NCLEX-PN Test #24 2 — Questions and Answers

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?

Hypertensive crisis unrelated to the injury
Neurogenic shock
Autonomic dysreflexia (Correct answer)
Increased intracranial pressure

Correct answer: Autonomic dysreflexia

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.

Autonomic dysreflexia (hyperreflexia) is a medical emergency occurring in clients with spinal cord injuries at T6 or above. A noxious stimulus below the injury level (most commonly a distended bladder or impacted bowel) triggers a massive sympathetic response that cannot be modulated because nerve signals cannot pass the spinal cord lesion. Symptoms include sudden severe hypertension (systolic may exceed 200 mmHg), pounding headache, flushing and diaphoresis above the injury level, pallor and gooseflesh below the injury, bradycardia, blurred vision, and nasal congestion. Immediate interventions: sit the client up (to lower BP using orthostatic effect), identify and remove the noxious stimulus (check catheter for kinks, perform digital disimpaction with anesthetic lubricant), loosen restrictive clothing, and monitor BP closely. If BP remains elevated, antihypertensive medication may be needed. Untreated autonomic dysreflexia can cause seizures, stroke, or death.

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?

Walking independently
Sitting with support and transferring objects between hands (Correct answer)
Speaking in two-word phrases
Drawing circles on paper

Correct answer: Sitting with support and transferring objects between hands

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

Developmental milestones at 6 months of age include: gross motor — sitting with support (tripod position), rolling from back to front and front to back; fine motor — transferring objects from one hand to the other, raking grasp; language — babbling (consonant-vowel combinations like 'ba-ba'), responding to name; social — stranger anxiety begins, enjoys social play. Walking independently typically occurs around 12 months. Two-word phrases develop around 18-24 months. Drawing circles occurs around 3 years. It is important for nurses to monitor developmental milestones at each well-child visit and refer for early intervention if delays are identified. The nurse should ask parents about milestone achievement and directly observe the infant's behavior during the visit.

Question 3: A client with a history of alcohol use disorder is admitted with confusion, ataxia, and ophthalmoplegia. Which intervention should the nurse anticipate?

Administration of benzodiazepines
IV thiamine (vitamin B1) administration (Correct answer)
Immediate CT scan of the abdomen
High-protein diet initiation

Correct answer: IV thiamine (vitamin B1) administration

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

Wernicke's encephalopathy is caused by thiamine (vitamin B1) deficiency, commonly seen in chronic alcohol use disorder due to poor nutrition and impaired thiamine absorption. The classic triad includes confusion (altered mental status), ataxia (unsteady gait), and ophthalmoplegia (paralysis of eye muscles, nystagmus). IV thiamine must be administered before glucose to prevent worsening of the condition — glucose metabolism requires thiamine, and giving glucose without thiamine can deplete remaining stores and precipitate or worsen Wernicke's encephalopathy. If untreated, it can progress to Korsakoff syndrome, characterized by irreversible anterograde amnesia and confabulation. Benzodiazepines are used for alcohol withdrawal (tremors, seizures, delirium tremens) but not specifically for Wernicke's encephalopathy.

Question 4: A nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which recommendation should be included?

Lie down immediately after meals to promote digestion
Eat large meals to reduce the number of eating episodes
Elevate the head of the bed 6 to 8 inches (Correct answer)
Drink caffeinated beverages to stimulate motility

Correct answer: Elevate the head of the bed 6 to 8 inches

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

GERD occurs when the lower esophageal sphincter (LES) relaxes inappropriately, allowing gastric acid to flow back into the esophagus. Elevating the head of the bed 6-8 inches (using blocks under the bed legs or a wedge pillow, not just extra pillows) uses gravity to help keep gastric contents in the stomach during sleep. Additional lifestyle modifications include eating small, frequent meals (not large meals); remaining upright for at least 2-3 hours after eating; avoiding trigger foods (spicy, fatty, acidic, chocolate, peppermint); avoiding caffeine and alcohol (both decrease LES pressure); losing weight if overweight; quitting smoking; and wearing loose-fitting clothing. Lying down after meals and large meals both worsen reflux by increasing gastric pressure against a weakened LES.

Question 5: A client is being discharged after placement of a permanent pacemaker. Which instruction should the nurse include?

Avoid using microwave ovens permanently
Count your pulse daily and report rates below the set pacemaker rate (Correct answer)
You may resume contact sports after two weeks
The pacemaker battery never needs replacement

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

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

After permanent pacemaker placement, clients should learn to take their pulse daily for one full minute and report any rate below the set pacemaker rate to their provider, as this may indicate pacemaker malfunction (failure to capture or sense). Additional discharge instructions include: avoid lifting the arm on the pacemaker side above shoulder level for the first few weeks; avoid MRI (unless MRI-compatible pacemaker); carry a pacemaker identification card; inform all healthcare providers, including dentists; avoid direct pressure over the generator site; stay away from strong electromagnetic fields (industrial equipment, large magnets) but household appliances including microwave ovens are safe with modern pacemakers. Contact sports should be avoided permanently to protect the generator and leads. Pacemaker batteries typically last 5-15 years and will need replacement.

Question 6: A nurse is assessing a newborn 12 hours after birth. Which finding should be reported to the provider?

Jaundice appearing within the first 24 hours of life (Correct answer)
Milia across the nose and cheeks
Acrocyanosis of the hands and feet
Epstein pearls on the palate

Correct answer: Jaundice appearing within the first 24 hours of life

Jaundice appearing within the first 24 hours is pathological jaundice and requires immediate evaluation, as it may indicate hemolytic disease.

Jaundice appearing within the first 24 hours of life is considered pathological and requires urgent evaluation. Common causes include ABO or Rh incompatibility, G6PD deficiency, or infection. Physiological jaundice typically appears after 24 hours (usually day 2-3), peaks around day 3-5, and resolves by day 7-10 in term infants. Pathological jaundice can lead to dangerously high bilirubin levels and kernicterus (bilirubin encephalopathy) causing permanent brain damage. Treatment may include phototherapy or exchange transfusion. Milia (small white bumps from blocked sebaceous glands), acrocyanosis (bluish discoloration of hands and feet from immature peripheral circulation), and Epstein pearls (small white cysts on the palate) are all normal newborn findings that require no intervention.

NCLEX-PN Test #24 2

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?