a patient is being treated in the neurology unit for meningitis which of these is a priority assessment for the nurse to make
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Review Answers

1. A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?

Correct answer: D

Rationale: Monitoring for increased lethargy and drowsiness is crucial as these symptoms indicate a decreased level of consciousness, which is the cardinal sign of increased Intracranial Pressure (ICP). Elevated ICP can lead to serious complications and requires immediate intervention. Assessing for nuchal rigidity is important in suspected cases of meningitis but monitoring lethargy and drowsiness takes precedence due to its direct correlation with ICP. Determining past exposure to infectious organisms and checking WBC lab values are important for diagnosing and treating meningitis but do not directly address the immediate concern of increased ICP.

2. During an assessment of a child admitted to the hospital with a probable diagnosis of nephrotic syndrome, what assessment findings should the nurse expect to observe? Select one that applies.

Correct answer: A

Rationale: In nephrotic syndrome, the hallmark finding is massive proteinuria due to increased glomerular permeability. This leads to hypoalbuminemia, resulting in generalized edema. Weight gain, not weight loss, is typically seen due to fluid retention. Serum lipids are elevated, not decreased, in nephrotic syndrome. Hematuria, the presence of blood in the urine, is not a typical finding in nephrotic syndrome.

3. Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?

Correct answer: B

Rationale: The most important topic to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis is avoiding alcohol ingestion. Alcohol abstinence is crucial in stopping or reversing the progression of the disease. While maintaining good nutrition, taking lactulose (Cephulac), and using vitamin B supplements are important interventions in managing cirrhosis, abstaining from alcohol is the priority for this patient to prevent further damage to the liver and halt disease progression.

4. Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select the one that doesn't apply:

Correct answer: D

Rationale: Claudication is a symptom of peripheral vascular disease where there is an inadequate supply of oxygen to the muscles due to reduced blood flow. This mismatch between oxygen demand and supply leads to tissue hypoxia, resulting in cramping, weakness, and discomfort. Option D correctly states that claudication is characterized by cramping and weakness, making it the correct answer. Options A, B, and C are incorrect. Claudication occurs when oxygen demand exceeds supply, not the other way around as stated in Option A. Pain in claudication typically occurs with activity, not at rest as mentioned in Option B. While tissue hypoxia is a consequence of claudication, it is not the primary cause, making Option C incorrect.

5. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

Correct answer: B

Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.

Similar Questions

What is the primary nursing concern when caring for patients being treated with splints, casts, or traction?
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
A patient is undergoing a stress test on a treadmill and turns to talk to the nurse. Which of these statements would require the most immediate intervention?
After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?
Which of the following types of dressing changes works as a form of wound debridement?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses