NCLEX-RN Exam Questions - Part 100

1. A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

A) Loss of ability to speak and communicate effectively
B) Aspiration and weight loss
C) Secondary infection resulting from poor oral hygiene
D) Drooling



2. A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?

A) Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
B) Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
C) Potential for injury related to impaired mobility and seizures
D) Impaired verbal communication related to aphasia



3. A 32-year-old female client is being treated for Guillain- Barr syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

A) Complaints of a headache
B) Loss of superficial and deep tendon reflexes
C) Complaints of shortness of breath
D) Facial paralysis



4. A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:

A) Reclining to control bleeding
B) Any position in which the client is comfortable
C) Side-lying, either left or right
D) Sitting with head support



5. A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

A) Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
B) Advise the client to discontinue the drug at the first sign of dizziness.
C) Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
D) Instruct the client in Valsalva - s maneuver to equalize middle ear pressure and to prevent hearing loss.