the condition. - ✔✔19) Which of the following
assessment data indicated nuchal rigidity?
A. Positive Kernig's sign
B. Negative Brudzinski's sign
C. Positive homan's sign
D. Negative Kernig's sign
A.
A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of
toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary
incontinence. Incontinence may occur during or after a seizure. - ✔✔5) Which of the following
symptoms may occur with a phenytoin level of 32 mg/dl?
A. Ataxia and confusion
B. Sodium depletion
C. Tonic-clonic seizure
D. Urinary incontinence
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A.
DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into
the tissues. An abnormal coagulation phenomenon - ✔✔16) Which of the following would lead the
nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
A. Hemorrhagic skin rash
B. Edema
C. Cyanosis
D. Dyspnea on exertion
A.
Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and
dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about
abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood
pressure maintenance. - ✔✔A client with subdural hematoma was given mannitol to decrease
intracranial pressure (ICP). Which of the following results would best show the mannitol was
effective?
A. Urine output increases
B. Pupils are 8 mm and nonreactive
C. Systolic blood pressure remains at 150 mm Hg
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D. BUN and creatinine levels return to normal
A.
Normal ICP is 0-15 mm Hg. - ✔✔4) Which of the following values is considered normal for ICP?
A. 0 to 15 mm Hg
B. 25 mm Hg
C. 35 to 45 mm Hg
D. 120/80 mm Hg
A.
Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's
sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is
especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and
spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle
position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the
nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect
score and indicates the client is awake and alert with no neurological deficits. - ✔✔13) The nurse is
evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client
is developing meningitis as a complication of surgery if the client exhibits:
A. A positive Brudzinski's sign
%
B. A negative Kernig's sign
C. Absence of nuchal rigidity
D. A Glascow Coma Scale score of 15
A.
The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the
abdomen, and with the head bent down onto the chest. This position helps to open the spaces
between the vertebrae. - ✔✔10) The client is having a lumbar puncture performed. The nurse would
plan to place the client in which position for the procedure?
A. Side-lying, with legs pulled up and head bent down onto the chest
B. Side-lying, with a pillow under the hip
C. Prone, in a slight Trendelenburg's position
D. Prone, with a pillow under the abdomen.
B.
A change in vital signs may be a late sign of increased intracranial pressure. Trends include
increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory
irregularities also may arise. - ✔✔12) The nurse is caring for the client with increased intracranial
pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.
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