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NUR205 NCLEX EXAM/ Study Guide Questions with Correct Detailed Answers/ Updated 2024.
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NUR205 NCLEX EXAM/ Study Guide Questions with CorrectDetailed Answers/ Updated 2024.
AG a citadel student living on campus presented to the emergency department. He developed a fever
(Tmax 103/F/ 39.4C) 1 day prior. He presented with mild rhinorrhea, headache, decreased appetite, and
was lethargic with an O2 sat of 97%. This morning his room mate had difficulty arousing him. Which of
the following assessment/ intervention would a nurse perform FIRST?
- perform a focused neuro assessment
- obtain a set of vital signs
- obtain a peripheral blood glucose level
- auscultation of the respiratory system - ANSWER - - obtain a set of vital signs
*** you would want to get vitals first, perform a neuro assessment, obtain SMBG, auscultate respiratory
last
While assessing a client with Parkinson disease, the nurse identifies bradykinesia when the client
exhibits which symptom?
- muscle flaccidity
- an intention tremor
- paralysis of the limbs
- slow spontaneous movements - ANSWER - - slow spontaneous movements
***Due to the decrease in dopamine in the substantia nigra, the Parkinson's disease patient has a hard
time initiating a spontaneous movement. With Parkinson's disease there is cogwheel rigidity, not
flaccidity. Parkinson's disease is a resting tremor, not intentional. There is no paralysis with Parkinson's
disease.
pg. 1
,bradykinesia - ANSWER - slow movement
What is the most common initial symptom that a nurse might expect a client with MS to complain
about?
- diarrhea
- headaches
- skin infections
- visual disturbances - ANSWER - - visual disturbances
***The demyelinating process of MS usually begins in the area of cranial nerve II, the optic nerve
causing an optic neuritis, resulting in blurred vision in the affected eye. Diarrhea is not an initial
symptom, later on in the course of the disease patients experience constipation. Very few MS patients
experience a headache. Skin infections are rare with MS.
A client who has GB asks, "Will I ever get better?" Which response would be the most appropriate
answer by the nurse?
- you'll notice your strength will improve each day
- we are doing everything we can to provide the best care
- you seem concerned about getting better. What do you think?
- your chances of recovery are very good, but recovery is slow. - ANSWER - - "your chances of recovery
are very good, but recovery is slow"
***Ninety percent of GB patients get better, but the recovery is very slow, over 1 to 2 years. Motor
strength does not improve each day; it occurs over months of recovery. "Providing the best care" does
not really answer the patient's question about getting better. Asking the patient what they think is not an
appropriate response in this situation.
What manifestations will the nurse observe in the patient undergoing a tonic-clonic seizure?
- jerking in one extremity that spreads gradually to adjacent areas
pg. 2
,- vacant staring and abrupt cessation of all activity
- facial grimaces, patting motions, and lip smacking
- loss of consciousness, body stiffening, and violent muscle contractions - ANSWER - - loss of
consciousness, body stiffening, and violent muscle contractions
***Tonic--clonic seizure is a type of generalized seizure in which the patient loses consciousness. Body
stiffening describes the tonic phase of the seizure, and muscle contractions describe the clonic phase.
Jerking in one extremity is a sign of a partial seizure that spreads into a generalized seizure. Vacant
staring and abrupt cessation of activity is descriptive for an absence seizure. Facial grimaces, patting
motions, and lip smacking are indicative of a partial seizure.
A 73-year old patient has been diagnosed with ischemic stroke following diagnostic studies. Which
medication must be given within a 4.5 hour window of symptom onset to be effective in lysing a clot?
- Heparin
- Coumadin
- Plavix
- Alteplase - ANSWER - - Alteplase
***Thrombolysis with recombinant tissue plasminogen activator (rtPA) is currently the only FDA-
approved drug for acute ischemic stroke within a 3-hour window of symptom onset. rtPA binds to fibrin
and converts plasminogen to plasmin which is responsible for clot breakdown. Plavix, Coumadin, and
Heparin do not function in lysing clots.
What would the nurse expect to document in a patient diagnosed with a right hemisphere stroke?
- aphasia
- slow, cautious behavior
- right visual field deficit
- impulsive behavior - ANSWER - - impulsive behavior
***A patient diagnosed with a stroke that has affected the right hemisphere may exhibit spatial-
perceptual deficits and impulsive behavior. A patient with a left hemispheric stroke may exhibit aphasia,
slow, cautious behavior, and right visual field deficit. See Box 47-2.
pg. 3
, What initial diagnostic test is recommended to assess for a cerebral bleed?
- MRI
- non-contrast CT
- CT w/ contrast
- Cerebral angiography - ANSWER - non-contrast CT
***A noncontrast CT scan is an important immediate diagnostic to differentiate between ischemic and
hemorrhagic stroke. A CT scan with contrast is useful to rule out lesions that may mimic ischemia,
especially when symptoms are related to hemispheric deficits. An MRI offers excellent soft-tissue
contrast discrimination with superior demarcation of mass lesion from surrounding structures including
areas of ischemia and infarction. Cerebral angiography is ordered for patients who are considered
candidates for CEA to define precisely the percentage of occlusion and in patients with unusual
presentation with aneurysms, vasculitis, and high-grade stenosis. See Table 47-3.
When assessing a patient, the nurse knows that which clinical manifestations are shared by rheumatoid
arthritis and OA?
- joint space narrowing and a decreased C4 level
- symmetrical knee involvement and joint effusions
- tophi, joint enlargement, and severe pain
- joint swelling, stiffness, and pain - ANSWER - - joint swelling, stiffness, and pain
***Joint swelling, stiffness, and pain are manifestations of rheumatoid arthritis (RA) and osteoarthritis
(OA). Joint space narrowing is seen on x-ray in OA and RA, however, a decreased C4 level is found only in
RA, an autoimmune disorder. Osteoarthritis typically affects joints asymmetrically, while RA typically
affects symmetrical joints and more commonly results in effusions. Tophi are only found in patients with
gout.
AG student living on campus presented to the emergency department. He developed a fever (Tmax
103F/ 39.4C) 1 day prior. He presented with mild rhinorrhea, headache, decreased appetite, and is
lethargic. This morning his room mate had difficulty arousing him. Reviewing the lab values, which of the
following would the nurse suggest to the provider?
pg. 4
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