1.

The nurse assesses a client with dizziness and identifies the following client findings: Acute
vestibular neuronitis, spontaneous horizontal nystagmus, and staggering gait. The nurse should
recognize these findings indicate
a. hearing loss.
b. sinusitis.
c. vertigo.*
d. otitis media.
Rationale: the symptoms of vestibular neuronitis, spontaneous nystagmus, and staggering gait
are indicative of Vertigo.
Blooms level: Application
NCLEX test plan: Physiological Adaptation

2. A client is scheduled to start taking warfarin (Coumadin). A nurse should teach the client to
observe for side effects, which include bleeding gums, nose bleeds, and
a. increased urine output.
b. prolonged bleeding from a cut.*
c. elevated blood pressure.
d. decreased pulse rate.
Rationale: Prolonged bleeding from a cut is a side effect of Coumadin therapy.
Blooms Level: Application
NCLEX test plan: Pharmacological therapies

3. Which of the following data would be most important for a nurse to obtain when assessing a
client who has a head injury?
a. Employment history: type of work, use of helmet, exposure to toxins
b. Associated symptoms: pain, blurred vision, discharge from nose or ears*
c. Family history: headaches, thyroid dysfunction
d. Medical history: past surgeries, diagnosis
Rationale: Associated symptoms of a head injury would be the most important data to obtain
when assessing a client with a head injury.
Blooms Level: Application
NCLEX test plan: Physiological Adaptation

4. Which of the following manifestations, if identified in a client with a fractured femur, should a
nurse associate with the development of a pulmonary embolism?
a. Tingling to upper extremities
b. Pleuritic chest pain, dyspnea*
c. Edema to fracture site
d. Headache, malaise
Rationale: Pleuritic chest pain and dyspnea are signs of a pulmonary embolism.
Blooms Level: Analysis
NCLEX test plan: Physiological Adaptation