Question

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Answer 1

Correct Answers:

Inability to recognize his family members

Rationale :

🧠 A right hemisphere stroke primarily affects perception, spatial awareness, and visual recognition, not language centers.

🧠 Prosopagnosia (inability to recognize familiar faces, including family members) is a common perceptual deficit with right-brain involvement.

🧠 The right hemisphere also controls visual-spatial skills, attention, and judgment, which may lead to neglect of the left side of the body or environment.

🧠 Aphasia and difficulty reading are more commonly associated with left hemisphere strokes, which involve language centers (Broca’s and Wernicke’s areas).

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Answer 2

Correct Answers:

Assume there is a cervical spine injury

Rationale :

🩺 When a head injury is suspected, always assume a cervical spine injury until diagnostic imaging (e.g., X-ray, CT, MRI) rules it out.

🩺 This precaution prevents further spinal cord damage that could result in paralysis or neurological deficits.

🩺 The nurse should maintain cervical spine immobilization (e.g., cervical collar, log-rolling) during all assessments and transfers.

🩺 This is a standard trauma care principle following the ABC and spinal precautions protocols.

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Answer 3

Correct Answers:

“I need to take the antiviral medications at the prescribed dosing times for the full 28 days to be effective.”

Rationale :

💊 Post-exposure prophylaxis (PEP) for HIV is most effective when started as soon as possible, ideally within 2 hours and no later than 72 hours after exposure.

💊 The medication regimen must be taken consistently at the prescribed times for the full 28-day course to significantly reduce the risk of HIV transmission.

💊 Skipping doses or stopping early decreases the effectiveness and increases the risk of viral resistance.

💊 PEP is recommended for all significant exposures, including needle-stick injuries, regardless of pre-existing conditions like high blood pressure (unless contraindicated by the provider).

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Answer 4

Correct Answers:

Restlessness

Rationale :

🧠 Restlessness is an early and significant indicator of increased intracranial pressure (ICP) because it reflects cerebral hypoxia and decreased cerebral perfusion.

🧠 As ICP rises, mental status changes such as irritability, confusion, and restlessness occur before vital sign changes, making it a critical early sign.

🧠 Persistent elevated ICP can progress to lethargy, stupor, and coma if not promptly treated.

🧠 Other listed findings (positive Kernig’s sign, photophobia, and nuchal rigidity) are classic signs of meningitis itself but are not specific indicators of increased ICP.

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Answer 5

Correct Answers:

Psychological distress

Rationale :

🩺 Psoriasis is a chronic autoimmune skin disorder that causes visible, scaly, and inflamed patches, which can significantly affect a patient’s self-image and emotional well-being.

🩺 Many clients experience psychological distress, anxiety, depression, and social withdrawal due to embarrassment or stigma associated with the skin’s appearance.

🩺 Nurses should assess for emotional impact and provide supportive care, education, and referrals to counseling or support groups if needed.

🩺 Other listed conditions (decreased breath sounds, UTI, hiatal hernia) are not common complications of psoriasis.

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Answer 6

Correct Answers:

Phenytoin is used to prevent or treat seizures.

Rationale :

🧠 Phenytoin (Dilantin) is an anticonvulsant commonly used in head injury patients to prevent or control post-traumatic seizures.

🧠 Seizures can increase intracranial pressure (ICP), worsen cerebral hypoxia, and lead to further neurological damage, making seizure prophylaxis crucial in head trauma.

🧠 It is not used to decrease bleeding and is not contraindicated in head injuries; instead, it is part of neuroprotective management in some cases.

🧠 Its use is not limited to pediatric patients; it is prescribed for both adults and children as clinically indicated.

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Answer 7

Correct Answers:

Administer antibiotics when available

Rationale :

🧠 Bacterial meningitis is a medical emergency due to the rapid progression of infection and inflammation in the meninges.

🧠 Early administration of broad-spectrum IV antibiotics significantly reduces mortality and neurological complications such as hearing loss, brain damage, or seizures.

🧠 Antibiotics should be given immediately after blood cultures are obtained and not delayed for diagnostic procedures like lumbar puncture

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Answer 8

Correct Answers:

Severe headache
Confusion
Dilated or pinpoint nonreactive pupils
Nausea/Vomiting
Seizures

Rationale :

✅ Severe headache

🌟 A severe, persistent headache is a hallmark sign of increased intracranial pressure (ICP) caused by stretching of pain-sensitive meninges, blood vessels, and brain tissue.

🌟 It often worsens with activities that increase ICP, such as coughing, bending, or straining (Valsalva maneuver).

🌟 Early recognition of this symptom is crucial for preventing further neurological deterioration.

✅ Confusion

🧠 Mental status changes such as confusion, restlessness, or disorientation are early warning signs of ICP due to decreased cerebral perfusion and brain hypoxia.

🧠 As pressure increases, the confusion can progress to lethargy, stupor, or coma, indicating worsening brain dysfunction.

🧠 Frequent neurological assessments help detect these changes promptly.

✅ Dilated or pinpoint nonreactive pupils

👁️ Pupil changes occur as pressure affects cranial nerve III (oculomotor nerve) or brainstem function.

👁️ Unequal, dilated, or nonreactive pupils are late but serious signs, often signaling impending brain herniation.

👁️ Immediate intervention is required to prevent permanent brain damage or death.

✅ Nausea/Vomiting

🤢 Projectile vomiting, often without nausea, results from direct pressure on the vomiting center in the medulla.

🤢 This symptom commonly appears in sudden or acute increases in ICP, such as head trauma or intracerebral hemorrhage.

🤢 Monitoring and documenting vomiting patterns help in tracking ICP progression.

✅ Seizures

⚡ Seizures may occur due to cortical irritation, hypoxia, and neuronal hyperexcitability associated with ICP.

⚡ Seizures can further increase metabolic demands, worsening cerebral edema and hypoxia.

⚡ Seizure precautions and immediate treatment (e.g., benzodiazepines, anticonvulsants) are essential to protect brain tissue.

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Answer 9

Correct Answers:

Genetics

Rationale :

🧬 Genetics (family history) is a nonmodifiable risk factor for stroke because individuals cannot change their hereditary predisposition to cardiovascular or cerebrovascular diseases.

🧬 A family history of stroke, hypertension, or clotting disorders increases the likelihood of developing a stroke due to inherited vascular or metabolic abnormalities.

🧬 Other nonmodifiable risk factors include age, gender, and race/ethnicity, which are important to consider in risk assessment and prevention education.

🧬 Modifiable factors like smoking, obesity, and hypertension can be managed through lifestyle changes and medical treatment.

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Answer 10

Correct Answers:

Provides immediate results

Rationale :

🌟 Skin allergy testing (e.g., skin prick or intradermal test) is preferred because it gives rapid results, usually within 15–20 minutes.

🌟 This allows for immediate interpretation and quicker formulation of an allergy management plan.

🌟 Although it may cause temporary discomfort or localized itching, it is still the fastest diagnostic method compared to blood tests (e.g., RAST or IgE tests), which take several days for laboratory processing.

🌟 Blood tests are typically reserved for patients who cannot undergo skin testing due to severe eczema, dermatographism, or high risk of anaphylaxis.

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RN Custom Exam 2 N221(Summer~2025)

No.

1 :
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

2 :
What is the appropriate assumption to make when a head injury is suspected until a cervical injury is ruled out?

3 :
A nurse is teaching a client who has a prescription for HIV post exposure prophylaxis (PEP) about how to take the medications. Which of the following client statements indicates understanding of the teaching?

4 :
A nurse suspects that a client admitted for treatment of a bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse Supports this suspicion?

5 :
A nurse is caring for a client who has psoriasis presenting as reddish/purple and flaky patches on their arms and legs. The nurse should be alert to which of the following potential complications of the condition?

6 :
Which of the following statements is true regarding the use of phenytoin (Dilantin) in head injury?

7 :
A nurse is caring for a child who has suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse’s priority?

8 :
Which of the following are manifestations of Increased intracranial pressure? (Select All that Apply)

9 :
A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

10 :
Which of the following is a primary advantage of skin allergy testing over blood allergy testing?

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RN Custom Exam 2 N221(Summer~2025)

No.

1 : A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

2 : What is the appropriate assumption to make when a head injury is suspected until a cervical injury is ruled out?

3 : A nurse is teaching a client who has a prescription for HIV post exposure prophylaxis (PEP) about how to take the medications. Which of the following client statements indicates understanding of the teaching?

4 : A nurse suspects that a client admitted for treatment of a bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse Supports this suspicion?

5 : A nurse is caring for a client who has psoriasis presenting as reddish/purple and flaky patches on their arms and legs. The nurse should be alert to which of the following potential complications of the condition?

6 : Which of the following statements is true regarding the use of phenytoin (Dilantin) in head injury?

7 : A nurse is caring for a child who has suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse’s priority?

8 : Which of the following are manifestations of Increased intracranial pressure? (Select All that Apply)

9 : A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

10 : Which of the following is a primary advantage of skin allergy testing over blood allergy testing?

1 :
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

2 :
What is the appropriate assumption to make when a head injury is suspected until a cervical injury is ruled out?

3 :
A nurse is teaching a client who has a prescription for HIV post exposure prophylaxis (PEP) about how to take the medications. Which of the following client statements indicates understanding of the teaching?

4 :
A nurse suspects that a client admitted for treatment of a bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse Supports this suspicion?

5 :
A nurse is caring for a client who has psoriasis presenting as reddish/purple and flaky patches on their arms and legs. The nurse should be alert to which of the following potential complications of the condition?

6 :
Which of the following statements is true regarding the use of phenytoin (Dilantin) in head injury?

7 :
A nurse is caring for a child who has suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse’s priority?

8 :
Which of the following are manifestations of Increased intracranial pressure? (Select All that Apply)

9 :
A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

10 :
Which of the following is a primary advantage of skin allergy testing over blood allergy testing?