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40. For a client who has ataxia, which of the following tests would
be performed to assess the ability to ambulate?
a. Kernig's
b. Romberg's
c. Riley-Day's
d. Hoffmann's
Answer: b
Rationale: Romberg's test is the ability to maintain an upright position without swaying
when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction,
is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.
41. A client admitted to a surgical unit for possible bleeding in the cerebrum
has vital signs taken every hour to monitor to neurological status. Which
of the following neurological checks will give the nurse the best information
about the extent of bleeding?
a. Pupillary checks
b. Spinal tap
c. Deep tendon reflexes
d. Evaluation of extrapyramidal motor system
Answer: a
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as it becomes displaced by blood, tumor, etc.
42. Assessing for immediate postoperative complications, the nurse knows that
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a. Hemorrhage
b. Infection
c. Pneumonia
d. Pulmonary embolism
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43. A young client is in the hospital with his left leg in Buck's traction. The
team leader asks the nurse to place a footplate on the affected side at the
bottom of the bed. The purpose of this action is to
a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot
Answer: b
Rationale: The purpose of the footplate is to prevent footdrop while the client is
immobilized in traction. This will not anchor the traction, keep the client from sliding
down in bed, or prevent pressure areas.
Respiratory Disorders NCLEX Review
January 12, 2011
1. A Mantoux test signifies exposure to Mycobacterium Tubercle Bacilli. The test is read for how many hours after injection?
2. A nurse is about to perform a Mantoux test. The test is done by using which route?
3. A client is suspected to have an HIV. The nurse knows that in the Mantoux test result, a client is considered positive with HV if he has an induration of:
Answers: 1. Answer: C. Mantoux test is read 48-72 hours after injection.
2. Answer: A. Mantoux tests are done intradermally.
3. Answer: D. Mantoux test is considered positive for Mycobacterium Tubercle Bacilli if the induration is 10 mm or more. For HIV positive clients, induration of 5mm is considered positive.
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