NCLEX Daily Practical Exercise 56

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6. A 55-year-old client, who is a renowned pianist, is admitted to the neurology unit after a right-sided cerebrovascular accident (CVA) following a high-pressure concert performance. The client’s family is anxious about the potential implications on his career. The nurse is performing a neurological assessment while considering the client’s profession and the family’s concerns. Amidst the assessment, which finding should prompt the nurse to take immediate action and possibly escalate care?

A. Decrease in the level of consciousness

B. Loss of bladder control

C. Altered sensation to stimuli, especially in the fingers

D. Emotional lability, with episodes of sudden crying

Correct Answer: A

Answer Explanation:

A decrease in the level of consciousness is a critical sign that indicates potential deterioration in a client’s neurological status, especially after a cerebrovascular accident (CVA). It can suggest increasing intracranial pressure, further brain injury, or other serious complications. Immediate action and escalation of care are essential when there’s a decline in consciousness to prevent further complications and potentially life-threatening situations.

7. A 6-year-old child, who has recently moved to a high-altitude region with his family, has been diagnosed with cystic fibrosis. The parents bring him to a pediatric clinic for an initial assessment and are concerned about how the altitude might impact his condition. They also mention that he has been more active and playing outside with new friends. Considering the early stage of this disease and the child’s recent environmental changes, which later-stage symptom associated with cystic fibrosis would the nurse NOT expect to observe at this time?

A. Positive sweat test

B. Bulky greasy stools

C. Moist, productive cough

D. Meconium ileus

Correct Answer: C

Answer Explanation:

Cystic fibrosis is a progressive genetic disorder that affects the respiratory and digestive systems. A moist, productive cough is a symptom that typically develops in the later stages of the disease as the lungs become more affected by thick mucus secretions. In the early stages of cystic fibrosis, symptoms like a positive sweat test, bulky greasy stools, and meconium ileus (in newborns) are more common. While clubbing of the fingers and toes and shortness of breath can also be seen in later stages, the moist, productive cough is a hallmark later-stage symptom that would not be expected in a 6-year-old with a recent diagnosis. Respiratory failure is the most dangerous complication of CF.

8. During a home health visit in a remote mountainous area with limited cell reception, a nurse arrives at a cabin to find a male client lethargic and confused. His wife, who seems visibly distressed, mentions that he fell down the stairs approximately two hours ago while they were preparing for a storm. She adds that he seemed fine immediately afterward and didn’t want to worry their children who are playing in the adjacent room. Given the circumstances, what actions should the nurse prioritize? Select all that apply.

A. Place a call to the client’s health care provider for instructions, even if it means driving to a location with better reception.

B. Arrange for immediate transport or send him to the nearest emergency room for evaluation.

C. Reassure the client’s wife that the symptoms are likely to be transient and will resolve soon.

D. Instruct the client’s wife to monitor his condition and to call the doctor if symptoms worsen, providing her with emergency numbers.

E. Assess for other signs of head trauma like pupil dilation, irregular breathing, or fluid drainage from ears or nose.

F. Keep the client in a calm and quiet environment, away from the children, to reduce stimulation.

G. Check the home environment for potential hazards that could lead to further injury.

Correct Answer: A, B, E, and F.

Answer Explanation:

Following a fall, especially with a delayed presentation of symptoms like lethargy and confusion, there’s a concern for a potential traumatic brain injury or intracranial bleeding. Immediate medical evaluation is crucial. The nurse should contact the healthcare provider for guidance and prioritize sending the client to the emergency room. Assessing for other signs of head trauma can provide valuable information about the client’s condition. Given the scenario, keeping the client calm and reducing stimulation is also essential.

9. A 72-year-old client with a history of recurrent urinary tract infections and recent complaints of flank pain is scheduled for KUB (Kidney, Ureter, Bladder) radiography in an outpatient setting. The client is anxious and mentions reading various preparation methods online. Given the client’s age, history, and concerns, which of the following actions should the nurse take to adequately prepare the client for the test? Select all that apply.

A. Instruct the client that they must be NPO for 6 hours before the examination.

B. Administer an enema the evening before the examination to ensure clear imaging.

C. Administer furosemide 20 mg IV half an hour before the examination to enhance visualization.

D. Reassure the client and inform them that no special preparation is needed for this examination.

E. Ask the client to drink fluids and empty the bladder just prior to the examination to ensure a clear view.

F. Check for any allergies to contrast, even though it’s not typically used in a standard KUB.

G. Advise the client to wear loose-fitting clothing without any metal objects for the examination.

Correct Answer: D & E.

Answer Explanation:

A KUB radiography is a diagnostic imaging test that provides a view of the kidneys, ureters, and bladder. Typically, no special preparation is needed for this examination. However, asking the client to drink fluids and then empty the bladder just before the test can help ensure a clear view of the urinary structures. The other options, such as being NPO, administering an enema, or giving furosemide, are not standard preparations for a KUB.

10. The nurse is giving discharge teaching to a 45-year-old client, a professional athlete, seven (7) days post-myocardial infarction. The client, anxious about returning to his normal life and activities, asks the nurse why he must wait six (6) weeks before having sexual intercourse. He also inquires about the impact on his athletic performance. Given his profession and concerns, what is the best response by the nurse to this question?

A. “You need to regain your strength before attempting such exertion, especially considering your profession.”

B. “When you can climb 2 flights of stairs without problems or feeling short of breath, it is generally safe to engage in activities like sex.”

C. “Have a glass of wine to relax you, then you can try to have sex.”

D. “Your heart needs time to heal, and premature exertion can risk another cardiac event.”

E. “You should consider discussing this with your cardiologist, who can provide guidelines tailored to your athletic needs.”

Correct Answer: B

Answer Explanation:

After a myocardial infarction, it’s essential for the heart to heal and for the patient to gradually return to physical activities. The ability to climb 2 flights of stairs without experiencing symptoms is often used as a general benchmark to gauge a person’s cardiovascular fitness and readiness to engage in activities that require exertion, such as sexual intercourse. Given the client’s profession as an athlete, this benchmark is particularly relevant. The other options either provide incomplete advice or are not directly related to the client’s primary concern.

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