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NGNclex Questions - 05.05.2023


NGN Drop - Down Close Q.: The nurse is monitoring a client who has a head injury. The client was admitted to the neurological unit. he has alert and oriented. He is complaining of a headache and pain level is 4/10.He is restless. His pupils is slow to react. His Glasgow Coma Scale is 11. His vitals; T: 39 C, HR: 59 bpm, RR: 19 bpm and irregular, BP 155/73 mmHg.


The nurse analysis his assessment data and recognizes that he most likely has ________ (1). The priority for his care is to ensure _________ (2).


Options for 1

1-Aneurysm

2-Intracranial pressure

3-Autonomic dysreflexia

Options for2

4- Monitor neurological status

5- Initiate seizure precautions

6-Monitor for dysrhythmias

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