Font size
S
M
L
XL
WorksheetsNCLEX - NERVOUS SYSTEM Day2 (Part 2)
Total questions: 10
Worksheet time: 10mins
Name
Class
Date
1.
The nurse in the emergency department is caring for a client who sustained a traumatic head injury 30 minutes ago and has an order for insertion of a nasogastric tube. Which of the following findings would be a contraindication for nasogastric tube insertion?
a)
an ecchymotic area on the forehead
b)
frontal headache rated as 10 on a scale of 0-10
c)
moderate amount of bright red blood oozing from a cheek laceration
d)
nasal drainage collected on sterile gauze that has a red center surrounded by serous fluid
e)
-
2.
The nurse in the emergency department is caring for a client with new-onset right-sided weakness and slurred speech. Which of the following actions should the nurse take first?
a)
Ensure the client's airway is patent
b)
Determine the time of symptom onset
c)
Prepare the client for a CT scan of the head
d)
Insert a large-bore peripheral venous access device
e)
-
3.
The nurse is caring for a client who sustained a cervical spinal cord injury 1 hour ago and is paralyzed in all four extremities. Which of the following actions would be a priority for the nurse to take?
a)
Reposition the client every 2 hours
b)
Perform frequent, focused respiratory assessments
c)
Monitor the client for autonomic dysreflexia
d)
Perform passive range-of-motion exercises every 4 hours
e)
-
4.
The emergency department nurse receives several prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first?
a)
Administer IV push naloxone once now
b)
Draw specimen for blood alcohol content testing STAT
c)
Initiate continuous lactated Ringer solution infusion
d)
Obtain urine sample for drug abuse screening ASAP
e)
-
5.
The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?
a)
Auscultate breath sounds to assess for crackles
b)
Monitor for >50 mL/hr urine output
c)
Monitor Glasgow Coma Scale increasing from 8/15 to 9/15
d)
Press over the tibia to assess for pitting edema
e)
-
6.
The nurse in the emergency department is caring for assigned clients. The nurse should first assess the client with
a)
unilateral facial pain that is aggravated by consumption of hot beverages
b)
an epidural hematoma who has a decreased level of consciousness
c)
Bell palsy who has unilateral facial droop and drooling
d)
multiple sclerosis who is reporting blurred vision
e)
-
7.
The nurse is assessing a client who experienced an ischemic stroke affecting the Broca area of the brain. Which of the following findings would be consistent with the condition?
a)
blurred vision
b)
expressive aphasia
c)
decreased sensation
d)
uncoordinated motor movement
e)
-
8.
The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately?
a)
Diminished gag reflex after endotracheal tube removal
b)
Increased agitation level and pulling at linens
c)
Left arm drift during bilateral arm extension
d)
Responds to verbal commands with eyes closed
e)
-
9.
The nurse is talking with a client who has Huntington disease and is considering becoming pregnant. Which of the following statements would be appropriate for the nurse to make?
a)
There are alternative methods to expand your family. You should consider adoption.
b)
Genetic counseling is recommended. You will receive a referral before you leave.
c)
Huntington disease inheritance requires both biological parents to carry the gene.
d)
Huntington disease occurs spontaneously and is not likely to affect your children.
e)
-
10.
The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply.
a)
Client coughs and gasps when swallowing food and liquids
b)
Client is easily frustrated while attempting to speak
c)
Client is unable to understand speech and is completely nonverbal
d)
Client misunderstands and inappropriately responds to verbal instruction
e)
Client's speech is limited to short phrases that require effort
Reset
