Neurology, Fluid and Electrolytes and Disaster 2011 Nursing

NURSING PRACTICE IV SET A ________________________________________________________________________ NURSING PRACTICE: Medical Surgical Nursing

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 boxes shaded will invalidate your answer. 4. AVOID ERASURES. 5. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is punishable 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 box provided. 3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B.

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Situation - Ms. May Mansur encountered vehicular accident on her way to the office and he remains conscious. Police officers brought her to the hospital.

a. Encourage her to observe bed rest b. Check blood pressure every shift c. Observe complete best rest d. Measure intake and output

You have to observe for increase intracranial pressure. Which of the following is not a sign of increased intracranial pressure? a. Headache b. Vomiting c. Vertigo d. Changes on the level of consciousness

In what manner would you be able to assess accurately her motor strength? a. Observe how he talks b. Instruct her to squeeze her hands c. Allowing him to stand alone d. Pricking her skin with pin

2. Which of the following drug may be

5. Which of the following activities

given to reduce increase intracranial pressure? a. Scopalamine b. Lanoxin c. Coumadin d. Mannitol
3. Since she medicated to reduce

would cause her a risk in the increase of intracranial pressure? a. Coughing b. Reading c. Turning d. Sleeping Situation: Richard Gabatan, a 32year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.

increased intracranial pressure. What nursing measure must be done to prevent further complication?

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
6. A nurse finds Mr. Gabatan under

the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first: a. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help b. Gently raise Mr. Gabatan to a sitting position to see if the pain either c. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover him with any material available d. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
7. Once admitted to hospital the

a. Active exercise b. Deep massage c. Use of tilt board d. Proper positioning
10. Rehabilitation plans for Mr.

Gabatan; a. Should be left up to Mr. Gabatan and his family b. Should be considered and planned for early in his care c. Are not necessary, because he will return to former activities d. Are not necessary, because he will probably not able to work again 11. A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure? a. “Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure” b. “It is necessary to remove any metal/ metal containing objects before having the MRI done, to avoid the metal being drawn into the magnetic field” c. “MRI machine is long, hollow, narrow tube, and make you feel somewhat claustrophobic” d. “You will be able to eat before the procedure unless you get nauseous easily. If so, you should eat lightly” 12. A nurse is providing information to a client scheduled for a lumbar puncture. Which information will the nurse provide to the client? a. an informed consent form will be required b. food and fluids will be restricted until after the test

physician indicates that Mr. Gubatan is a paraplegic. The family asks 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 paralyzed d. Both lower and upper extremities are paralyzed
8. The nurse recognizes that the

major early problem for Mr. Gabatan will be: a. Bladder control b. Client education c. Quadriceps setting d. Use of aids for ambulation

9. The nurse should expect Mr.

Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
c. there is no need to maintain bed rest after the test d. the test will probably take about 2 hours 13. A nurse develops a plan of care for a client after a lumbar puncture. Which of the following nursing interventions is not included in the plan of care? a. assess the client’s ability to void and move extremities b. inspect puncture site for swelling, redness and drainage c. maintain client in flat position d. restrict fluid intake for a period of 2 hours 14. A nurse has formulated a nursing diagnosis of Ineffective Breathing Pattern for a client with neurological disorder. The nurse would avoid including which of the following activities in the care plan for this client? a. elevate the head of the bed 30 degrees b. keep the client lying in supine position c. keep the head and neck in good alignment d. keep suction equipment available at bedside 15. A nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted and stayed in the vicinity of which level? a. b. c. d. 3 mmHg 8 mmHg 11 mmHg 15 mmHg A client is admitted for overnight observation following a blow to the head during a baseball game. Which of the following assessments warrants immediate nursing action? a. Widening pulse pressure and bradycardia b. Narrowing pulse pressure and tachycardia c. Increasing respiration and irregular pulse rate d. Narrowing pulse deficit and decreased level of consciousness 17. A client with a spinal cord injury at the level of C5 has weakened respiratory effort and ineffective cough, and is using accessory neck muscles in breathing. The nurse carefully monitors the client, and formulates which of the following nursing diagnosis? a. b. c. d. Impaired gas exchange ineffective breathing pattern risk for aspiration risk for injury A client is transferring to a chair for the first time following a posterior spinal fusion. To assist the client, the nurse should first a. secure a mechanical lift to transfer the client from bed to chair. b. have the client roll on his side, bend his knees, and sit up with assistance without bending his trunk. c. pull the client to a sitting position using his arms and turn him to dangle on the side of the bed. d. call physical therapy to supervise the transfer of the client. 19. A nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which of the following as



Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
the most critical index of central nervous system dysfunction? a. b. c. d. Ability to speak blood pressure level of consciousness temperature with this deficit, the nurse plans care activities that will: a. encourage communication b. increase client’s awareness of the affected side c. promote adequate bowel elimination d. provide a consistent daily routine 24. T he best position for the client who is admitted with risk of increased intracranial pressure from a concussion would be: a. b. c. d. Trendelenburg. Semi-fowler's. Sim’s lateral. Supine

20. A client is experiencing chronic insomnia. The nurse interprets that which of the following areas of the nervous system is involved? a. hippocampus and frontal lobe b. limbic system and cerebral hemispheres c. reticular activating system & cerebral hemisphere d. temporal lobe & frontal lobe 21. A nurse is teaching a paraplegic client measures to maintain skin integrity. Which of the following instructions will be least helpful to the client? a. checking the bottom sheet for wetness & wrinkles b. shifting weight every 2 hours while in wheelchair c. using a mirror to inspect for the redness & breakdown twice a week d. using a pressure relief pad while in a wheelchair 22. A nurse is developing a plan of care for a client with cerebrovascular accident (CVA) who has dysphagia. Which of the following would not be a component of the plan of care? a. assess for the presence of swallow reflex b. place the food on the affected side of the mouth c. provide ample time for the client to chew and swallow d. thicken the liquids 23. A nurse is caring for a client with diagnosis of cerebrovascular accident (CVA) with anosognosia. To meet the needs of the client

25. A client with stroke has right sided hemianopsia. The nurse plans to do which of the following to help the client adapt to this visual deficit? a. ensure that the family brings the client’s eyeglasses to hospital b. place all objects within the left visual field c. place all the objects within the right visual field d. teach the client to scan the environment 26. A client has residual difficulty with chewing food after experiencing a cerebrovascular accident. The nurse interprets that the client has residual dysfunction of which of the following cranial nerves (CN)? hypoglossal (CN XII) spinal accessory (CN XI) trigeminal (CN V) vagus (CN X) 27. The client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety?

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
a. check the temperature of the food on the dietary tray b. provide clear path for ambulation without obstacles c. speak loudly to the client d. test the temperature of shower water 28. A nurse is providing instructions to a client with seizure disorder who will be taking phenytoin (Dilantin). Which statement if made by the client indicates that the client understands the information about this medication? a. “I need to perform good oral hygiene, including brushing and flossing my teeth” b. “I should monitor for side effects and adjust my medication dose depending on how severe the side effects are” c. “I should take the medication before coming to the laboratory to have blood level drawn” d. “I should try to avoid alcohol but if I’m not able to I can drink alcohol in moderation” 29. A nurse is documenting in the record of a client who experienced a tonic clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of seizure? a. Body stiffening b. brief flexion of extremities c. sudden loss of consciousness d. violent extension spasm of entire body 30. A nurse is performing an assessment of a client suspected of having trigeminal neuralgia (tic doloreux). Which of the following assessment questions would elicit data specific to this disorder? a. “Have you had any numbness and tingling in your face?” b. “Have you had any facial paralysis?” c. “Have you had any sharp pain or any twitching in any part of your face?” d. “Have you noticed that your eyelid has been drooping?” 31. A client with trigeminal neuralgia asks the nurse what causes the painful episodes associated with the condition. The nurse’s response is based on an understanding that the symptoms can be triggered by which of the following? a. hypoglycemic effect on the cranial nerve b. local reaction to nasal stuffiness c. release of cathecholamines with infection/ stress d. stimulation of the affected nerve by pressure & temperature 32. A nurse performing an assessment of a client with a diagnosis of Bell’s palsy, the nurse would expect to observe which of the following in the client? a. b. c. d. facial drooping periorbital edema ptosis of eyelid twitching on affected side of face

33. Which of the following pathophysiological changes in the brain causes the sign and symptoms of alzheimer’s disease? a. atrophy of frontal lobe b. degeneration of cholinergic system c. glucose inadequacy d. intracranial bleeding in limbic system 34. A client with Alzheimer’s disease becomes extremely agitated. Which of the following initial nursing measures should be

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
implemented client? a. b. c. d. to calm the Which of the following indicates (+) MG? a. An increase in joint pain following administration of medications b. an increase in muscle strength within 1-3 minutes c. a decrease in muscle strength d. an exacerbation of client’s weakness 39. A nurse has provided instructions to an elderly client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? a. “I can change the time of my medication on the mornings that I feel stronger” b. “If I get abdominal cramps and diarrhea, I should call my doctor” c. “I should cough and deep breathe many times during the day” d. “I will rest afternoon after my walk” 40. A client is admitted with exacerbation of multiple sclerosis (MS). The nurse is assessing the client for possible precipitating factors. Which of the following factors, if stated by the client, would the nurse assess as being unrelated to the exacerbation? a. b. c. d. a recent bout of flu a stressful week at work inability to sleep well ingestion of more fruits and vegetables

Brighten the lights Raise the side rails Ambulate the client Play soft music

35. A client with Alzheimer’s disease mumbles incoherently and rambles in a confused manner. To help redirect the client’s attention, the nurse should encourage the client to: a. fold towels and pillow cases b. participate in board games c. perform an aerobic exercise d. play cards with another client 36. A client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. excess medication b. increased intake of fatty foods c. omitted doses of medication d. too little exercise 37. A home nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals because of decreased muscle strength. Which of the following suggestions would the nurse avoid giving to the client? a. cut food into small pieces, chewing thoroughly b. lift the head while swallowing liquids c. sit straight up in the chair while eating d. swallow when the chin is tipped slightly downward to the chest 38. A client with myasthenia gravis received Tensilon test.

41. A home health nurse has been discussing interventions to prevent constipation with a client with multiple sclerosis (MS). The nurse would evaluate that the client is using the information most effectively if the client reports which of the following? a. drinking total of 1500 ml/day

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
b. initiating a bowel movement every other day, 45 minutes after largest meal of day c. taking stool softeners daily, glycerine suppository once a week d. use of enema every morning before breakfast 42. A client with Parkinson’s disease has a nursing diagnosis of Risk for Falls related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait? a. b. c. d. accelerating with walking on toes broad based and waddling shuffling and propulsive unsteady and staggering 45. A nurse is preparing for the admission of a client with a suspected diagnosis of GuillainBarre syndrome. The client arrives on the nursing unit and the nurse is reviewing the physician’s documentation. The nurse expects to note documentation of which of the following hallmark clinical manifestations of this syndrome? a. Abrupt onset of fever and headache b. altered level of consciousness c. development of progressive muscle weakness d. multifocal seizure 46. The client with Guillain Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with his illness? a. giving client full control over care decisions and restricting visitors b. providing information, giving positive feedback, and encouraging relaxation c. providing intravenously administered sedatives, reducing distractions, and limiting visitors d. providing positive feedback and encouraging active range of motion 47. After a cataract surgery, a client is taught to avoid strain on the operative eye. Which of the following statements if made by the client would alert the nurse that further teaching is needed? a. “I can lie on my operative site” b. “I cannot lift more than 5 lbs” c. “I cannot rub my eye” d. “I need to take stool softeners to prevent straining”

43. A nurse has given instructions to a client with Parkinson’s disease about maintaining mobility. The nurse would evaluate that the client understood the directions if the client stated he/she should: a. buy clothes with many buttons to maintain finger dexterity b. exercise in the evening to combat fatigue c. rock back and forth to start movement with bradykinesia d. sit in soft, deep chairs 44. A client with diagnosis of Parkinson’s disease began taking amantadine HCl (Symmetrel) approximately 2 weeks ago. The client reports to the clinic for a follow up evaluation. The nurse would determine that the client is experiencing an adverse effect of this medication if which of the following is noted? a. Blood pressure of 130/80 mmHg b. complaint of urinary retention c. decreased akinesia d. decreased rigidity

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
48. Appropriate nursing diagnosis in client with cataract: a. alteration in nutrition b. alteration in role function c. self care deficit d. sensory perceptual alterations 49. W hich of the following statements by a client who has had a cataract removed would indicate a correct understanding of the nurse’s after-care instructions? a. “I have to cancel my hairdresser appointment.” b. “My daughter will be coming over to vacuum for a while.” c. “I will not have to cancel my golf game.” d. “I will be able to cook something for tonight.” 50. is: a. b. c. d. Normal IOP using tonometer c. eye pain and nausea should be reported to physician d. opacity of the lens is a sign of complication 53. A nurse is performing an admission assessment on a client with diagnosis of detached retina. Which of the following is associated with this eye disorder? a. pain in the affected eye b. sense of a curtain falling across the field of vision c. total loss of vision d. yellow discoloration of sclera 54. A nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? a. b. c. spots d. a reddened conjunctiva a sudden sharp pain in the eye complaints of burst of black or floaters total loss of vision

2-7 mmHg 7-10 mmHg 8-21 mmHg 22-30 mmHg

51. The nurse would identify which ocular response as desirable for the client using pilocarpine (Isopto carpine) eye drops: a. b. c. d. Corneal lubrication pupillary constriction pupillary dilation mydriasis

55. A client arrives in an emergency room with a penetrating eye injury from wood chips produced while the client was cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? a. apply an eye patch b. irrigate the eye with sterile saline c. perform visual acuity test d. remove piece of wood with sterile eye clamp 56. A client with Meniere’s disease is experiencing vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? a. b. c. d. avoid sudden head movements increase fluid intake to 3000ml/day increase sodium in the diet Lie still and watch the television

52. Which instruction would the nurse include in a discharge teaching plan for a client with a diagnosis of glaucoma: a. anticipate gradual increase in visual field b. decrease intake of saturated fats and potassium

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
d. stabilize blood sugar 57. A six year old has short arm cast place on right extremity. While assessing the fingers during the immediate period after casting, a nurse would report which of the following findings? a. capillary refill greater than 3 seconds b. mild edema c. pain on movement d. slight coolness of cast when touched 58. A nurse is giving a client with a left leg cast crutch walking instructions, using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the: a. crutches and then both legs simultaneously b. crutches and the right leg, then advance the left leg c. left leg, right crutch, then right leg and left crutch d. right crutch, then left leg, then left crutch, then right leg 59. Which of the following is the best way for the nurse to assist a blind client in ambulation? 61. A nurse in the emergency room is assessing a client with an open leg fracture. The nurse inquires about the date of the client’s last: a. b. c. d. Chest radiograph physical examination tetanus vaccine tuberculin test

62. A nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. Which of the following assessment findings is not an associated risk factor? a. family history of osteoporosis b. high calcium diet consumption c. long term use of corticosteroid d. post menopausal age 63. A nurse is caring for a client in skeletal traction. The nurse is assessing the pin sites and notes the presence of purulent discharge. Which nursing action would be most appropriate?

a. apply antibiotic ointment to a. allow client to take nurse’s arm with the the pin sites nurse walking slightly ahead of the client b. clean the pin sites more b. allow client to walk beside frequently than prescribed the nurse with the nurse’s c. document findings hand on the client’s back d. notify the physician c. allow the client to walk down the hall with his/her hand 64. A nurse is caring for a client along the wall with long bone fracture who is at d. push the client in a risk for fat embolism. The nurse wheelchair specifically monitors for the earliest signs of this complication by 60. A client is admitted post performing an assessment in the: craniotomy . Decadron 4 mg IV is ordered q6h. the nurse a. cardiovascular system understands that decadron is b. client’s mobility status ordered to: c. neurological and a. decrease cerebral edema respiratory system b. maintain integrity of gastric d. renal system mucosa c. prevent seizure

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
65. A client has been instructed in crutch walking techniques and has been fitted for crutches. Before the client begins ambulation, the nurse checks the fit of the crutches to assure that there is a space between the axilla and the top crutch pad of: a. b. c. d. ½ -1 inch ½ -2 inches 2-3 inches 3-4 inches 69. The client with thyrotoxicosis says to the nurse. “I am so irritable. I am having problems at work because I lose my temper easily.” Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? a. Your behavior is cause by temporary confusion brought on by illness. b. Your behavior is cause by excess thyroid hormone in your system. c. Your worrying is caused by seriousness of your system. d. Your behavior is cause by stress of trying to manage a career and cope with illness. 70. Serum concentration of thyroid hormones and thyroid stimulating hormones (TSH) are test ordered for the client with thyrotoxicosis. Which of the following laboratory values are indicative of thyrotoxicosis? a. Elevated thyroid hormone concentration and normal TSH b. Elevated TSH and normal thyroid hormone concentrations c. Decrease thyroid hormone concentration and elevated TSH d. Elevated thyroid hormone concentrations decrease TSH 71. The nurse would teach the client to prevent corneal irritation fro mild exopthalmus by a. Massaging the eyes at regular intervals b. Instilling an ophthalmic anesthetic as ordered c. Wearing dark colored glasses d. Covering both eyes with moistened gauze pads 72. The client is treated with Radioactive Iodine (RAI) in the form of sodium iodide 131 I. which of the following statement by the nurse will explain to the client how the drug works?

Situation : Care of client with Thyrotoxicosis requires knowledge and skills to a beginning nurse. The following question will test your knowledge in Thyrotoxicosis and its related care. 66. The nurse is completing a health assessment of 53 year old women with suspected Grave’s Disease. The nurse should assess this client for a. Anorexia b. Tachycardia c. Weight gain d. Cold skin 67. A female client with thyrotoxicosis would probably report which changes related to the menstrual cycle during initial assessment? a. Dysmenorrhea b. Metrorrhagia c. Oligomenorhea d. Menorrhagia 68. Prophylthioracil (PTU) is prescribed for a client with graves disease to decrease the circulating thyroid hormone. The nurse should teach the client to immediately report which of the following signs and symptoms? a. Sore throat b. Painful excessive menstruation c. Constipation d. Increase urine output

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
a. The radioactive iodine stabilizes the thyroid hormone levels before thyroidectomy b. The radioactive iodine reduces uptake of thyroxine and thereby improves your condition. c. The radioactive iodine lowers the levels of thyroid hormones by slowing your bodys production of them. d. The radioactive iodine destroys thyroid tissue so that the thyroid hormones are no longer produced. 73. After treatment with RAI in the form of sodium iodide 131 I. the nurse teaches the client to a. Monitor for signs and symptoms of hyperthyroidism b. Rest for 1 week to prevent complications of the medication. c. Take the thyroxine replacement for the remainder of the clients life d. Assess for hypertension and tachycardia resulting from altered thyroid activity 74. A client with large goiter is scheduled for subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason in using this drug is to a. Slow progression of exopthalmos b. Reduce the vascularity of the thyroid gland c. Decrease the ability of the body’s ability to excrete thyroxine d. Increase the body’s ability to excrete thyroxine 75. Which of the following symptoms might indicate that a client was developing Tetany after subtotal thyroidectomy ? a. Pain the joints of hands and feet b. Tingling in the fingers c. Bleeding on the back of the dressing d. Tension on the suture line Situation: Diabetes Mellitus is the 8th leading cause of death of old age. Care of patient with DM plays an important role in preventing the complication. The following question tackles about DM. 76. The client with type 1 DM is admitted to the emergency department. Which of the following respiration patterns requires immediate action? a. Deep, rapid respirations with long expiration b. Shallow respiration alternating with long expirations c. Regular depth of respiration with frequent pause d. Short expiration and inspiration 77. The client with type 1 DM is prescribed with the Sulfonyurea compound Tobutamide (Orinase). The patient is concerned about eh diagnosis and says “ I know nothing about Diabetes”. The nurse determines that the client needs teaching and support. The nurse explain that tolbutamide is believed to lower the blood glucose level by which of the following actions? a. Potentiating the action of insulin b. Lowering the renal threshold of glucose c. Stimulating insulin release from functioning beta cells in the pancreas d. Combining with glucose to render it inert 78. The client with type 1 DM is taught to take isophane insulin suspension NPH (Humulin N) at 5 pm each day. The client should be instructed that the greatest risk for hypoglycemia will occur at about what time? a. 11 am, shortly before lunch b. 1 pm, shortly after lunch c. 6 pm, shortly after dinner d. 1 am, while sleeping

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
79. The Diabetic client who is taking insulin lispro ( Humalog) injections would be advised to eat a. Within 10-15 min after injection b. 1 hour after injection c. At any time , because timing of meals with humalog injections is necessary d. 2 hours before injection 80. The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates impending hypoglycemia? a. 59 mg/dl b. 75 mg/dl c. 108 mg/dl d. 119 mg/dl Situation: Care of patient with pituitary adenoma. As a surgical nurse proper assessment and intervention should be initiated to prevent further complication. 83. Initial treatment for CSF leak after transphenoidal hypophysectomy would most likely involve a. Repacking the nose b. Return the client to surgery c. Enforcing bed rest with the head of the bed elevated d. Administering high dose corticosteroid therapy 84. After pituitary surgery the nurse should assess the client for which of the following? a. Urine specific gravity less than 1.010 b. Urine output between 1 and 2 L/day c. Blood glucose level higher than 300 mg/100 ml d. Urine negative for glucose and ketones 85. Vassopressin is administered to the client with diabetes insipidus (DI) because it a. Decrease blood pressure b. Increase tubular reabsorption of water c. Increase release of insulin from pancreas d. Decrease glucose production from the liver Situation – Andrea is admitted to the ER following an assault where she was hit in the face and head. She was brought to the ER by a police woman. Emergency measures were started. 86. As Andrea’s nurse, what will be your priority interventions A. Insert an intravenous catheter B. Insert an oral or nasopharyngeal airway C. Obtain arterial blood gases D. Give 100% oxygen by mask 87. Andrea’s arterial blood gases reflect respiratory acidosis. This is most likely related to: A. Partially obstructed airway B. Ineffective breathing pattern

81. Galactorrhea is caused by overproduction of which hormone? a. Prolactin b. Adrenocortocotropic hormone c. Growth hormone d. Thyroid stimulating hormone 82. Before undergoing a transphenodal hypophysectomy for pituitary adenoma, the client ask the nurse how the surgeon will close the incision in the Dura. The nurse would response base on the knowledge that: a. Dissolve suture are used to close the dura b. Nasal packing provides pressure until normal wound healing occurs c. A patch is made with a piece of facia d. A sybthetic mesh is used to facilitate healing

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
C. Head injury D. Pain 88. Andrea loses consciousness. You should prepare for which of the following FIRST? A. Placement of a nasogastric tube B. Placement of a second IV line C. Endotracheal intubation or surgical airway placement D. CT scan of the head 89. Andrea’s physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP. This is given to: A. promote cerebral-tissue fluid movement B. promote renal perfusion C. correct acid-base imbalances D. enhance renal excretion of drugs 90. As Andrea’s nurse your goal is to prevent increased intracranial pressure (ICP). Which of the following independent nursing interventions nursing interventions is NOT suited for her? A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration B. Keep head of bed 30-45 degrees elevated C. Maintain Andrea’s head in straight alignment and prevent hip flexion D. Prevent constipation and increases in intra-abdominal pressure Situation: Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse. 91. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure? A. clenching his fist every 2 minutes B. breathing in and out through the nose with his mouth open C. tensing the shoulder muscles while lying on his back D. holding his breath periodically for 30 seconds 92. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication: A. nausea and vomiting B. shortness of breath and laryngeal stridor C. blood tinged sputum and coughing D. sore throat and hoarseness 93. Immediately after bronchoscopy, you instructed Fernan to: A. exercise the neck muscles B. breathe deeply C. retrain from coughing and talking D. clear his throat 94. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: A. keep the sterile equipment from contamination B. assist the physician C. open and close the three-way stopcock D. observe the patient’s vital signs 95. Right after thoracentesis, which of the following is most appropriate intervention? A. instruct the patient not to cough or deep breathe for two hours B. observe for symptoms of tightness of chest for bleeding C. place an ice pack to the puncture site D. remove the dressing to check for bleeding Situation : Nurses have important responsibilities when caring for hospitalized acutely ill patients. 95. Domingo, 80 years old diabetic and hypertensive is admitted in the private ward for degenerative neurological changes. His physician was considering dementia. Side rails were placed to ensure that he will not fall from bed. At 2:00 AM, the call light at his room was on.

Neurology, Fluid and Electrolytes and Disaster 2011 Nursing
You came in and saw Domingo slumped on the floor moaning. His daughter told you that he got out of bed to go to the toilet. He climbed over the side rail but his foot got caught in the beddings. He has an open wound on his forehead. Which among the following will you do FIRST? A. Transfer him to bed B. Apply restraints C. Ensure airway, breathing, circulation D. Call his physician 96. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. Based on the ECG obtained on admission at the ER and clinical findings, the physician gave a diagnosis of myocardial infarction (MI) and prescribed IV morphine to relieve continuing pain. A primary goal of nursing care for Aimee is to recognize life-threatening complications of MI. As Aimee’s nurse, you have to anticipate occurrence of complications. Take note that the major cause of death after an MI is: A. Cardiac arrhythmias C. Cardiogenic shock B. Heart failure D. Pulmonary embolism 97. The cardiac monitor indicates that Cedric’s heart rate has increased to 150 beats per minute. Shortly after this increase, you notice Cedric is in ventricular tachycardia. after reporting this to the physician, you anticipate that the physician will order. A. intracardiac epinephrine B. insertion of a pacemaker C. bolus of Lidocaine D. manual cardiopulmonary resuscitation 98. Hermie with a left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. You should recognize this as signs and symptoms of: A. cardiogenic shock C. acute pulmonary edema B. right-sided heart failure D. pneumonia 99. You are caring for Lulu has acute pulmonary edema. To immediate promote oxygenation and relief of dyspnea, you should first: A. perform chest physiotherapy B. have her take deep breaths and cough C. place Lulu on high fowler’s position D. administer oxygen 100. A difficult problem to deal with when caring for a patient with a partial-thickness burns sustained 3 days ago is: A. alteration in body image C. frequent dressing change B. maintenance of sterility D. severe pain

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