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NUR205 NCLEX EXAM QUESTIONS AND VERIFIED DETAILED ANSWERS
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NUR205 NCLEX EXAM QUESTIONS AND VERIFIEDDETAILED ANSWERS
The nurse is performing a cranial nerve examination on a patient with the diagnosis of
myasthenia gravis. The nurse has the patient clench their jaw while palpating the
temporal and masseter muscles. Which of the following cranial nerves does the nurse
appropriately assess?
abducens
trigeminal
acoustic
hypoglossal Answer trigeminal
***To assess chewing, the patient is asked to clench his jaw while the nurse palpates the
temporal and master muscles. This assesses the trigeminal nerve which is cranial nerve
V. The abducens nerve is assessed with EOMs. The acoustic nerve assesses hearing.
Assessment of tongue movement the nurse is assessing cranial nerve XII or the
hypoglossal nerve.
A patient is admitted through the emergency department with a history of spinal tumor.
Which of the following signs and symptoms should trigger the nurse's suspicion for
SCC?
seizures
headache
back pain
diplopia - Answer - back pain
***The nurse identifies that an early symptom of SCC is a patient complaint of back pain,
which usually occurs when the patient is in the prone position and may be located in the
area of the tumor.
A patient who has a decreased LOC and an absent gag reflex has just been admitted to
,the neurologic unit. In what position should the nurse place the patient?
prone
head of bed should be elevated 45 to 90 degrees
flat
side lying with head of bed elevated to 10-30 degrees Answer side lying with head of bed
elevated to 10-30 degrees
***The patient should be placed in a side-lying position to decrease the risk of
aspiration. Suction should also be readily available at the bedside.
What is a late sign of increasing ICP?
- papilledema
- alteration of the LOC
- vomiting
- Hypertension - Answer - hypertension rest are early signs
***Early signs of rising ICP include headache, seizures, nausea and vomiting, cognitive
impairment, and visual disturbances such as papilledema. Late vital sign changes
associated with rising ICP, termed Cushing's triad include: hypertension with a widening
pulse pressure (the difference between systolic and diastolic pressure), bradycardia,
and respiratory depression.
The patient has a brain tumor and is receiving palliative care. What does the nurse
understand to be true about palliative care? (select all that apply)
comfort care
early identification of spiritual needs to the patient
, management of symptoms
does not include pain management
is not an option with a patient with a brain tumor Answer providing comfort care, early
identification of spiritual needs, management of symptoms
***Palliative care is symptom management of people with serious illness in order to
provide symptom relief of a serious illness to improve a patient's quality of life. This
includes early identification, assessment and management of pain, physical,
psychological, cultural, social and spiritual needs.
A patient has just been admitted to the hospital diagnosis of brain tumor. She makes a
comment that drinking alcohol has caused her brain tumor. What does the nurse
understand to be a cause of brain tumor?
- smoking
- ionizing radiation
- diet high in fat
- exposure to the sun - Answer - ionizing radiation
***Ionizing radiation and cancer-causing chemicals are the only established etiologies
for brain tumors. Nonionizing radiation, acoustic trauma, and dietary factors are
suspected causes under study. Genetic syndromes are also under study.
CN: Physiology Integrity
Client with Parkinson disease-The nurse is assessing a client with Parkinson disease.
The nurse identifies that the client is exhibiting bradykinesia when the client exhibits
which symptom?
Muscle flaccidity
An intention tremor
Paralysis of the limbs
Slow spontaneous movements Answer Slow spontaneous movements
***Because of the reduction of dopamine in the substantia nigra, it is hard for the
Parkinson's disease client to initiate a spontaneous movement. With Parkinson's
disease, there is cogwheel rigidity, not flaccidity. Parkinson's disease is a resting
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