1. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:
a. body temperature control.
b. balance and equilibrium.
c. visual acuity.
d. thinking and reasoning.
2. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?
a. phenytoin (Dilantin)
b. mannitol (Osmitrol)
c. lidocaine (Xylocaine)
d. furosemide (Lasix)
3. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?
a. Give him a barbiturate.
b. Place him on mechanical ventilation.
c. Perform a lumbar puncture.
d. Elevate the head of his bed.
4. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report:
a. light flashes and floaters in front of the eye.
b. a recent driving accident while changing lanes.
c. headaches, nausea, and redness of the eyes.
d. frequent episodes of double vision.
5. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?
a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury
6. To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should:
a. stay with the client and encourage him to eat.
b. help the client fill out his menu.
c. give the client privacy during meals.
d. fill out the menu for the client.
7. The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following?
a. Cerebellar function
b. Intellectual function
c. Cerebral function
d. Sensory function
8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?
a. In 30 to 45 seconds
b. In 10 to 15 minutes
c. In 30 to 45 minutes
d. In 1 to 2 hours
9. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?
a. Parasympathomimetic agent
b. Sympatholytic agent
c. Adrenergic blocker
d. Cholinergic blocker
10. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the highest priority?
a. Assessing the left leg
b. Assessing the pupils
c. Placing the client in Trendelenburg’s position
d. Assessing level of consciousness
11. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:
a. increasing the exudative reaction of ocular tissue.
b. decreasing leukocyte infiltration at the site of ocular inflammation.
c. inhibiting the action of carbonic anhydrase.
d. producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.
12. Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal?
a. More back pain than the first postoperative day
b. Paresthesia in the dermatomes near the wounds
c. Urine retention or incontinence
d. Temperature of 99.2° F (37.3° C)
13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:
a. instilling one drop of pilocarpine 0.25% into both eyes daily.
b. instilling one drop of pilocarpine 0.25% into both eyes four times daily.
c. instilling one drop of pilocarpine 0.25% into the right eye daily.
d. instilling one drop of pilocarpine 0.25% into the left eye four times daily.
14. A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
a. The client leaves the side rails down.
b. The client uses a mirror to inspect the skin.
c. The client repositions only after being reminded to do so.
d. The client hangs the left arm over the side of the wheelchair.
15. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half circle. To document the client’s gait, the nurse should use which term?
16. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?
a. A private room down the hall from the nurses’ station
b. An isolation room three doors from the nurses’ station
c. A semiprivate room with a 32-year-old client who has viral meningitis
d. A two-bed room with a client who previously had bacterial meningitis
17. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine?
a. Ulcerative colitis
b. Blood dyscrasia
c. Intestinal obstruction
d. Spinal cord injury
18. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière’s disease. When assessing this client, the nurse expects to note:
a. vertigo, tinnitus, and hearing loss.
b. vertigo, vomiting, and nystagmus
c. vertigo, pain, and hearing impairment.
d. vertigo, blurred vision, and fever.
19. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?
a. “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.”
b. “Try to ambulate independently after about 24 hours.”
c. “Shampoo your hair every day for 10 days to help prevent ear infection.”
d. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days.”
20. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?
a. Excessive tearing
b. Urine retention
c. Muscle weakness
d. Slurred speech
21. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?
b. Increased salivation
22. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign highest priority to which nursing diagnosis?
a. Impaired physical mobility
b. Ineffective breathing pattern
c. Disturbed sensory perception (tactile)
d. Self-care deficient: Dressing/grooming
23. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:
a. long-term treatment of epilepsy.
b. postoperative pain management of laminectomy clients.
c. postoperative pain management of diskectomy clients
d. treatment of spasticity associated with spinal cord lesions.
24. A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by:
a. introducing ice water into the external auditory canal.
b. touching the cornea with a wisp of cotton.
c. turning the client’s head suddenly while holding the eyelids open.
d. shining a bright light into the pupil.
25. While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?
a. The client may be less sensitive to the effects of a neuromuscular blocking agent.
b. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.
c. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.
d. Pancuronium and succinylcholine both require cautious administration.
26. A male client is color blind. The nurse understands that this client has a problem with:
d. aqueous humor.
27. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
28. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?
a. Vision changes
b. Absent deep tendon reflexes
c. Tremors at rest
d. Flaccid muscles
29. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
a. Sit with the client for a few minutes.
b. Administer an analgesic.
c. Inform the nurse manager.
d. Call the physician immediately.
30. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates:
a. cranial nerves I and II.
b. cranial nerves III and V.
c. cranial nerves VI and VIII.
d. cranial nerves IX and X.
More NCLEX Questions coming up…