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NUR205 NCLEX Exam Study with complete solutions 2024_2025.
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NUR205 NCLEX Exam Study with complete solutions 2024_2025.
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NUR205 NCLEX Exam Study withcomplete solutions 2024/2025
The nurse is teaching the patient about amoxicillin prior to discharge and
includes what important teaching point?
- even if it seems like the infection is not improving, the drug is still working
- yeast infections are unlikely to occur with this medication because it is a narrow
spectrum
- infections of the tongue may occur but will subside when the drug is
discontinued
- appearance of a rash is common and does not indicate an allergic reaction -
ANSWER-- infections of the tongue may occur but will subside when the drug is
discontinued
*** lingua villosa nigra = remember furry tongue, or hairy tongue that can cause
the tongue to look black in appearance, can happen with antibiotics. The best
intervention/ pt. education the RN can do = maintain and promote good oral
hygiene. Best preventative measure as well as treatment option.
The nurse is providing discharge teaching for a patient prescribed prednisone to
be taken on alternate days. The patient asks why he cannot take half a pill every
day. What is the nurse's best response?
to eliminate adverse side effects
to prolong therapeutic efforts
to prevent steroidal tolerance
to decrease adrenal suppression - ANSWER-- to decrease adrenal suppression
,*** remember this can help DECREASE adverse side effects not eliminate them.
Many of the side effects are the result of adrenal gland suppression/ reduction in
cortisol production. So decreasing the suppression of the adrenal glands makes
the most sense!
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
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?
- request an order for frequent (q2hr) neurosensory assessment, an order for
blood cultures (WBC elevated so we need to see what infection he is fighting off),
request and opioid for pain. - ANSWER-*** remember elevated C-reactive protein
levels in the blood increase inflammation. This can lead to an increased risk in
ischemia possible resulting in an ischemic CVA. (too much inflammation = too
much pressure on vessels = could cause stroke). So if patient has high CRP then
neuro checks need to be frequent to assess for S and S of too much inflammation
in the brain. CRP should be 0.1 or lower his was 12. something!!!
In assessing the neurological status on an older patient, the nurse needs to
consider which-age related change of the neurological system?
- reaction time is slower
,- flexibility is maintained
- pain sensation is heightened
- higher basal body temperature - ANSWER-- reaction time is slower
***with age, our temperature regulators aren't as effective as they used to be
(hypothalamus) resulting in an overall decrease in basil body temp. Why elderly
patients often describe feeling cold, keep their rooms at warmer temps, require
extra blankets, and dress for cold weather even when it's relatively warm outside.
Pain sensation is actually dullened. Flexibility slightly decreases (typically/ norm)
and slower reaction time. The brains shrinks, loses a little weight, and thus
decreases the firing speed of neurons and interferes with neuronal transfer at the
synaptic cleft = delayed neuronal transmissions which presents as slowed or
delayed reaction time. Both gross and motor.
A nurse receives report on a patient who recently experienced a 15-minute
generalized (Tonic Clonic)} seizure in the emergency department. On arrival to
the unit, the patient is prone, breathing noisily, and hard to arouse. The nurse
would initiate which of the following? (select all that apply)
- place an oral airway
- administer intravenous antibiotics
- place patient in side lying position
- perform a neurovascular assessment
- obtain oxygen saturation level
- call rapid response team - ANSWER-- place patient in side lying position
- obtain oxygen saturation level
- call a rapid response team
*** remember this patient had a TONIC CLONIC!!! = total loss of muscle control,
often aphasic and dysphasic. So we aren't putting anything in their mouth. IV
antibiotics aren't going to do anything as this likely isn't from a bacterial infection
of the brain.
A SIDE LYING position is best to prevent aspiration and prevent pt. from biting
their tongue. A neuro assessment? - pt. isn't capable and it's past assessment
time it's intervention and evaluation time. You would want to obtain O2 sats to
assess O2 to the brain. Call a rapid response team because you may need all
hands on deck!
, The nurse notes that a patient has ataxia. Which test does the nurse use to gain
more information about the patient's gait?
- romberg
- patellar reflex
- planter reflex
- noninvasive carotid flow studies - ANSWER-- Romberg test. Screening test for
balance. Pt. stands with feet together, arms at the side. First with eyes open then
eyes closed for 20-30 seconds. The examiner stands close bye (fall risk) and
slight swaying is normal. Loss of balance considered - positive test
abdominal, planter, and babinski tests what type of reflexes? - ANSWER-
superficial or cutaneous reflexes
biceps, brachioradialis, patellar, triceps, and ankle tests for what type of reflexes?
- ANSWER-deep tendon reflexes
A nurse is discharging home a patient who suffered a stroke. He present with a
flaccid right arm and leg, and some urinary incontinence. The nurse makes a
referral to a home health nurse due to an awareness of what common patient
response to a change in body image? (select all that apply)
- fear
- depression
- dissociation
- stress of dealing with life changes
- manipulation - ANSWER-- fear, depression, and stress of dealing with life
changes
***dissociation is more referring to someone with a neurological disease like PD
who in the later stages dissociate themselves from friends, family, loved ones.
Manipulation makes no sense in this question.
A patient sustains an injury to the left temporal lobe. Which body functions does
the nurse expect to be affected by this injury? (select all that apply)
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