NCLEX Jeopardy #2

Eye and Ear 902

100

776. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. What is the chief clinical manifestation that the nurse expects to note in the early stages of cataract formation?

1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

200

775. A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

300

780. The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which nursing action is most appropriate?

1. Document the finding 2. Continue to monitor the drainage 3. Notify the health care provider (HCP) 4. Mark the drainage on the dressing and monitor for any increase in bleeding

400

784. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

500

783. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client's chart, knowing that which is the range for normal intraocular pressure?

1. 2 to 7 mmHg 2. 10 to 21 mmHg 3. 22 to 30 mmHg 4. 31 to 35 mmHg

Neurological 944

100

799. The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain?

1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

200

804. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

300

800. The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

400

812. The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease?

1. Meningitis of encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

500

806. The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply.

1. The client is aphasic 2. The client has weakness in the face and tongue 3. The client has weakness on the right side of the body 4. The client has complete bilateral paralysis of the arms and legs 5. The client has lost the ability to move the right arm but is able to walk independently 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance

Musculoskeletal Medications 993

100

852. Alendronate (Fosamax) is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide?

1. Take the medication at bedtime 2. Take the medication in the morning with breakfast 3. Lie down for 30 minutes after taking the medication 4. Take the medication with a full glass of water after rising in the morning

200

851. Colchicine (Colcrys) is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder?

1. Myxedena 2. Kidney disease 3. Hypothyroidism 4. Diabetes mellitus

300

857. The nurse is administering an intravenous dose of methocarbamol (Robaxin) to a client with multiple sclerosis. For which side/adverse effects should the nurse monitor?

1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertensions

400

854. The nurse is analyzing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which laboratory test would identify an adverse effect associated with the administration of this medication?

1. Platelet count 2. Creatinine level 3. Liver function tests 4. Blood urea nitrogen level

500

856. In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply.

1. Symptom control during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection is given 6. A low-grade temperature on rising in the morning that remains throughout the day

Immune 1005

100

861. A client with pemphigus is being seen in the clinic regularly. The nurse plans care cased on which description of this condition?

1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

200

870. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding?

1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

300

872. The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item?

1. Eggs 2. Milk 3. Yogurt 4. Bananas

400

864. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy?

1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

500

868. A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing actions are most appropriate? Select all that apply.

1. Tell the client that testing is not necessary unless arthralgia develops 2. Tell the client to avoid any woody, grassy areas that may contain ticks 3. Instruct the client to immediately start to take the antibodies that are prescribed 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease 5. Tell the client if this happens again to never remove the tick but vigorously scrub the area with an antiseptic

Guess What? 1096

100

978. The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position?

1. Elevated on a pillow 2. Level with the right atrium 3. Dependent to the right atrium 4. Elevated above shoulder level

200

963. The nurse assesses a client with admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?

1. Incessant talking and sexual innuendoes 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake

300

977. The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, PCO2 of 58 mmHg, PO2 of 80 mmHg, and HCO2 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

400

994. The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

1. The nail beds 2. The skin in the sacral area 3. The skin in the abdominal area 4. The membranes in the ear canal

500

1022. A client has had radical neck dissection and begins to hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply.

1. Monitor vital signs 2. Monitor the client's airway 3. Apply manual pressure over the site 4. Lower the head of bed to a flat position 5. Call the health care provider immediately