NCLEX-RN Practice Quiz Test Bank #3 (75Questions)_Chamberalain/NCLEX-RN Practice Quiz Test Bank #3 (75
Questions)
NCLEXRN-03-001
Question Tag:
... [Show More] Parkinson’s disease
Question Category: Safe and Effective Care Environment, Management of Care
A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related to
neuromuscular impairment. You observe a nursing assistant performing all of these actions. For
which action must you intervene?
A. The NA assists the patient to ambulate to the bathroom and back to bed.
B. The NA reminds the patient not to look at his feet when he is walking.
C. The NA performs the patient’s complete bath and oral care.
D. The NA sets up the patient’s tray and encourages the patient to feed himself.
Correct Answer: C. The NA performs the patient’s complete bath and oral care.
The nursing assistant should assist the patient with morning care as needed, but the goal is to keep
this patient as independent and mobile as possible.
Option A: Assisting the patient to ambulate prevents incidences of fall and injury.
Option B: Reminding the patient not to look at his feet while walking maintains the client’s
independence while keeping him safe.
Option D: Encouraging the patient to feed himself is an appropriate goal of maintaining
independence.
NCLEXRN-03-002
Question Tag: low back pain
Question Category: Health Promotion and Maintenance
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the
patient indicates that additional teaching is necessary?
A. “I will avoid exercise because the pain gets worse.”
B. “I will use heat or ice to help control the pain.”
C. “I will not wear high-heeled shoes at home or work.”
D. “I will purchase a firm mattress to replace my old one.”
Correct Answer: A. “I will avoid exercise because the pain gets worse.”
Exercises are used to strengthen the back, relieve pressure on compressed nerves and protect the
back from re-injury. Doing exercises to strengthen the lower back can help alleviate and prevent
lower back pain. It can also strengthen the core, leg, and arm muscles. According to researchers,
exercise also increases blood flow to the lower back area, which may reduce stiffness and speed up
the healing process.
Option B: Ice and heat application are appropriate interventions for back pain. Applying ice or
a reusable gel pack constricts blood vessels and reduces swelling around the injury. This is
particularly useful for conditions, like a sprained ankle, that cause significant swelling. Heat
has the opposite effect, increasing blood flow to the area. This relaxes muscle fibers, which
can help when the client experiences spasms or stiffness.
Option C: People with chronic back pain should avoid wearing high-heeled shoes at all times.
The normal s-curve of the spine acts as a cushion or spring, reducing stress on the vertebrae.
When wearing high heels, the shape of the spine is altered and the client doesn’t get that
same shock absorption as she walks, which, over time, can lead to uneven wear on the
cartilage discs, joints and ligaments of the back.
Option D: A firm mattress prevents lower back pain. Sleeping on a mattress that is too firm
can cause aches and pains on pressure points. A medium-firm mattress may be more
comfortable because it allows the shoulder and hips to sink in slightly. Patients who want a
firmer mattress for back support can get one with thicker padding for greater comfort.
NCLEXRN-03-003
Question Tag: Spinal cord injury
Question Category: Physiological Integrity, Physiological Adaptation
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly
started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and
decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should
you take first?
A. Administer the ordered acetaminophen (Tylenol).
B. Check the Foley tubing for kinks or obstruction.
C. Adjust the temperature in the patient’s room.
D. Notify the physician about the change in status.
Correct Answer: B. Check the Foley tubing for kinks or obstruction.
These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that
must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious
stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage,
bladder distention, or fecal impaction is the first action that should be taken.
Option C: Adjusting the room temperature may be helpful, since too cool a temperature in the
room may contribute to the problem.
Option A: Tylenol will not decrease the autonomic dysreflexia that is causing the patient’s
headache.
Option D: Notification of the physician may be necessary if nursing actions do not resolve
symptoms.
NCLEXRN-03-004
Question Tag: Neurologic unit
Question Category: Safe and Effective Care Environment, Management of Care
Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the
neurologic unit?
A. A 28-year-old newly admitted patient with spinal cord injury.
B. A 67-year-old patient with a stroke 3 days ago and left-sided weakness.
C. An 85-year-old dementia patient to be transferred to long-term care today.
D. A 54-year-old patient with Parkinson’s who needs assistance with bathing.
Correct Answer: B. A 67-year-old patient with stroke 3 days ago and left-sided weakness.
The new graduate RN who is oriented to the unit should be assigned stable, non-complex patients,
such as the patient with stroke.
Option A: The newly admitted SCI should be assigned to experienced nurses. Most cases of
SCI take place when trauma breaks and squeezes the vertebrae, or the bones of the back.
This, in turn, damages the axons—the long nerve cell “wires” that pass through vertebrae,
carrying signals between the brain and the rest of the body. The axons might be crushed or
completely severed by this damage. Someone with injury to only a few axons might be able to
recover completely from their injury. On the other hand, a person with damage to all axons will
most likely be paralyzed in the areas below the injury.
Option C: A patient for transfer should be assigned to a nurse who has experience in the
process of transferring patients.
Option D: The patient with Parkinson’s disease needs assistance with bathing, which is best
delegated to the nursing assistant.
NCLEXRN-03-005
Question Tag: Spinal cord injury
Question Category: Physiological Integrity, Physiological Adaptation [Show Less]