NCLEX PN Practice Test with NGN Practice Question
Scenario/Extract:
The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation
Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally
Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension
Musculoskeletal
Right-sided lower extremity weakness is seen
Endocrine
The client has diabetes mellitus
Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.
Select findings that require immediate follow-up.
Correct Answer: B, G
Rationale: Sudden-onset right-sided facial drooping (B) and lower extremity weakness (G) are signs of a possible stroke, requiring urgent evaluation. Being alert (A), normal pupils (C), and normal respiratory rate (D) are stable findings. Hypertension (E) and diabetes (F) are chronic and less urgent in this context.
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