NCLEX-PN Test #5 3 — Questions and Answers
Question 1: The PN is caring for a client post-craniotomy. Which finding requires the most immediate nursing action?
- Complaint of a mild headache, rated 3/10
- Blood pressure of 160/90 mmHg with heart rate of 54 bpm (Correct answer)
- Serosanguineous drainage on the head dressing
- Temperature of 37.8°C (100°F)
Correct answer: Blood pressure of 160/90 mmHg with heart rate of 54 bpm
Hypertension combined with bradycardia (Cushing's triad — hypertension, bradycardia, and irregular respirations) signals increased intracranial pressure (ICP), which is a life-threatening emergency requiring immediate notification of the provider. This triad indicates impending brainstem herniation.
Question 2: A client has a cast applied to the right forearm after a fracture. Two hours later, the client reports severe pain that increases with passive extension of the fingers. What complication does the nurse suspect?
- Normal post-casting discomfort
- Compartment syndrome (Correct answer)
- Delayed union of the fracture
- Cast allergy
Correct answer: Compartment syndrome
Pain with passive stretch of muscles within the compartment is the hallmark early sign of compartment syndrome. This is a surgical emergency (fasciotomy) as increased compartment pressure causes ischemia and irreversible muscle and nerve damage within 4–6 hours.
Question 3: A client is admitted with a new stroke affecting the left hemisphere. Which deficit is most likely?
- Left-sided hemiplegia and spatial-perceptual deficits
- Right-sided hemiplegia and aphasia (Correct answer)
- Left visual field deficit only
- Difficulty with recognition of faces
Correct answer: Right-sided hemiplegia and aphasia
The left hemisphere controls the right side of the body (motor/sensory) and language. A left hemisphere stroke typically causes right-sided hemiplegia and aphasia (expressive, receptive, or mixed). Left-sided hemiplegia and spatial deficits indicate right hemisphere involvement.
Question 4: A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). The nurse knows this drug works by:
- Blocking acetylcholine receptors at the neuromuscular junction
- Inhibiting acetylcholinesterase to increase available acetylcholine (Correct answer)
- Stimulating dopamine receptors in the basal ganglia
- Enhancing GABA activity in the brain
Correct answer: Inhibiting acetylcholinesterase to increase available acetylcholine
Pyridostigmine is an acetylcholinesterase inhibitor. Myasthenia gravis is caused by autoimmune destruction of acetylcholine receptors. By inhibiting the enzyme that breaks down acetylcholine, pyridostigmine increases its availability at the neuromuscular junction, improving muscle strength.
Question 5: A client with a hip replacement is being prepared for discharge. Which instruction is most important to prevent dislocation?
- Avoid crossing the legs and bending the hip beyond 90 degrees (Correct answer)
- Sleep only on the operative side for the first 6 weeks
- Perform daily hip flexion exercises beyond 90 degrees
- Use a standard toilet seat without a raised adapter
Correct answer: Avoid crossing the legs and bending the hip beyond 90 degrees
After total hip replacement, the most common cause of early dislocation is violating hip precautions: no hip flexion beyond 90 degrees, no adduction (crossing legs), and no internal rotation. A raised toilet seat and chair seat raisers help maintain safe positioning.
Question 6: The nurse assesses a client with Parkinson's disease. Which is the classic triad of symptoms?
- Spasticity, hyperreflexia, and Babinski sign
- Tremor at rest, rigidity, and bradykinesia (Correct answer)
- Intention tremor, ataxia, and dysarthria
- Chorea, dementia, and personality changes
Correct answer: Tremor at rest, rigidity, and bradykinesia
The classic Parkinson's triad is: pill-rolling resting tremor, cogwheel or lead-pipe rigidity, and bradykinesia (slow movement). A fourth hallmark is postural instability. Intention tremor, ataxia, and dysarthria are cerebellar signs; chorea and dementia suggest Huntington's disease.
NCLEX-PN Test #5 3
The PN is caring for a client post-craniotomy.
Which finding requires the most immediate nursing action?