Jersey College of Nursing - NCLEX Fundamental Review. Questions and Answers. All 100% Correct.
Question 1
0 / 100 pts
The general survey begins a
... [Show More] review of the patient’s primary health problems and evaluation of
the patient’s vital signs, height and weight, general behavior, and appearance. It also provides
information about the patient’s illness, hygiene, skin condition, body image, and emotional state.
Which of the following cannot be delegated to nursing assistive personnel?
Monitoring I&O
Measuring the patient’s height and weight
You Answered
Reporting subjective signs and symptoms
Correct Answer
Obtaining initial vital signs
You cannot delegate the general survey to nursing assistive personnel (NAP). The nurse directs
NAP to obtain vital signs (not the initial set, but subsequent measurements if patient is stable).
The nurse directs NAP to report a patient’s subjective signs and symptoms to the nurse, to
measure the patient’s height and weight, and to monitor oral intake and urinary output.
Question 2
100 / 100 pts
The nurse is caring for a patient who is recovering from an acute myocardial infarction. While
providing cardiac education, the nurse realizes that the patient needs more education when he:
Correct!
States that he will take his medication when he has chest pain or when his heart rate is greater
than 100
Describes the schedule, dosage, and purpose of his medication
Describes the benefits of taking his medication regularly
Describes changes in his behavior that may improve cardiovascular function
The patient should not take medications for cardiovascular function intermittently. Medication
should be taken on the regular prescribed schedule to prevent additional cardiac events.
Describing changes in his behavior that may improve his cardiovascular function indicates that
the patient understands steps he may take to improve his own health. The ability to accurately
describe the schedule, dose, and purpose of his medication indicates that the patient understands
his treatment. Understanding the benefits of taking his medication regularly should improve
patient compliance with therapy.
Question 3
0 / 100 pts
The patient is diagnosed with Bell’s palsy. The nurse assesses the patient and notices drooping of
the patient’s right eye and the right side of his mouth. When the functions of the following nerves
are compared, the most likely cause of these symptoms would be a dysfunction of:
You Answered
The trigeminal nerve (CN V)
The glossopharyngeal nerve (CN IX)
The oculomotor nerve (CN III)
Correct Answer
The seventh cranial nerve
Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have patient frown, smile, puff
out cheeks, and raise eyebrows. Expressions should be symmetrical; Bell’s palsy causes drooping
of upper and lower face; cerebrovascular accident (CVA) causes asymmetry.
Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to
symmetrical areas of face. Sensations should be symmetrical; unilateral decrease or loss of
sensation is possibly due to CN V lesion or a lesion in higher sensory pathways. Assess cranial
nerve CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement
(EOM) functioning. Ask patient to follow the movement of your finger through the six cardinal
positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight.
These cranial nerves are most likely to be affected by increasing intracranial pressure (ICP),
which causes change in the pupil response or the pupil size; sometimes pupils change shape
(more oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired
swallowing; damage to CN X causes loss of gag reflex, hoarseness, and nasal voice. When the
palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis.
Question 4
100 / 100 pts
Which patient position maximizes the nurse’s ability to assess the patient’s body for symmetry?
Correct!
Sitting
Prone
Supine
Dorsal recumbent
Sitting upright provides full expansion of lungs and allows better visualization of symmetry of
upper body parts.
The supine position maximizes the nurse’s ability to assess pulse sites. The prone position is used
only to assess extension of the hip joint. The dorsal recumbent positi [Show Less]