1.

D
Klien yang mempunyai riayat infeksi streptokous dapat menyebabkan antibodi memroduksi
streptokinase tidak efektif. Terapi streptokinase berarti sebelumnya terkena streptokokus ,
infeksi pling umum yang menyebabkan radang tenggorokan dan nyeri menelan
2.B
3. B
. The drug rt-PA may be administered, but a
cerebrovascular accident (CVA) must be
verified by diagnostic tests prior to
administering it. rt-PA helps dissolve a
blood clot, and it may be administered if an
ischemic CVA is verified; rt-PA is not given
if the client is experiencing a hemorrhagic
stroke.
2. Teaching is important to help prevent
another CVA, but it is not the priority
intervention on admission to the emergency
department. Slurred speech indicates
problems that may interfere with teaching.
3. A CT scan will determine if the client is
having a stroke or has a brain tumor or
another neurological disorder. If a CVA
is diagnosed, the CT scan can determine
if it is a hemorrhagic or ischemic
accident and guide treatment.
4. The client may be referred for speech
deficits and/or swallowing difficulty, but
referrals are not priority in the emergency
department.
TEST-TAKING HINT: When “priority” is used
in the stem, all answer options may be
appropriate for the client situation, but
only one option is priority. The client must
have a documented diagnosis before
treatment is started.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive Level –
Synthesis.

4. D
objects; therefore, observing the client for
possible aspiration is not appropriate.
2. A semi-Fowler’s position is appropriate for
sleeping, but agnosia is the failure to
recognize familiar objects; therefore, this
intervention is inappropriate.
3. Placing suction at the bedside will help if
the client has dysphagia (difficulty
swallowing), not agnosia, which is failure to
recognize familiar objects.
4. A collaborative intervention is an
intervention in which another
health-care discipline—in this case,
occupational therapy—is used in the
care of the client.
TEST-TAKING HINT: Be sure to look at what
the question is asking and see if the answer
can be determined even if some terms are
not understood. In this case, note that the
question refers to “collaborative intervention.”
Only option “4” refers to collaboration
with another discipline.

5. C

9. 1. Potential for injury is a physiological

problem, not a psychosocial problem.
2. Expressive aphasia means that the client
cannot communicate thoughts but
understands what is being communicated;
this leads to frustration, anger,
depression, and the inability to verbalize
needs, which, in turn, causes the client to
have a lack of control and feel powerless.
3. A disturbance in thought processes is a
cognitive problem; with expressive aphasia
the client’s thought processes are intact.
4. Sexual dysfunction can have a psychosocial
component or a physical component, but it
is not related to expressive aphasia.
TEST-TAKING HINT: The test taker should
always make sure that the choice selected
as the correct answer matches what the
question is asking. The stem has the
adjective “psychosocial,” so the correct
answer must address psychosocial
needs.
Content – Medical: Category of Health Alteration
– Neurological: Integrated Nursing Process –
Diagnosis: Client Needs – Psychosocial Integrity:
Cognitive Level – Analysis

6D

1. Assessment is important, but with clients

with head injury the nurse must assume
spinal cord injury until it is ruled out with
x-ray; therefore, stabilizing the spinal cord
is priority.
2. Removing the client from the water is an
appropriate intervention, but the nurse
must assume spinal cord injury until it is
ruled out with x-ray; therefore, stabilizing
the spinal cord is priority.
3. Assessing the client for further injury is
appropriate, but the first intervention is
to stabilize the spine because the impact
was strong enough to render the client
unconsciousness.
4. The nurse should always assume that a
client with traumatic head injury may
have sustained spinal cord injury. Moving
the client could further injure the
spinal cord and cause paralysis; therefore,
the nurse should stabilize the cervical
spinal cord as best as possible prior
to removing the client from the water.
TEST-TAKING HINT: When two possible
answer options contain the same directive
word—in this case, “assess”—the test
taker can either rule out these two as
incorrect or prioritize between the two
assessment responses.

7. C

1. The client is at risk for seizures and does

not process information appropriately.
Allowing him to return to his occupation
as a forklift operator is a safety risk for
him and other employees. Vocational
training may be required.
2. “Cognitive” pertains to mental
processes of comprehension,
judgment, memory, and reasoning.
Therefore, an appropriate goal would
be for the client to stay on task for
10 minutes.
3. The client’s ability to dress self addresses
self-care problems, not a cognitive problem.
4. The client’s ability to regain bowel and
bladder control does not address cognitive
deficits
8. B
1. Spinal shock associated with SCI
represents a sudden depression of
reflex activity below the level of the
injury. T12 is just above the waist;
therefore, no reflex activity below the
waist would be expected.
2. Assessment of the movement of the upper
extremities would be more appropriate
with a higher level injury; an injury in the
cervical area might cause an inability to
move the upper extremities.
3. Complaints of a pounding headache are
not typical of a T12 spinal injury.
4. Hypotension (low blood pressure) and
tachycardia (rapid heart rate) are signs of

hypovolemic or septic shock, but these do

not occur in spinal shock.
TEST-TAKING HINT: If the test taker does
not have any idea what the answer is, an
attempt to relate the anatomical position
of keywords in the question stem to
words in the answer options is appropriate.
In this case, T12, mentioned in the
stem, is around the waist, so answer
options involving the anatomy above that
level (e.g., the upper extremities) can be
eliminated.
Content – Medical: Category of Health Alteration
– Neurological: Integrated Nursing Process –
Assessment: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Analysis
9. B

1. Oxygen is administered initially to

maintain a high arterial partial
pressure of oxygen (PaO2) because
hypoxemia can worsen a neurological
deficit to the spinal cord initially, but this
client is in the rehabilitation department
and thus not in the initial stages of the
injury.
2. Deep vein thrombosis (DVT) is a
potential complication of immobility,
which can occur because the client
cannot move the lower extremities as
a result of the L1 SCI. Low-dose
anticoagulation therapy (Lovenox)
helps prevent blood from coagulating,
thereby preventing DVTs.
3. The client is unable to move the lower
extremities. The nurse should do passive
ROM exercises.
4. A client with a spinal injury at C4 or
above would be dependent on a ventilator
for breathing, but a client with an L1 SCI
would not.
TEST-TAKING HINT: The test taker
should notice any adjectives such as
“rehabilitation,” which should clue the
test taker into ruling out oxygen, which
is for the acute phase. The test taker
should also be very selective if choosing
an answer with a definitive word such as
“all” (option “1”).
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Application.
10. B

37. 1. The nurse needs to protect the client from

injury. Moving furniture would help
ensure that the client would not hit
something accidentally, but this is not
done first.
2. This is done to help keep the airway
patent, but it is not the first intervention
in this specific situation.
3. Assessment is important but, when the
client is having a seizure, the nurse should
not touch him or her.
4. The client should not remain in the
chair during a seizure. He should be
brought safely to the floor so that he
will have room to move the extremities.
TEST-TAKING HINT: All of the answer
options are possible interventions, so the
test taker should go back to the stem of
the question and note that the question
asks which intervention has priority.
“In the chair” is the key to this question
because the nurse should always think
about safety, and a patient having a
seizure is not safe in a chair.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.

11. D
1. Antiseizure drugs, tranquilizers, stimulants,
and depressants are withheld before an
EEG because they may alter the brain
wave patterns.
2. Meals are not withheld because altered
blood glucose level can cause changes in
brain wave patterns.
3. The goal is for the client to have a
seizure during the EEG. Sleep deprivation,
hyperventilating, or flashing lights
may induce a seizure.
4. Electrodes are placed on the client’s scalp,
but there are no electroshocks or any type
of discomfort.
TEST-TAKING HINT: The test taker should
highlight the words “diagnose a seizure
disorder” in the stem and ask which answer
option would possibly cause a seizure.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Planning: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Synthesis.
12. D

1. Nervousness is not a symptom of a brain

tumor, and brain tumors rarely metastasize
outside of the cranium. Brain tumors kill by
occupying space and increasing intracranial
pressure. Although seizures are not uncommon
with brain tumors, seizures are not
part of the classic triad of symptoms.
2. The classic triad of symptoms
suggesting a brain tumor includes a
headache that is dull, unrelenting, and
worse in the morning; vomiting
unrelated to food intake; and edema of
the optic nerve (papilledema), which
occurs in 70% to 75% of clients
diagnosed with brain tumors.
Papilledema causes visual disturbances
such as decreased visual acuity and
diplopia.
3. Hypertension and bradycardia, not
hypotension and tachycardia, occur with
increased intracranial pressure resulting
from pressure on the cerebrum. Tachypnea
does not occur with brain tumors.
4. Abrupt loss of motor function occurs with a
stroke; diarrhea does not occur with a brain

mor, and the client with a brain tumor

does not experience a change in taste.
TEST-TAKING HINT: The test taker can rule
out option “4” because of the symptom of
diarrhea, which is a gastrointestinal symptom,
not a neurological one. Considering
the other three possible choices, the
symptom of “headache” would make
sense for a client with a brain tumor.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Analysis.
13. C

1. This is providing information and is not

completely factual. MRIs are loud, but
frequently the client will require an IV
access (an invasive procedure) to be started
for a contrast medium to be injected.
2. This is restating and offering self.
Both are therapeutic responses.
3. This statement is belittling the client’s
feeling.
4. This is not dealing with the client’s
concerns and is passing the buck. The
nurse should explore the client’s feeling
to determine what is concerning the
client. The MRI may or may not be the
problem. The client may be afraid
of the results of the MRI.

TEST-TAKING HINT: When the question

asks the test taker for a therapeutic
response, the test taker should choose
the response that directly addresses the
client’s feelings.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Implementation: Client Needs –
Physiological Integrity, Reduction of Risk Potential:
Cognitive Level – Application.
14. C

1. A headache after this surgery would be an

expected occurrence, not a complication.
2. An output much larger than the intake
could indicate the development of
diabetes insipidus. Pressure on the
pituitary gland can result in decreased
production of vasopressin, the
antidiuretic hormone.
3. A raspy sore throat is common after
surgery due to the placement of the
endotracheal tube during anesthesia.
4. Dizziness on arising quickly is expected;
the client should be taught to rise slowly
and call for assistance for safety.
TEST-TAKING HINT: The test taker could
eliminate options “1” and “3” as expected
occurrences following the surgery and not
complications. Option “4” can also be
expected.
Content – Surgical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Assessment: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Analysis.

Meningitis

15 . A
1. This is a definition of aseptic meningitis,
which refers to irritated meninges from
viral or noninfectious sources.
2. This is another example of aseptic
meningitis, which refers to irritated
meninges from viral or noninfectious
sources.
3. Septic meningitis refers to meningitis
caused by bacteria; the most common
form of bacterial meningitis is caused
by the Neisseria meningitides bacteria.
4. This is the explanation for encephalitis.
TEST-TAKING HINT: The nurse should
explain the client’s diagnosis in layperson’s
terms when the stem is identifying the
significant other as asking the question. Be
sure to notice that the adjective “septic” is
the key to answering this question, ruling
out options “1” and “2.”
Content – Medical: Category of Health Alteration
– Neurological: Integrated Nursing Process –
Implementation: Client Needs – Physiological
Integrity, Physiological Adaptation: Cognitive
Level – Application.
16 . A
1. A nurse administering antibiotics is a
collaborative intervention because the
HCP must write an order for the
intervention; nurses cannot prescribe
medications unless they have additional
education and licensure and are nurse
practitioners with prescriptive
authority.
2. The nurse needs an order to send a
culture to the laboratory for payment

purposes, but the nurse can obtain a

specimen without an order. A sputum
specimen is not appropriate for meningitis.
3. A pulse oximeter measures the amount of
oxygen in the periphery and does not
require an HCP to order.
4. Intake and output are independent nursing
interventions and do not require an HCP’s
order.
TEST-TAKING HINT: The test taker must
note adjectives and understand that a
collaborative nursing intervention is
dependent on another member of the
health-care team; an independent nursing
intervention does not require collaboration.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Diagnosis: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Analysis.
17.

1. Dementia involves behavior changes that

are irreversible and occur over time.
Delirium, however, occurs suddenly (as in
this man’s symptom onset), is caused by an
acute event, and is reversible.

2. Drug toxicity and interactions are

common causes of delirium in the
elderly.
3. This is blaming the family member for the
client’s paranoid ideation.
4. Watching old movies on television will not
cause delirium.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive Level –
Application.

18. D

1. Symptoms of marijuana use are apathy,

delayed time, and not wanting to eat.
2. Heroin symptoms include pupil changes
and respiratory depression.
3. Ecstasy is a hallucinogen that is an
“upper.”
4. Disorderly behavior and the symptoms
of epistaxis and nasal congestion
would make the nurse suspect cocaine
abuse.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Evaluation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive Level –
Analysis.

19. C
In order of priority: 3, 2, 1, 5, 4.
3. Stabilizing the client’s neck is priority
action to prevent further injury to the
client, and it must be done prior to
moving the client

2. The nurse should assess for any other

injuries prior to moving the client from
the vehicle.
1. Because the vehicle is leaking fuel and
there is potential for an explosion or
fire, the client should be moved to an
area of safety.
5. Placing the client in a functional
anatomical position is an attempt to
prevent further spinal cord injury.
4. Because the vehicle is leaking fuel, the
priority is to remove the client and
then obtain emergency medical
assistance.

20. B

1. This would be done for thrombocytopenia

(low platelets), not neutropenia (low white
blood cells).
2. Fresh fruits and flowers may carry bacteria
or insects on the skin of the fruit
or dirt on the flowers and leaves, so they
are restricted around clients with low
white blood cell counts.
3. Clients with severe neutropenia may be
placed in reverse isolation, but not all
clients with neutropenia will be placed in
reverse isolation. Clients are at a greater
risk for infecting themselves from endogenous
fungi and bacteria than from being
exposed to noninfectious individuals.
4. This is an intervention for thrombocytopenia.
TEST-TAKING HINT: The test taker must
match the problem with the answer option.
Options “1” and “4” would probably be
implemented for the client with a bleeding
disorder. Option “3” has the word “all” in
it, which would make the test taker not
select this option.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management
21. B

1. The anemia that occurs in leukemia is not

related to iron deficiency, and eating foods
high in iron will not help.
2. The platelet count of 22 103/mm3
indicates a platelet count of 22,000. The
definition of thrombocytopenia is a
count less than 100,000. This client is at
risk for bleeding. Bleeding precautions
include decreasing the risk by using
soft-bristle toothbrushes and electric
razors and holding all venipuncture sites
for a minimum of five (5) minutes.
3. The sodium level is within normal limits.
The client is encouraged to eat whatever he
or she wants to eat unless some other
disease process limits food choices

4. The client is at risk for infection, but

unless the family or significant others are
ill, they should be encouraged to visit
whenever possible.
TEST-TAKING HINT: The test taker could
eliminate option “3” on the basis of a
normal laboratory value. The RBC, WBC,
and platelet values are all not in normal
range. The correct answer option must
address one of these values.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process – Planning:
Client Needs – Physiological Integrity, Reduction of
Risk Potential: Cognitive Level – Synthesis.
22. A
1. The rugae in the stomach produce
intrinsic factor, which allows the body
to use vitamin B12 from the foods
eaten. Gastric bypass surgery reduces
the amount of rugae drastically. Clients
develop pernicious anemia (vitamin B12
deficiency). Other symptoms of anemia
include dizziness and the tachycardia
and dyspnea listed in the stem.
2. Folic acid deficiency is usually associated
with chronic alcohol intake.
3. Iron deficiency is the result of chronic
blood loss or inadequate dietary intake of
iron.
4. Sickle cell anemia is associated with
African Americans, but the symptoms and
history indicate a different anemia.
TEST-TAKING HINT: The question did not
give a lifetime history of anemia, which
would be associated with sickle cell disease.
The stem related a history of obesity
and surgery. The test taker should look
for an answer related to intake of vitamins
and minerals. A review of the anatomy of
the stomach is the key to the question.
Content – Medical: Category of Health
23. C
1. The nurse should monitor the hemoglobin
and hematocrit in all clients diagnosed
with anemia.
2. Because decreased oxygenation levels
to the brain can cause the client to
become confused, a room where the
client can be observed frequently—
near the nurse’s desk—is a safety issue.
3. The client should include leafy green vegetables
in the diet. These are high in iron.
4. Numbness and tingling may occur in
anemia as a result of neurological
involvement.
5. Fatigue is the number-one presenting
symptom of anemia.
TEST-TAKING HINT: This is an alternativetype
question requiring the test taker to
select multiple correct answers. The test
taker could eliminate option “3” because
the only clients told to limit green leafy
vegetables are those receiving Coumadin,
an oral anticoagulant.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process – Diagnosis:
Client Needs – Safe Effective Care Environment,
Management of Care: Cognitive Level – Analysis
24.C

1. The client must give permission to

receive blood or blood products
because of the nature of potential
complications.
2. Most blood products require at least a
20-gauge IV because of the size of the cells.
RBCs are best infused through an 18-gauge
IV. If unable to achieve cannulation with an
18-gauge, a 20-gauge is the smallest acceptable
IV. Smaller IVs damage the cell walls
of the RBCs and reduce the life expectancy
of the RBCs.
3. Because infusing IV fluids can cause a
fluid volume overload, the nurse must
assess for congestive heart failure.
Assessing the lungs includes auscultating
for crackles and other signs of
left-sided heart failure. Additional
assessment findings of jugular vein
distention, peripheral edema, and liver
engorgement indicate right-sided
failure.
4. Checking for allergies is important
prior to administering any medication.
Some medications are administered
prior to blood administration.
5. A keep-open IV of 0.9% saline would be
hung. D5W causes red blood cells to
hemolyze in the tubing.
TEST-TAKING HINT: This is an alternativetype
question. This type of question can

appear anywhere on the NCLEX-RN

examination. Each answer option must be
evaluated on its own merit. One will not
rule out another. Assessing is the first
step of the nursing process. Unless the
test taker is absolutely sure that an option
is wrong, the test taker could select an
option based on “assessing,” such as
options “3” and “4.” Ethically speaking,
informed consent should always be given
for any procedure unless an emergency
life-or-death situation exists. The other
options require knowledge of blood and
blood product administration.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Application..
25. B

1. This should be done, but the client requires

the IV first. This client is at risk for
shock.
2. The first action in a situation in which
the nurse suspects the client has a fluid
volume loss is to replace the volume as
quickly as possible.
3. The client will probably need to have
surgery to correct the source of the bleeding,
but stabilizing the client with fluid
resuscitation is first priority.
4. This is the last thing on this list in order
of priority.
TEST-TAKING HINT: The question requires
the test taker to decide which of the actions
comes first. Only one of the options
actually has the nurse treating the client.
The test taker must not read into a
question—for example, that consent is
needed to send a client to surgery to
correct the problem, so that could be
first. Only one answer option has the
potential to stabilize the client.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Synthesis
26. A

O– (O-negative) blood is considered

the universal donor because it does not
contain the antigens A, B, or Rh.
(ABis considered the universal recipient
because a person with this blood
type has all the antigens on the blood.)
2. Ablood contains the antigen A that the
client will react to, causing the development
of antibodies. The unit being Rhis
compatible with the client.
3. Bblood contains the antigen B that the
client will react to, causing the development
of antibodies. The unit being Rhis
compatible with the client.
4. This client does not have antigens A or B
on the blood. Administration of these
types would cause an antigen-antibody reaction
within the client’s body, resulting in
massive hemolysis of the client’s blood and
death.
27. B

1. This is the etiology for sickle cell anemia

(SCA), but a layperson would not understand
this explanation.
2. This explains the etiology in terms that
a layperson could understand. When
both parents are carriers of the disease,
each pregnancy has a 25% chance of
producing a child who has sickle cell
anemia.
3. The cause of SCA is known, and genetic
counseling can explain it to the prospective
parent.
4. A virus does not cause sickle cell anemia.
TEST-TAKING HINT: When discussing disease
processes with laypersons, the nurse
should explain the facts in terms that the
person can understand. Would a layperson
know what “autosomal recessive” means
The test taker should consider terminology
when selecting an answer.
Content – Medical: Category of Health
Alteration – Hematology: Integrated Nursing

28 . E
1. Chest syndrome refers to chest pain, fever,
and a dry, hacking cough with or without
pre-existing pneumonia, and is not a fatal
complication. It can occur in either
gender.
2. Compartment syndrome is a complication
of a cast that has been applied too tightly
or a fracture in which there is edema in a
muscle compartment.
3. This is a term that means painful and
constant penile erection that can occur
in male clients with SCA during a
sickle cell crisis.
4. A hypertensive crisis is potentially fatal,
but it is not a complication of SCA. The
client with sickle cell anemia usually has
cardiomegaly or systolic murmurs; both
genders have this.
TEST-TAKING HINT: This is a knowledgebased
question, but if the test taker
realized that priapism could only occur in
males, this might help the test taker select
option “3” as a correct answer. Whenever
there is a gender for the client, it usually
has something to do with the correct
answer.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process – Diagnosis:
Client Needs – Physiological Integrity, Physiological
Adaptation: Cognitive Level – Analysis.
29. B

1. The normal RBC is 4.7 to 6.1 (106) for

males and 4.2 to 5.4 (106) for females.
The RBC is within normal limits.
2. All the laboratory values are within normal
limits. The nurse should continue
to monitor the client.
3. The normal WBC is 4.5 to 11 (103), so a
biologic response modifier to increase the
numbers of WBCs is not needed.
4. Thrombocytopenia does not occur until
the client’s platelet count is less than 100
(103); there is no reason to institute
bleeding precautions.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective
Care Environment, Management of Care: Cognitive
Level – Application
30. B

1. Thrombocytopenia is low platelets and

would not cause shortness of breath.
2. Because thrombocytopenia causes
bleeding, the nurse should assess for
any type of bleeding that may be occurring.
A young female client would
present with excessive menstrual
bleeding.
3. The problems associated with ITP are
bleeding, not clotting.
4. ITP does not cause migraine headaches.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process – Assessment:
Client Needs – Physiological Integrity, Reduction of Risk
Potential: Cognitive Level – Analysis.