NCLEX-PN Test #24 2

Question 1

A nurse is caring for a client with a spinal cord injury at the T6 level who suddenly develops a severe headache, blurred vision, and a blood pressure of 220/130 mmHg. Which condition should the nurse suspect?

Accepted Answer

Autonomic dysreflexia

Answer

Autonomic dysreflexia is a life-threatening emergency that occurs in clients with spinal cord injuries at T6 or above, triggered by a noxious stimulus below the level of injury.

Question 2

A 6-month-old infant is brought to the clinic for a well-child visit. Which developmental milestone should the nurse expect to observe?

Accepted Answer

Sitting with support and transferring objects between hands

Answer

At 6 months, infants typically sit with support, transfer objects between hands, babble, and roll from back to front.

Question 3

A client with a history of alcohol use disorder is admitted with confusion, ataxia, and ophthalmoplegia. Which intervention should the nurse anticipate?

Accepted Answer

IV thiamine (vitamin B1) administration

Answer

Confusion, ataxia, and ophthalmoplegia are the classic triad of Wernicke's encephalopathy, which is treated with IV thiamine.

Question 4

A nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which recommendation should be included?

Accepted Answer

Elevate the head of the bed 6 to 8 inches

Answer

Elevating the head of the bed uses gravity to prevent gastric acid from refluxing into the esophagus during sleep.

Question 5

A client is being discharged after placement of a permanent pacemaker. Which instruction should the nurse include?

Accepted Answer

Count your pulse daily and report rates below the set pacemaker rate

Answer

Clients with pacemakers should monitor their pulse daily and report rates below the programmed pacemaker rate, as this may indicate pacemaker malfunction.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #24 2