NCLEX-RN Practice Quiz Test Bank #3 (75 Questions)

NCLEX-RN Practice Quiz Test Bank #3 (75 Questions) 1. 1. Question 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? o A. The NA assists the patient to ambulate to the bathroom and back to bed. o B. The NA reminds the patient not to look at his feet when he is walking. o C. The NA performs the patient’s complete bath and oral care. o D. The NA sets up the patient’s tray and encourages the patient to feed himself. Incorrect 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. 2. 2. Question 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.” Incorrect 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. 3. 3. Question 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. Incorrect 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.