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.
Which 3 additional findings or diagnostic results are most important to plan care for this client?
Correct Answer: B, C, E
Rationale: A CT scan (C) is critical to diagnose stroke type. A standardized stroke assessment (E) evaluates severity and guides treatment. Capillary glucose (B) ensures hypoglycemia is not contributing to symptoms. Blood alcohol level (A) is less relevant with minimal alcohol history. EEG (D) is not urgent for suspected stroke.
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