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Nursing Practice Set a 2011

Nursing Practice Set a 2011

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Published by: Nheil Restie D'Great on Jul 10, 2011
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Neurology, Fluid and Electrolytes and DisasterNursing
2011
NURSING PRACTICE IV SET A ________________________________________________________________________ 
NURSING PRACTICE: Medical Surgical Nursing
GENERAL INSTRUCTIONS:
1.This test booklet contains 100 test questions.2.Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.3.Shade only one (1) box for each question on your answer sheets. Two or more boxesshaded will invalidate your answer.4.AVOID ERASURES.5.This is
PRC property.
Unauthorized possession, reproduction, and/or sale of this test ispunishable by law. Per RA 8981.
 ________________________________________________________________________ 
INSTRUCTIONS:
1.Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.2.Write the subject title
“Nursing Prace: Medical Surgical Nursing”
on the boxprovided.3.Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if yourtestbooklet is Set B.===============================================================================================
Situation - Ms. May Mansurencountered vehicular accident onher way to the office and he remainsconscious. Police officers broughther to the hospital.
1.
You have to observe for increaseintracranial pressure. Which of thefollowing is not a sign of increasedintracranial pressure?a. Headacheb. Vomiting
c.
Vertigo
 
d. Changes on the level of consciousness
2.
Which of the following drug may begiven to reduce increaseintracranial pressure?a. Scopalamineb. Lanoxinc. Coumadin
d.
Mannitol 
 
3.
Since she medicated to reduceincreased intracranial pressure.What nursing measure must bedone to prevent furthercomplication?a. Encourage her to observe bedrestb. Check blood pressure every shiftc. Observe complete best rest
d.
Measure intake and output 
 
4.
In what manner would you be ableto assess accurately her motorstrength?a. Observe how he talks
b.
Instruct her to squeeze her hands
 
c. Allowing him to stand aloned. Pricking her skin with pin
5.
Which of the following activitieswould cause her a risk in theincrease of intracranial pressure?
a.
Coughing
 
b. Readingc. Turningd. Sleeping
Situation: Richard Gabatan, a 32-year-old car salesman, suffered aspinal cord injury in a motor vehicleaccident resulting to paraplegia.
 
Neurology, Fluid and Electrolytes and DisasterNursing
2011
6.
A nurse finds Mr. Gabatan underthe wreckage of the car. He isconscious, breathing satisfactorily,and lying on the back complainingof pain in the back and an inabilityto move his legs. The nurse shouldfirst:a. Leave Mr. Gabatan lying on hisback with instructions to move andthen go seek additional helpb. Gently raise Mr. Gabatan to asitting position to see if the paineitherc. Roll Mr. Gabatan on hisabdomen, place, a pad under hishead, and coverhim with any material availabled. Gently lift Mr. Gavatan into a flatpiece of lumber and using anyavailable transportation, rush himto the nearest medical institution
7.
Once admitted to hospital thephysician indicates that Mr.Gubatan is a paraplegic. The familyasks the nurse what that means. The nurse explains that:a. Upper extremities are paralyzed
b.
Lower extremities are paralyzed 
 
c. One side of the body is paralyzedd. Both lower and upperextremities are paralyzed
8.
 The nurse recognizes that themajor early problem for Mr.Gabatan will be:
a.
Bladder control 
b. Client educationc. Quadriceps settingd. Use of aids for ambulation
9.
 The nurse should expect Mr.Gabatan to have some spasticity of the lower extremities. To preventthe development of contractures,careful consideration must begiven to:a. Active exerciseb. Deep massagec. Use of tilt board
d.
Proper positioning
 
10.
Rehabilitation plans for Mr.Gabatan;a. Should be left up to Mr. Gabatanand his family
b.
Should be considered and  planned for early in his care
 
c. Are not necessary, because hewill return to former activitiesd. Are not necessary, because hewill probably not able to work again11.A client is somewhat nervousabout having magnetic resonanceimaging (MRI). Which statement bythe nurse would provide the mostreassurance to the client about theprocedure?
a.Even though youare alone in the scanner,you will be in voicecommunication with thetechnologist at all timesduring the procedure”
b.It is necessary toremove any metal/ metalcontaining objects beforehaving the MRI done, toavoid the metal being drawninto the magnetic field”c.MRI machine is long,hollow, narrow tube, andmake you feel somewhatclaustrophobic”d.You will be able to eatbefore the procedure unlessyou get nauseous easily. If so, you should eat lightly”12.A nurse is providinginformation to a client scheduledfor a lumbar puncture. Whichinformation will the nurse provideto the client?
a.an informed consent form willbe required
b.food and fluids will be restricteduntil after the test
 
Neurology, Fluid and Electrolytes and DisasterNursing
2011
c.there is no need to maintain bedrest after the testd.the test will probably take about 2hours13.A nurse develops a plan ocare for a client after a lumbarpuncture. Which of the followingnursing interventions is notincluded in the plan of care?a.assess the client’s ability to voidand move extremitiesb.inspect puncture site for swelling,redness and drainagec.maintain client in flat position
d.restrict fluid intake for a periodof 2 hours
14.A nurse has formulated anursing diagnosis of IneffectiveBreathing Pattern for a client withneurological disorder. The nursewould avoid including which of thefollowing activities in the care planfor this client?a.elevate the head of the bed 30degrees
b.keep the client lying in supineposition
c.keep the head and neck in goodalignmentd.keep suction equipment availableat bedside15.A nurse is caring for a clientwith an intracranial pressure (ICP)monitoring device. The nurse wouldbecome most concerned if the ICPreadings drifted and stayed in thevicinity of which level?a.3 mmHgb.8 mmHgc.11 mmHg
d.15 mmHg16.Aclient is admitted forovernight observationfollowing a blow to the headduring a baseball game. Whichof the following assessmentswarrants immediate nursingaction?
a. Widening pulse pressure andbradycardiab. Narrowing pulse pressure andtachycardiac. Increasing respiration andirregular pulse rate
d. Narrowing pulse deficitand decreased level oconsciousness
17.A client with a spinal cordinjury at the level of C5 hasweakened respiratory effort andineffective cough, and is usingaccessory neck muscles inbreathing. The nurse carefullymonitors the client, and formulateswhich of the following nursingdiagnosis?a.Impaired gas exchange
b.ineffective breathing pattern
c.risk for aspirationd.risk for injury
18.Aclient is transferring to a chairfor the first time following aposterior spinal fusion. Toassist the client, the nurseshould first
a.secure a mechanical lift totransfer the client from bedto chair.
b.
have the client roll on hisside, bend his
 
knees, andsit up with assistancewithout
 
bending histrunk.
c.pull the client to a sittingposition using his arms andturn him to dangle on theside of the bed.d.call physical therapy tosupervise the transfer of theclient.19.A nurse in the neurologicalunit is caring for a client with asupratentorial lesion. The nurseassesses which of the following as

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