John J.

Teodoro PTRP, RN

1. A home care nurse is preparing to visit a client with a diagnosis of Meniere’s disease. The nurse review’s the physician’s orders and expects to note that which of the following dietary measures will be prescribed? A. low fiber diet with decreased fluids B. low sodium diet and fluid restriction C. low carbohydrate diet and elimination of red meats . low fat with restriction of citrus fruits !. A nurse is assigned to care for a client who has "ust undergone eye surgery. The nurse plans to instruct the client that which of the following activities is permitted in the postoperative period? A. reading B. watching television C. bending over . lifting ob"ects #. A nurse is instilling an otic solution into an adult client’s left ear. The nurse avoids doing which of the following as part of this procedure? A. warming the solution to room temperature $. placing the client in a side lying position with the ear facing up C. pulling the auricle bac%ward and upward D. placing the tip of the dropper on the edge of the ear canal &. A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the clients? A. wound healing usually ta%es 1! wee%s $. expected the vision will be permanently impaired

C. a shield or eye patch should e worn to protect the eye . the sutures are removed after 1 wee% '. (hich assessment findings provide the best evidence that a client with acute angle) closure glaucoma is responding to drug therapy? A. swelling of the eyelids decreases $. redness of the sclera is reduced C. eye pain is reduced or eliminated . peripheral vision is diminished *. At the time of retinal detachment+ a client most li%ely describes which symptoms? !. a seeing flashes of light $. being unable to see light C. feeling discomfort in light . seeing poorly in daylight ,. The most important health teaching the nurse can provide to the client with con"unctivitis is toA. eat a well balanced+ nutritious diet $. wear sunglasses in bright light C. cease sharing towels and washcloths . avoid products containing aspirin .. (hen the nurse prepares the client or the myringotomy+ the best explanation as to the purpose for the procedures is that it willA. prevent permanent hearing loss B. provide a pathway for drainage C. aid in administering medications . maintain motion of the ear bones

/. A nurse is reviewing the record of the client with a disorder involving the inner ear. (hich of the following would the nurse expect to see documented as an assessment finding in this client? A. severe hearing loss $. complaints of severe pain in the affected ear C. complaints of burning in the ear D. complaints of tinnitus 10. A client with a conduction hearing loss as%s the nurse how a hearing aid improves hearing. The nurse most accurately informs the client that a hearing aid!. amplifies sound heard $. ma%es sounds sharper and clearer C. produces more distinct+ crisp+ speech . eliminates garbled bac%ground sounds 11. (hich nursing action is best for controlling the client’s nosebleed? A. have the client lay down slowly and swallow fre1uently $. have the client lay down and breathe through his mouth C. have the client lean forward and apply direct pressure . have the client lean forward and clench his teeth 2ituation- $en"ie '/ years old male was admitted to the hospital complaining of nausea+ vomiting+ weight loss of !0 lbs+ constipation and diarrhea. A diagnosis of carcinoma of the colon was made. 1!. A sigmoidoscopy was performed as a diagnostic measures. (hat position $en"ie should assume for hi examination? !. "nee#chest $. 2im’s

4f colostomy irrigation is done+ the height of the irrigator can must be how many inches above the stoma? A. As part of the preparation of the client for sigmoidoscopy the nurse shouldA. advance the catheter about one inch . 10)1& inches . The doctor performed a colostomy+ post operative nursing care include!. uring the irrigation of the colostomy+ $en"ie complains of abdominal cramps+ the nurse shouldA. limiting fluid inta%e 1'. add color water 1*. limiting visitors C. discontinue the irrigation B. withholding . !0)!& inches .C. 1&)1. explain to $en"ie that he will swallow a chal%)li%e substance $. %&#'( inches C. Trendelenburg 1#. 3owler’s . inches B. administer a cathartic the night before C. withhold fluids and foods on the day of examination D. administer cleansing enema in the morning of the e$amination 1&. "eeping the s"in around the opening clean and dry $. clamp the catheter for a few minutes C.

Mr. hemorrhoids $. (hich of the following gastrointestinal condition is %nown to predispose to Cancer of the colon? A. in the stomach $. eructation . (hich of this diagnostic measure is not indicated for Mr. gastrointestinal series . Antacids are administered to Mr. 1. gastric analysis !0. 5 is to!. prevent constipation . delay gastric emptying C. nausea 1/. vomiting C.1. patient)s history C. pyloric stenosis 2ituation. delay surgery !1. islated colonic polyps . diarrhea $. x)ray of the abdomen B. 5 to- .. The purpose of dietary treatment of Mr. 5 due to his peptic ulcer isA. A fre1uent discomfort experience by Mr. 5? A. iagnosis is peptic ulcer. 5 was brought to the 67 complaining of pain located in the upper abdomen hematemesis and melena. neutrali*e the free +C.. intussusception C.

The stool 9uiac test was ordered to detect the presence ofA.A. decrease of pituitary function !#. inflammatory cells . astringent C. decrease gastric motility C. analgesic B. undigested food !'. a soft mass of the necrotic tissue with bleeding $. an erosion of the mucosa covered with thic% exudates C. a sharp e$cavation of tissue mem rane with a clean ase . aid in digestion !!. The tissue change most characteristics of peptic ulcer isA. hydrochloric acid B. disturbance o cerebral cortex appetite control . 4t is thought that emotional stress contribute to ulcer formation through!. an elevated fibrous tissue membrane with soft margins !&. increased activity of the sympathetic nervous system C. 4n addition to its antacids effects+ aluminum hydroxide gel is locallyA. tran1uili8e the intestine $. e$cessive stimulation of the parasympathetic nervous system $. occult lood C. irritating . lower the acidity of gastric secretion .

gastric lavage using iced cold normal saline solution $. instruct him to lie down after eating . giving of fluids after meals must be avoided #0. note and report excessive bleeding only . gastric using warm normal saline solution C. feeling of fullness .. provide laxative at bedtime C. To prevent dumping syndrome the following includes your nursing care exceptA. render sponge bath $. insertion of :9T !. 2ince she has :9T the appropriate nursing action isA. application of tourni1uet . <our operative nursing assessment after surgeryA. 4ntervention that would help control his bleeding!.. feeling of soreness $.e underwent total gastrectomy+ dumping syndrome may occur and the least symptoms he may experience would be!. administer enema once a day D. wea%ness C. . allow him to wal" for a while after eating C. depressant !*.. diaphoresis !/. provide oral hygiene -$ a day !. serve dry meals B.

chec% the drainage from the :9 tube everyday #1. A nurse is giving instructions to the client with peptic ulcer disease about symptom management. . malnutrition . The nurse tells the client to!. (hat is the involvement of her total gastrectomy? A. The nurse tells the client to ta%e this medicationA. use acetylsalicylic acid =aspirin> to relieve gastric pain ##.@im was %nown to be alcoholic for 1' yrs. eat slowly and chew food thoroughly $. removal of the stomach only B. "ust after meals 2ituation.unum C.e. -( minutes efore meals C. with meals . assess for e$cessive secretions from the operative site C. #&. The most probable cause of @im’s cirrhosis isA. removal of the stomach with anastomosis of the duodenal to "e"unum #!. eat large meals to absorb gastric acid C. with antacids B. A client has been given a prescription for ?ropantheline =?robanthine> as ad"unctive treatment for peptic ulcer disease. ensure that the :9 tube is detached from suction apparatus . removal of the ovary and fallopian tube . removal of the stomach with anastomosis of the esophagus to the .B.e was admitted in the hospital after having vomited a large 1uantity of bright red blood with some coffee ground appearance. limit the inta%e of water .

flat with one pillow under his head . inguinal hernia . $ and vit. hold his breath when the needle has reached the liver site C. acceleration of portal blood flow secondary to severe anemia D. $+ vit.. A+ vit. C+ and vit. exhale forcefully and to hold his breath for a few seconds $. (hat instructions regarding respiration is essential for the nurse to give him prior to the biopsyA. ta"e several deep reaths and to hold his reath while needle is eing introduced . vit. twisting and constriction of intralo ular and interlo ular lood vessels #. varicose veins $. splenic rupture C. @im’s portal hypertension is the result ofA. compression of the liver substance due to emotional stress C. obstruction of ma"or bile ducts #'. @im is scheduled for a liver biopsy. umbilical hernia #. vit. contraction of vascular muscles response to psychological stress $. bacterial inflammation of liver cells C. A and vit. vit ! and vit B . C. (hich of the following vitamins are stored by the normal liver? A. vit. C #*.$.. alcoholism . The nurse should %now how that pathophysiology predispose him to!. C $. A+ vit.

anyway that he is comfortable C. Clay colored stool are caused by- . The nurse prepares for the procedure %nowing that the deflation of the esophageal balloon places. recurrent hemorrhage from the esophageal varices . ma%e certain that the desired degree of pressure is constantly maintained C. with a small pillow under the costal margin $. alternate inflate and deflate the esophageal alloon $. semi)3owler’s with his %nees flexed . The nurse responsibility in this instance would be to!. A $la%emore)2engsta%en tube is inserted to prevent bleeding from esophageal varices. gastritis &!. mil% products C. esophageal necrosis C. cereal products D. on his right side. 3oods usually omitted from diet of @im with cirrhosis of liver areA. whole grain cereals $. The client is at ris% forA.#/. (hich position in bed would be best for @im immediately after he has the needle biopsy of the liver? !. increased ascites $. flat with one pillow under his head &0. A physician orders the deflation of the esophageal balloon of a 2engsta%en) $al%emore tube in a client. rich gravies and sauces &#. deflate both balloons periodically . encourage @im to swallow fre1uently while tube is 4 place &1.

improper utili8ation of vitamin @ by the body B. fruity odor breath &. A nurse performs which intervention as a priority measure to assist the client with breathing? A. nystagmus #. portal o struction C. 1 and # &*. fetid breath A. flapping tremor !. rich gravies and sauces &&. arterial obstruction &'.@arla is confine with a diagnosis of chronic cholecystitis. @im develop ascites+ this is caused byA. . capillary obstruction . ! and # B. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and has difficulty breathing. auscultates the lung fields every & hours $. encourages deep breathing exercises every ! hours D. the a sence of ile salt in the feces C. 2ymptoms indicating progression into hepatic coma include1.A. repositions side to side every ! hours C. ! and & C. elevates the head of the ed 0( degrees 2ituation. pulmonary failure B. % and / . the absence of bile pigments in the urine .

&,. After thorough examination your findings would beA. high red blood cell counts and fever $. leu%ocyte count is low and high fever C. leu"ocyte count high and pyre$ia . leu%ocytosis and abdominal pain that radiates to the groin &.. The surgical intervention indicated for @arla isA. choledochostomy $. cholecystostomy C. cholecystotomy D. cholecystectomy &/. 3ollowing exploration of the common duct is a T)tube inserted. The rationale for this is toA. facilitate healing of the operative site $. offer a route to post operative cholecystectomy C. provide sufficient drainage to promote healing D. ensure ade1uate ile drainage during duct healing '0. Apon admission her doctor ordered for cholecystoghram in AM. The preparations of this procedure beginsA. in early am B. with evening meal C. at bedtime . upon admission '1. The ingestion of fatty food usually precipitates rubies episodes of the upper abdominal pain becauseB A. fat in the stomach increases the rate of peristaltic movements

B. fat in the duodenal contents initiate the reaction that cause gall ladder contraction C. fatty foods are li%ely to generate gas . fatty foods contain higher amount of cholesterol than do proteins '!. @arla is having pruritus of the extremities. (hich of the following nursing measures might be most helpful in relieving her discomfort. A. rubbing the s%in with potassium permanganate 10-1000 solution B. athing in wea" sodium icar onate solution C. dusting with liberal amount of talcum powder . rubbing the s%in with alcohol '#. @arla is experiencing severe biliary colic. The drug of choice during attac% isA. ponstan B. Demerol C. atropine sulfate . morphine sulfate '&. A T)tube was inserted into the common bile duct. ;er nursing care of the T)tube is!. empty and measure the ile drainage every / hours $. report 2TAT for any bile seen in the drainage system C. secure it very well . irrigate the T)tube with sterile normal saline every & hours ''. A client with diverticulitis has "ust been advanced from a li1uid diet to solids. The nurse encourages the client to eat foods that are!. low residue $. high residue C. moderate in fat

. high roughage '*. A client has "ust undergone an upper gastrointestinal =94> series. The nurse provides which of the following upon the client’s return to the unit as an important part of routine post procedure care? A. increased fluids $. bland diet C. :?C status D. la$ative ',. A nurse is administering continuous tube feedings to the client. The nurse ta%es which of the following actions as party of routine care for this client? !. chec"s the residual every /hours $. changes the feeding bag and tubing every 1! hours C. pours additional feeding into bag when !' ml are left . holds the feeding if greater than !00 ml are aspirated '.. A nurse is monitoring drainage from a nasogastric =:9> tube in a client who had a gastric resection. :o drainage has been noted during the past & hours and the client complains of severe nausea. The most appropriate nursing action would be toA. reposition the tube $. irrigate the tube C. notify the physician . medicate for nausea '/. A nurse is performing a health history on a client with chronic pancreatitis. The nurse expects to most li%ely note which of the following when obtaining information regarding the client’s health history? A. abdominal pain relieved with food or antacids $. exposure to occupational chemicals C. weight gain

2they are going to loo" at my gall ladder and ducts. The client has developed stomatitis. Dthis procedure will drain my gallbladderE C. decrease inta%e of dietary iron $. encouraging increased fluid inta%e *!. (hich client statement indicates that the client understands the purpose of this procedure? !. A client who has a history of chronic ulcerative colitis is diagnosed with anemia. intestinal malabsorption C. A nurse is caring for a client with is receiving total parenteral nutrition =T?:>. drin% "uices that are not citrus *1. Dthey will put medication in my gallbladderE *#. monitoring serum blood urea nitrogen =$A:> daily C. use of alcohol *0. weighing the client daily . A home care nurse visits a client with bowel cancer who recently received a course of chemotherapy. Dmy gallbladder will be irritatedE . eat foods without spices C. The nurse interprets that which of the following factors is most li%ely responsible for the anemia? A.3 $. The nurse avoids telling the client to!. A nurse is caring for a client with possible cholelithiasis who is being prepared for a cholangiogram.D. The nurse plans which nursing intervention to prevent infection? !. drin" foods and li1uids that are cold $. using strict aseptic techni1ue for intravenous site dressing changes $. lood loss . The nurse teaches the client about the procedure. maintain a diet of soft foods .

the client has a history of ulcerative colitis C. intestinal hoo%worm *&. the client ta%es a daily stool softener $. reduce the number of bacteria near the incision **. flush the carbonated li1uids+ such as cola . aspirate the tu e C. will feel referred pain in the opposite 1uadrant *. e$perienced more pain when pressure is released $. 7eplace the tube *'. prevent the onset of postoperative diarrhea . have extreme discomfort with the slightest pressure . flush the tube with warm water B. the client wor%s as a computer programmer . suppress the growth of intestinal acteria C. A client’s nasogastric =:9> feeding tube has become clogged. (hich factor most probably contributed to the development of the client’s hemorrhoids? A. 4f the client is typical of others with appendicitis the nurse can expect that when the client’s abdomen is palpated midway between the umbilicus and right iliac crest+ the client will!.. the client is fre1uently constipated . (hen the client as% the nurse why he must ta%e the neomycin sulfate =Mycifradin>+ the most accurate explanation in this case is that the drug is given toA. The nurse’s first action is toA. treat any current infection he may have B. lac% any sensation of pain or pressure on palpation C..

1. before rising in the morning */.. (hich nursing action is appropriate prior to assisting with the paracentesis? . excessive caffeine . A transmission is from!. infected blood . 4t is essential that the nurse inform the client with hepatitis $ that for the remainder of his lifetime he must avoidA.!. foreign travel . especially on an empty stomach C. fecal contamination $. (hen the client describes her discomfort to the nurse she is most li%ely to indicate that the pain she experiences becomes worse!. (hich nursing action is essential for reestablishing the negative pressure within this drainage device? !. the nurse secures the bulb reservoir to the s%in near the wound . (hen the client as%s the nurse how she ac1uired hepatitis A+ the best answer is that a common route of hepatitis. insect carries C. the nurse compresses the ul reservoir and closes the drainage valve $. the nurse fill the bulb reservoir with sterile normal saline . shortly after eating $. sexual activity B. wound drainage . the nurse opens the drainage valve+ allowing the bulb to fill with air C. (hen the nurse empties the drainage in the 5ac%son ?ratt bulb reservoir. donating lood C. following periods of activities .0.*.

sudden. slow+ strong pulse . the client wears loose)fitting garments $. A nurse is caring for a client with peptic ulcer. Ddid you ta%e something for you nausea?E C.*. (hich assessment is most important for the nurse to ma%e before advancing a client from li1uid to solid food? A. (hich assessment 1uestion best determines if a food borne pathogen is the cause of the client’s syndrome? !. the nurse cleanses the client’s abdomen with $etadine . the nurse obtains a suction machine from storage room . severe a dominal pain C. 2what food did you eat43 $.#. the client ta%es a shower each day C. positive 9uaiac test . increase bowel sounds B.&.!. increase bowel sounds . the nurse as"s the client to void $. the nurse withholds food and water C. Dhave you ever had food poisoning?E . A previously health client comes to the emergency department complaining of severe nausea and vomiting hours after eating in a restaurant. (hich statements provides the best evidence that a client with colostomy is ad"usting to the change in body image? A. the client empties the appliance . the client avoids foods that form gas . 4n assessing the client for gastrointestinal perforation =94>+ the nurse monitors forA.'. Ddid your food loo% spoiled?E .

. multiple vesicles+ with some that have ruptured . A male being seen in the ambulatory care clinic has a history of being treated for syphilis infection. butterfly rash on the face D. radycardia . proteinuria+ hematuria+ edema and hypertension . serum protein levels C. A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. appetite C. costovertebral angle pain . The nurse monitors the client %nowing that which of the following clinical manifestation is not associated with this disease? A.$. presence of bowel sounds D. absence of any and symptoms B. muscular aches and pains C... itching and vaginal discharge C. fever $.. daily weights $./. (hich findings would the nurse expect to note on assessment of the client? A.0. The nurse interprets that the client has been reinfected if which of the following characteristics is noted in a penile lesion? A. daily inta%e and output . chewing a ility . (hat method would a nurse use to most accurately assess the effectiveness of a weight loss diet for an obese client? !. daily caloric counts . A nurse is caring for a client who is hospitali8ed with acute systemic lupus erythematosus =2F6>. pain.

use oral contraceptives as a preferred method of birth control C. popular areas and erythema C. A nurse is preparing a poster for a booth at a health care to promote primary prevention of cervical cancer. Ddiscontinue the medicationE C. (hich of the following nursing statements to the client would be most appropriate? A. The nurse includes which of the following recommendations on the poster? A. perform monthly breast self)examination =$26> $. this is a normal occurrence with the use of medication3 2ituation. Dnotify the physicianE D. The nurse assists the client in doing which of the following exercises during the first !& hours following surgery? !. use a commercial douches on a daily basis D. cauliflower)li%e appearance D. hand wall climbing . The client calls the clinic nurse and says that the s%in has become very red and is beginning to pee. induration and a sence of pain .1. pendulum arm swing .#.$. el ow fle$ion and e$tension $. see" treatment promptly for infections of the cervi$ .Fu8 1/ years old single is scheduled for mastectomy of the right breast . Tretinoin =7etin)A> is prescribed for a client with acne.!. $ased on the health history and other assessment data+ Fu8’s nursing diagnosis includes the following except- . shoulder abduction and external rotation C. Dcome to the clinic immediatelyE $.&. A nurse is caring for a client who has "ust had a mastectomy.

A. give the medicine 2TAT C. lymphedema C. self)care deficit related to immobility of arm on the operative side . gynecomastia D. give fractional dose of Meperidine .CF '0 mg 4M ordered every & hours for the first !& hours only.*.CF D. fi roadenoma .'. hematoma $. <ou shouldA. infection . body image disturbance C.. <ou informed her that the most common breast tumor occurring in young women isA. papilloma C. The following are her possible post operative complication except!. Fu8 complains of pain ! hours after receiving her medication of Meperidine . use nursing measure to relieve pain .. fibrocystic $. potential sexual dysfunction $.. neurovascular deficits . C$C B.T. tell Fu8 to wait for ! hours more $. 5rinalysis C.. pain related to anesthesia . $. . (hich of these wor%)up is not related to her surgery? A.

A client has a left mastectomy with axillary lymph node dissection. decu itus ulcer /!. C. pleural drainage B. 7ationale for moderately elevating post operative affected arm is to!. . /0. (hich of the following is not a post operative complication A. pneumonia C. . bronchitis .T. atelectasis D. bronchopneumonia $. atelectasis C. reduce pain C. prevent infection . hemovac C. (hich of these maybe used to her post operatively? A./. Allowing her to do deep breathing exercise every ! hours would preventA. pneumonia /#.T. The nurse determines that client understands post operative restrictions and arm care if the client states to- .. bronchopneumonia B. $. improve coping ability /1.T. C. prevent lymphedema $.

personal history of ulcerative colitis or gastrointestinal =94> polyps $. age over #0 years D. (hich of the following if started by the client would indicate a need for further instructions regarding self)care related to the radiation therapy? A. use a straight ra8or to shave under the arms $. A nurse is teaching a client about the modifiable ris% factors that can reduce the ris% for colorectal cancer. distant relative with colorectal cancer C. self)esteem disturbance . low fi er diet 2ituation. D4 need to eat a high)protein dietE /'. carry a handbag and heavy ob"ects on the left arm D. D4 need to avoid exposure to sunlight?E $. allow blood pressures to be ta%en only on the left arm C. 26 need to apply pressure to the irritated area to prevent leeding3 . defensive coping $. The nurse places highest priority on discussing which of the following ris% factors with this client? A. use gloves when wor"ing in the garden /&.3e+ a !1)year)old fourth year physical therapy student has been diagnosed with peptic ulcer. The personal and family history shows that she has difficulty coping with the demands of the course and her mother is being treated for peptic ulcer to/*. A relevant diagnosis the nurse identifies is one of the followingA. A nurse has provided instructions to a client who is receiving external radiation therapy. D4 need to wash my s%in with a mild soap and pat dryE C.A. high#fat.

stress management techni1ue . sublimation . pro"ection . self)sacrificing and dependent . competitive and aggressive C. relaxation techni1ue $.. denial $. submissive and dependent B. reaction formation C. The defense mechanism usually used by patient with peptic ulcer is!. Cne of the nursing intervention is to teach 3eA. behavior modification C. sensory)perceptual alteration D. ineffective individual coping /. desensiti8ation techni1ue //. migraine B. peptic ulcer 100. perfectionist and assertive /. The following are psycho)physiological reactions exceptA. bronchial asthma . Typical personality traits of a person with peptic ulcerA. constipation C..C.

The client was hospitali8ed ' days ago have developed left calf tenderness and have a positive . The nurse plans to refer the client to aA. dietician C. The nurse is implementing a plan of care for a client with deep pain thrombosis of the right leg. The nurse is considering measures to help the client cope up with lifestyle changes needed to control the disease process.3 $. increased calf circumference . coolness and pallor of the affected limb $. medical social wor%er $. D4 have to go to the bathroom several times at nightE C. elevation of the right leg B. (hich of the following interventions does the nurse avoid when delivering care to this client? A. application of moist heat to the right leg . diminished distal peripheral pulses C. smo"ing cessation program . am ulation in the hall twice per shift C. The home health nurse is visiting the client who has had a prosthetic valve replacement for severe mitral valve stenosis. (hich statement by the client reflects an understanding of specific postoperative care for this surgery? !. D4 still do my deep breathing exerciseE !.oman’s sign. A client has been diagnosed with thromboangitis obliterans. administration of acetaminophen =Tylenol> &.1. The nurse assigned to this client next assess to this client next assesses the client forA. pain management clinic #. 26 threw away my straight ra*or and rought an electric ra*or. D4 count my pulse everydayE .

Maalox plus $. one to 1. 7C8 changes $. %eep the client :?C until n order is written $. . chec" the gag and swallowing refle$ . The nurse %nows that the client has understood essential teaching when the following statement is heard!.' times the control value C. A client is ta%ing (afarin =coumadin> following the placement of an artificial mitral valve. The nurse is monitoring a client with leu%emia who is receiving oxorubicin =Adriamycin> by 4G infusion. a red coloration of the urine *. Tylenol cold and flu medication D. The nurse instructs this client to avoid ta%ing the following commonly used drugA.. three times the control value . within normal range $. elevated creatinine . A &')year)old client is receiving heparin sodium for a pulmonary embolus. bilateral edema '. aspirin /.. two to '. (hich of the following assessment findings indicate toxicity of the medication? A. 6levated $A: C. sudafed C. 26 need to cut my nails straight across3 .9 times the control value . The nurse evaluates which of the following laboratory reports of partial thromboplastin time as indicative of effective heparin therapy. chec% the vital signs first C. A client with insulin dependent diabetes mellitus =4 M> is being discharged.. A &')year)old male returned to his room an hour ago following a bronchoscopy.e is re1uesting for some water. The nurse mustA. A. encourage coughing and deep breathing .

.igh ris% for aspiration D. report the situation to the physician C. $A: and creatinine 11. The nurse %nows that the client has understood teaching about the treatment when the following statement is heardA. D4 need not be concerned about radioactivityE C. Donly my thyroid gland will be radioactiveE $. A client has developed depression of the bone marrow from antineoplastic drugs. electrolyte studies . 2my ody fluids will e radioactive for a short time3 1#. The nurse states the nursing diagnosis of highest priority asA. complete blood count C. high ris" for infection 1!. prothrom in time $. rest mentally as well as physically . run the 4G at the prescribed site D. A client’s T?: is * hours behind schedule. A &')year)old client is in acute congestive heart failure. $. run the fluid at rate to ma%e up the lost time.$. The nurse assesses the following laboratory test dailyA. D4 can’t ma%e any substitutions in my dietE C. A client is on chemotherapy for acute myelogenous leu%emia. Dmy whole body will be radioactiveE D. D4 should eat less before exercisingE 10. ineffective thermoregulation $. Dmy insulin should be given into my armsE . 7adioactive iodine is being used to treat a client with cancer of the thyroid gland. chec" the lood glucose level 1&. The nurse and client establish a goal of highest priority as!. fluid volume deficit C. The nurse wouldA.

$. learn stress management C. train for a less demanding "ob . prevent complications of immobility 1'. A client diagnosed with 4 M becomes irritable and confusedB the s%in is cool and clammy and the pulse rate is 110. The first action of the nurse would be to!. give a half#cup of orange .uice $. chec% the serum glucose C. administer regular insulin . call the physician 1*. A client with 4 M is recovering from @A. 4nformation of the serum level of the following substance will be very important to the nurseA. sodium C. potassium $. calcium . magnesium

1,. A 1,)year)old client’s mother has been recently diagnosed with pulmonary tuberculosis. The nurse would expect the doctor to order which of the following tests initially? !. the mantou$ C. a sputum culture $. an H)ray . gram stain of the sputum

1.. The nurse in"ects 0.1 ml. of purified protein derivative =?? > intradermally into the inner aspect of the forearm of a client. This nurse will interpret the reaction to this test as positive when the following is seenA. redness greater than 'mm. $. swelling greater than ,mm. C. induration greater than %(mm. . exudates covering more than 1!mm

1/. A !/)year)old has been ta%ing ?rednisone *0 mg. daily for an inflammatory condition for the past * months. The physician "ust wrote an order to discontinue the medication. The nurse shouldA. stop the medication as ordered $. continue the medication until physician is available C. call the physician and 1uestion the order D. hold the medication until the physician is availa le !0. A '' year old has a chest tube connected to a ?leur 6vac system to remove blood from the pleural cavity. (hile turning the client the nurse remembers to!. "eep the Pleur 7vac elow the level of the wound $. 7emove the suction from the ?leur vac C. Clamp the tubing connected to the ?leur 6vac . drain the sterile water from the ?leur 6vac !1. A client on anti)neoplastic therapy has a platelet count of ! An appropriate intervention for the nurse to use would beA. administering Git. @ 4M $. massaging in"ection sites to avoid absorption C. encouraging the use of firm toothbrushes and vigorous flossing D. avoiding rectal temperatures and other rectal procedures !!. A nurse assumes responsibility for the care of the client at , A.M. :?; insulin is ordered for ,-#0 A.M. $efore giving the insulin+ the nurse chec%s to see if the client will eat that day and for theA. signs and symptoms of hypoglycemia $. previous sites of in"ection C. serum glucagons level D. serum glucose level

!#. A nurse is teaching a client to observe for signs of hypoxia. The nurse explains that cyanosis is not reliable indicator of the amount that tissues are receiving because the blue color is caused by!. reduced hemoglo in $. a low partial pressure of oxygen in the blood C. inability of oxygen to enter the cell . increased p; of the blood !&. A client has A7 2. The lowest fraction of inspired oxygen possible for optimi8ing gas exchange is used. The nurse explains to the family that the reason for this precaution is toA. avoid respiratory depression B. prevent o$ygen to$icity C. increase lung compliance . promote production of surfactant !'. A client who is recovering from a myocardial infarction demonstrates that touching has been effective with the statementsA. Dif my chest pain lasts for more than ' minutes+ 4 should get myself to the emergency roomE $. D4 "ust need to avoid salty foods and not add salt to my foodE C. 26 need to avoid constipation and all activities that have caused me chest pain in the past3 . D4 need to get to the drugstore to get some medicine for my coldE !*. A client is admitted to the hospital complaining of nervousness+ heat intolerance and muscle wea%ness. ;er pulse rate is 11. and she has exopthalmos. An essential part of her assessment will be!. palpation of the thyroid gland $. evaluation of fluid and electrolyte balance C. evaluation of deep tendon reflexes

gB the pulse is 11. hypervolemia C. render the parathyroid glands visible C. induce a euthyroid state in the ody .. intravenous fluids . The nurse anticipates that insulin and the following will be neededA. triiodothyroinine =T#> !/. (hen assessing for other ris% factors stro%e and heart attac%+ this nurse loo%s forA. The nurse teaches the client to!.. sodium bicarbonate #1. . The client is confused and has dry mucus membranes and poor s%in turgor. calcium gluconate $. epinephrine $. The serum sodium is 1&/B the blood pressure /0I*0 mm. restrict sodium in the diet C. thyro$ine :T/. The nurse teaches that the best laboratory test for evaluating whether a client has hypothyroidism or hyperthyroidism is the serum level of!.. increase the si8e of the thyroid gland $. use of the 9lasgow Coma 2cale !. A client with :4 M is admitted to the hospital. 2eparate the thyroid from the laryngeal nerve !. measure urinary output #0. The nurse explains that ?TA or an iodine preparation is given prior to surgery in order toA. ta%e the drug with meals . monitor the pulse regularly $. a potassium drip C. A client is being evaluated for the possibility of 9rave’s disease.B and the serum glucose &*' mgIdl. T2. A nurse is teaching a diabetic client how to attain the optimal level of health. A client is scheduled for thyroidectomy. A client is ta%ing Fevothyroxine =synthroid> for hypothyroidism. proteinuria . C.

$. chec% the level of consciousness $. with meals D.)year)old client is being prepared for discharge following a myocardial infarction. $ystanders said she acted as if she has been drin%ing. The nurse %nows that her teaching has been understood when she hearsA. && and deep.J .er pulse rate is 110. meta olic acidosis $. 2he complained of headache and acted confused. chec" for leeding ##. 2 the est way to "now the amount of e$ercise 6 should ta"e is to watch my pulse3 . A nurse stops at the sight of a motor vehicle accident to find a young woman slumped over the wheel. respiratory acidosis .er temperature is #. call the rescue s1uad D. respiratory al%alosis #'. A client with 4 M has "ust been admitted to the 67 after hitting a telephone pole with her car.. A '. D4 guess my sex life is overE $. hypo%alemia D. Dthe in"ured area will be replaced with a new heart tissueE #&.& degrees Celsius+ pulse . The nurse’s next action would beA. A client with peptic ulcer is ta%ing Maalox+ Amoxicillin and 3amotidine. Ddepression is bad for me. .. 1)! hours before meals C. 2he is breathing with a regular rhythm at a rate of !!B ventilation efforts normal.0+ resp. %#' hours after meals #*.#!+ pCC!J #*+ and bicarbonateJ 1. immobili8e the spine C. The nurse prepared for the treatment of!.E (hich response by the nurse would be the $62T? . . hypertension #!.er A$9 report readJ p. A fruity odor was noted on her breath. 4 must stay happy and optimisticE C. K hour before meals $.. . A client with varicose veins tells the nurse+ D4 am afraid they will burst while 4 am wal%ing. metabolic al%alosis C. The nurse teaches the client to ta%e the MaaloxA.

A client as%s why is it important to chec% the pupils. Dif that happens+ you could bleed to deathE D. hypo"alemia &1. 1 mg. disseminated tuberculosis $... 2rupture of varicose veins rarely occur3 #. A #*)year)old client with a history of Cushing’s disease is being seen in the 67 for complaints of anorexia+ vomiting+ wea%ness and muscle cramps for the past !& hours. hypoglycemia C. rain stem C. Dyou must find another "ob+ one that re1uires less wal%ingE C.A. cerebellum #. autoimmune response C. blastomycosis . midbrain . hypernatremia $. high potassium+ high cholesterol &0. hyperglycemia and weight loss $. hyperglycemia D. The nurse replies that changes in the pupils are a reflection of how well the following area of the nervous system is functioningA. hypoglycemia and gastric ulcers . Na C. (hen teaching a patient about home care related to outpatient corticosteroid therapy+ the nurse emphasi8es that side effects of corticosteroid therapy includeA. hyponatremia and hypotension C. The nurse %nows that the most common cause of the disease is attributed to!. low fat+ low cholesterol . :a B. A #!)year)old client is being evaluated in the clinic today for possible Addison’s disease.gms. . diabetes mellitus #/. spinal cord B. Dthe only way to prevent rupture is to have surgeryE $. The nurse recogni8es that these clinical findings are a result ofA. The nurse %nows that the recommended diet for a client with Addison’s disease includesA.

(hen planning care for a patient who is pancytopenic+ the ma"or goal should be!. cabbage B. 1-#0 pm . & pm &#. The nurse is caring for a client with folic acid deficiency. fried chic%en &'. Additional teaming to a newly diagnosed diabetic client related to the effects of regular insulin is necessary when the client as%s+ Dif 4 ta%e my regular insulin at .-#0 am B. a complicated pregnancy during the second trimester &*. hyperglycemia and weight gain &!.M. bradycardia+ hypotension+ facial flushing $. A. prevent hemorrhage and infection . poor nutritional inta%e due to alcoholism B. tapioca . The nurse recalls that one of the most fre1uent causes of folic acid deficiency isA. tachycardia &&. confusion+ bradycardia+ headache C. lac" of a sorption of the intrinsic factor C.+ when might 4 experience signs of low blood sugar reaction? A.D. .)year)old client has a new colostomy and is being treated today at the clinic for diarrhea. A *. restlessness. %% am C. (hen discussing diet with the client+ the nurse explains to him that the one food that caused this problem wasA. The nurse recogni8es which of the following as signs of early hypoxia? A. eggs C. a diet that consists of vegetables only and no meat . hypotension+ tachypnea+ lethargy D. yawning.

when explaining different effects of chemotherapy to students+ the nurse correctly identifies which group of chemotherapy drugs that does not affect :A synthesis to %ill tumor cells? !. preventing fatigue and fluid overload . decrease CN> stimulation ..I. serum sodium of 1#' m61IF+ $?J*!I&.! . decrease the vascularity of the thyroid gland C. serum potassium of 9. (hich of the findings would the nurse most li%ely note during an Addisonian crisis? A. (hat information $62T indicates the average degree of diabetes control during the past ! to & months? !. al%ylating agents $. '0.. serum glycosylated hemoglo in $.. BP=0'</& mm+g C. a written record of daily double voided urine glucose levels &/. The nurse evaluates the client’s ability to self)monitor blood glucose level at home.I. bloc% formation of the thyroid hormone $. inhibit peripheral conversion of T& and T# D.! mm. hormones C. vinca al%alosis &.g B. ?ropanolol =4nderal> is commonly prescribed for clients with hyperthyroidism toA.$. a written record of daily blood glucose levels . encouraging consumption of a neutropenic diet &. antimetabolites . administering an oral iron preparation C. postprandial blood glucose level C. serum sodium of 1'0 m61IF+ $?J 1'.& m71<. serum potassium of # m61IF+ $?J1'.

#+000 to .+000Icu. is characteristic of thrush infection C. The client suspected of having an abdominal tumor is scheduled for a CT scan with dye in"ection. /. The nurse assesses the oral cavity of a client with cancer and notes white patches on the mucous membranes. '&.mm. is common B.(((<cu. The client with cancer is receiving chemotherapy and develops thrombocytopenia.'1. (hich of the following is an accurate description of the scan? A. sensation may cause a warm. monitoring temperature C. The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. indicates that oral hygiene need to be improved . The nurse determines that the ($C count is normal if which of the following results is present? A. B. ambulation tree times a day $. the test ta%es approximately ! hours . Mm. the test maybe painful B. !+000 to '+000Icu. suggests that the client is anemic '#.((( to ?. .mm. the dye in. (hich goal should be given the highest priority in the :C?? A. C. The nurse determines that this occurrenceA. monitoring hemoglo in and hematocrit .+000 to 1'+000Icu. fluids will be restricted following the test . flushing. . monitoring for pathologic fractures '!.

avoid exposure to sunlight $. The nurse is analy8ing the laboratory results of a client with leu%emia who received a regimen of chemotherapy. decrease platelets $. adrimycin+ vincristine+ oncovin+ prednisone C. anemia C. decreased ($C D.. M74 C. CT scan '*. oncovin. procar a*ine. belomycin+ oncovin+ vincristine+ prednisone $. iopsy of the tumor $. wash the s%in with a mild soap and pat dry C. constipation $. The medications included in the therapy areA. adriamycin+ cytoxan+ prednisone+ oncovin D. The oncology nurse is preparing to administer chemotherapy to the client with . (hich of the following laboratory values does the nurse note specifically as a result of massive cell destruction that occurred from chemotherapy? A. eat a high protein diet . (hich of the following test will confirm the diagnosis of the malignancy? A. prednisone '. diarrhea '/. mechlorethemine. apply pressure on the irritated area to prevent leeding .''. dyspnea C. increased uric acid level '. The nurse is providing instructions to the client receiving external radiation therapy. (hich of the following is :CT a component of the instructions? A.. abdominal ultrasound D.odg%in’s disease. The MC2T li%ely side effect to be expected isA. 2everal diagnostic test are prescribed. The client is receiving external radiation to the nec% for cancer of the larynx. A multiagent medication regimen %nown as MC?? is prescribed. The client is diagnosed as having a bowel tumor. sore throat .

assess s%in turgor *!. The platelet count is 10+000Icu.odg%in’s disease. wea%ness $. The purpose of Allopurinol =Lyloprim> is toA. $ased on this laboratory value+ the priority nursing assessment is which of the following? !. The client with leu%emia is receiving $usulfan =myleran>. Allopurinol =Lyloprim> is prescribed for the client. D4 will wear loose fitting clothingE *1. measure abdominal girth . 26 will limit sun e$posure to % hour daily3 . The client is admitted to the hospital with a diagnosis of suspected . A gastrectomy is performed on a client with gastyric cancer. (hich of the following assessment signs would the nurse MC2T li%ely to note in the client? A. irrigate the :9T $. 4n the immediate postoperative period+ the nurse notes bloody drainage from the :9T. prevent diarrhea *&. D4 will avoid the use of deodorantsE C. preventgouty arthritis notify the physician C. (hich of the ff. assess temperature C.*0. D4 will handle the area gentlyE $. (hich of the following statements+ if made by the client indicates the need for further instruction? A. enlarged lymph nodes *#. continue to monitor the drainage . prevent hyperuricemia $. fatigue C. prevent stomatitis . assess level of consciousness $. The nurse teaches s%in care to the client receiving external radiation therapy. assess bowel sounds . is the MC2T appropriate nursing intervention? A. The nurse is reviewing the laboratory results of a client receiving chemotherapy. weight gain D.

placing cool compress on the affected arm B. The nurse is teaching $26 to a client who had a hysterectomy. hematuria $. avoiding arm exercises in the immediate post)operative period *.. gently feel the testicle with one finger to feel for a growth . at a specific day of the month and on the same day every month thereafter */. (hich of the following nursing interventions would assist in preventing lymphedema of the affected arm? A. at ovulation time . @ to %( days after menstruation $. The nurse is reviewing the history of a client with bladder cancer. a red and moist stoma .*'. maintaining an 4G site below the antecubital area of the affected side .. fre1uency of urination C. a pale stoma $. a dry stoma C. The MC2T appropriate instruction regarding $26 should be performed is!. urgency of urination . a dar%)colored stoma *. examine testicles when lying down B. The nurse is assessing the stoma of a client following a ureterostomy. elevating the affected arm on pillow elow the heart level C. The nurse is instructing the client+ $en how to perform testicular self) examination. the est time for the e$amination is after a shower C. The nurse is caring for a client following a radical mastectomy. dysuria **. "ust before menses begin C. (hich instruction is correct? A. The MC2T common symptom of this type of cancer is which of the following? A. (hich of the following does the nurse expect to note? A.

&. 0 .!. The nurse writes down which of the following instructions for the client to follow before the test? !. The client being seen in a physician’s office has "ust been schedule for a barium swallow the next day. at the onset of menstruation B. monitoring temperature . eat regular supper and brea%fast C. Cn review of the post)operative orders+ which of the following+ if prescribed+ does the nurse 1uestion and verify? .#. one wee" after menstruation egins C. assessing for the return of the gag refle$ $. monitor own bowel movement pattern for constipation . The nurse is instructing a group of female about $26. The client has undergone esophagogastroduodenoscopy =69 >. testicular examination should be done at least every * months .ewelry efore the test $. The nurse places highest priority on which of the following items as apart of the client’s care plan? !. # $. giving warm gargle for sore throat C. / C. every month during ovulation . monitoring complaints of heartburn . 1' .1. wee%ly at the same time of the day .. The nurse instructs the clients to perform the examinationA. ofA. The nurse is caring for a client following a $illroth 44 ?rocedure. The nurse should plan on maintaining an approximately gastric p. The client is diagnosed with bleed and the bleeding has been controlled antacid are prescribed to be administered every hour. continue to ta%e all oral medication as scheduled . removal all metal and .0.

. coughing and deep breathing exercises C. Dheal the gastric mucosaE C. abdominal cramping and pain B. (hen assessing the client+ which finding+ if noted+ would the nurse report to the physician? !. A client who has a peptic ulcer is schedule for a vagotomy. rebound tenderness . loody diarrhea $. radycardia and indigestion C. Ddecreases food absorption in the stomachE $. hemoglobin level of 1! mgIdl . limit the fluid ta"ing with food . double vision and chest pain . 2reduces the stimulus to acid secretion3 . irrigating the N8 tu e $. leg exercises .!. hypotension C. Dhalts stress reactionE D. (hich of the following syndrome indicate this occurrence? A. sweating and pallor .. The client as%s about the purpose of this procedure. The nurse ins monitoring a client for the early signs and symptoms of dumping syndrome. early ambulation . The $62T nursing response is which of the following? A.'.. eat high carbonated food B. The nurse is caring for a hospitali8ed patient with a diagnosis of ulcerative colitis.*. The nurse is providing discharge instruction to a client following gastrectomy which of the following measures will the nurse instruct the client to the following assist in preventing dumping syndrome? A..

(hich measure will the nurse include in the plan of care for this client? A. The client with ascites is schedule for a paracentesis. supine C. sit in a high)fowler’s position during meals . ambulate following a meal . (hich of the ff. upright $. diarrhea C.C. administer magnesium antacids .0. right side lying D./. constipation alternating with diarrhea . sexual dysnfunction . (hich of the following positions will the nurse assist the client to assume for this procedure? A. The client with cirrhosis has ascites and a fluid volume excess. (hich of the following stool characteristic does the nurse expect to note in this client? A.1. restrict the amount of fluids consumed C. The nurse is assisting the physician in performing the procedure. The nurse is caring for a client post)operatively following the creation of a colostomy. encourage ambulation fre1uently . increase the amount of sodium in diet B. bloody stool B. The nurse is reviewing the record of the client with Crohn’s disease. nursing diagnosis does the nurse include in the plan of care? A. ody image distur ance C. stool constantly oo8ing from the rectum . altered nutritionB more than body re1uirements B.!. fear related to poor diagnosis . left side lying .

teaching coughing and deep reathing e$ercises $. The nurse teaches the client to avoid which of these medications altogether because of the irritating effects on the lining of the 94 tract? . fresh fruit B. The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy.&. a"ed chic"en . eating ' to * small meals per day C. ability to wor% at home periodically D. The nurse explain to the client that this test!.#. is uncomfortable ..'.. The medication history of a client with peptic ulcer disease reveals intermittent use of the following medications. (hich of the following interventions is of highest priority in the preoperative teaching plan? !. sleeping . The client with peptic ulcer disease needs dietary modification to reduce episode of epigastric pain. fre1uent need to wor" overtime on short notice . fre1uent need to wor% overtime on short notice . The nurse plans to teach the client that which of the following items+ which the client en"oys+ does not need to be limited or eliminated with this disease? A. teaching leg exercises C.*. coffee . re1uires the client to lie still for short intervals $. re1uires that the client be :?C C. wine C. hours a night $. An ultrasound of the gallbladder is schedule for the client with a suspect diagnosis of cholecystitis. re1uires the administration of oral tables .. The nurse interprets that which of the following items mentioned by the client is most li%ely responsible for the exacerbations? A. A client with peptic ulcer states that stress fre1uently causes exacerbation of the disease. instructions regarding fluid restrictions .

/.A. limit fluid inta%e to prevent diarrhea . ta%e in high)fiber foods such as nuts C.. eggs /1. watches the nurse empty the ostomy bag B. massage the area below the stoma . i uprofen :Aotrin. cucumbers . :i8atidine =Axid> . The client who has undergone creation of a colostomy has a nursing diagnosis of $ody 4mage disturbance. reads the ostomy product literature . sucralfate =Carafate> . high carbohydrates D. low residue . high protein C. The nurse is giving dietary instruction for the client who has a new colostomy. The nurse evaluates that he client is ma%ing the most significant progress toward identified goals if the clientA. cleanse the peristomal s"in meticulously $. practices cutting the ostomy appliance /0. C. The nurse encourages the client to eat foods representing which of the following diets for the first & to * wee%s postoperatively? A. The nurse should teach the client to include which of the following foods in the diet to reduce odor? !. yogurt $. low calorie $. broccoli C. loo"s at the ostomy site C. =?rilosec> B.. The client with a new colostomy is concerned about odor from stool in the ostomy drainage bag. The nurse instructs the ileostomy client to do which of the following as part of essential care of the stoma? !.

/!. fresh whipped cream /*. a"ed scrod C. folate deficiency /&. The nurse evaluates that the client did not fully understand the instructions if the client stated that eating which of the following foods ma%es the stool less watery? A. oiled rice . The nurse assesses the client experiencing an acute episode of cholecystitis for pain that is located in the rightA. fried chic%en $. flexing the left leg /'. The nurse assesses the client in the immediate postoperatively period for which of the following most fre1uent complications of this type of surgery? A. fluid and electrolyte im alance C. pasta C. sauces and gravies . lying flat C. The client has "ust had surgery to create an ileostomy. The nurse evaluates that the client understands the instructions given if the client stated that which of the following food items is acceptable in the diet? !. leaning forward . lower 1uadrant and radiates to the umbilicus . low)fat cheese /#. upper 1uadrant and radiates to the right scapula and shoulder C. The nurse has given instructions to the client with an ileostomy about foods to eat to thic%en the stool. malabsorption of fat . upper 1uadrant and radiates to the left scapula and shoulder B. The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. bran B. The client with acute pancreatitis is experiencing severe pain from the disorder. intestinal obstruction B. sitting up B. The nurse teaches the client to avoid which of the following positions that could aggravate the pain? A.

low#roughage without mil" . carbohydrates /. lower 1uadrant and radiates to the bac% /. hepatitis $ C. *0 minutes after meals .The head nurse of an eye and ear clinic is ordering nursing students. during meals C. The client is beginning to show signs of hepatic encephalopathy. (hat type of hepatitis is this client most li%ely experiencing? !. low)roughage with mil% 100. 4t has been determined that the client with hepatitis has contracted the infection from contaminated food. high)fat with mil% $. minerals $... . upon arising and at bedtime //. The client with Crohn’s disease has an order to begin ta%ing antispasmodic medication. hepatitis ! $.. The nurse should time the medication so that each dose is ta%en!. The nurse plans a dietary consult to limit the amount of which of the following ingredients in the client’s diet? A. The client with ulcerative colitis is diagnosed with mild case of the disease. hepatitis C . The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets? A. hepatitis 2ituation. fat C. high)protein without mil% C. protein . -( minutes efore meals $.

emmetropia '. anterior to the retina $. medial half of the right eye and lateral half of the left eye . medial half of the left eye and lateral half of the right eye #. emmetropia . :ormal visual acuity as measured with a 2nellen eye chart is !0I!0. hyperopia C. (hat does a visual acuity of !0I#0 indicate? ! at '( feet. between the lens and the iris &. presbyopia . left eye only $. (hat condition results when rays of light are focused in front of the retina? !. right eye only C. between the iris and the cornea C. etween the lens and the cornea . An anterior chamber of the eye refers to all the space in what area? A. amage to the visual area of the occipital love of cerebrum+ on the left side+ would produce what type of visual loss? A. myopia $. an individual can read #0 out of '0 total letters on the chart at !0 feet !. As the person grows older+ the lens losses its elasticity+ causing which %ind of farsightedness? A. at #0 feet+ an individual can read letters large enough to be read at !0 feet C. an individual can only read letters large enough to e read at -( feet $. an individual can read !0 out of #0 total letters on the chart .1.

avoid snee8ing . examine the lower eyelid and then the upper eyelid C. 4f a person has a foreign ob"ect of un%nown material that is not readily seen in one eye+ what would the first action be? A. A sudden loss of an area of vision+ as if a curtain were being drawn+ is a principal symptom of? !. out of ed as desired $. and see" medical help . ?ostoperative care following stapedectomy would not include which of the following !.B.. irrigate the eye with opious amounts of water D. retinal detachment $. no moisture in the affected ear C. cataracts . shield the eye from pressure. %eratitis . imenhydrinate = ramamine> is given after a stapedectomy A. glaucoma C. to accelerate the auditory process $. irrigate the eye with a boric acid solution $. pres yopia C.. diplopia . no bending over or lifting /. myopia *. to dull the pain experienced with the semicircular canal is disturbed C. to minimi*e the sensations of e1uili rium distur ances and im alance .

severe earache $. 4n preparing to teach patient about ad"ustment to cataract lenses+ the nurse needs to %now that the lenses will. vertigo and resultant nausea . (hat is the cataract of the eyes? A. .. instillation of miotics $. papilledema 1!. to prevent an increase tendency toward nausea 10. type of surgery $. A client with Meniere’s syndrome is extremely uncomfortable because of which of these? A. how to prevent paralytic illeus . Treating a cataract primarily involves which of the following? A. many perceptual difficulties C. opacity of the cornea $. enucleation 1#. installation of mydriatics C. how to use the call bell C. facial paralysis 11. clouding of the a1ueous humor C. how to prevent respiratory infetins 1&. opacity of the lens . ?reoperative instruction will not need to include A. removal of the lens .

"eep side rails up.ects y one#third# with central vision $. magnify ob"ects by one)third with peripheral vision C. The patient is confused during her first night after eye surgery. 4n the immediate postoperative period the one action that is contraindicated for patient compared with clients after most other operations is which of the following? !. turning on the unoperative side C. Atelectasis $. measures to control nausea and vomiting . sedate her 1. and chec" her fre1uently . reduce ob"ects by one)third with peripheral vision 1'.!. (hat would the nurse do? A. staying in a dar"ened room as much as possi le . reduce ob"ects by one)third with central vision . magnify o . eating after nausea passes 1*. tell her to stay in bed $. prolapse of the iris 1.. e$plain why she cannot get out of ed. 4mmediate nursing care following cataract extraction is directed primarily toward preventing A.. coughing $. ischarge teaching would probably not need to include !. apply restraints to %eep her in bed C. hemorrhage . infection of the cornea C.

bloc%age of the outflow of a1ueous humor by the constriction of the pupil C. using no eye washes or drops unless they were prescribed by the physician . Fea’s glaucoma has been caused by the dilation of the pupil. sewing $. A. pressure of '9 mm+g .Fea visit her ophthalmologist and receives a mydriatic drug in order to facilitate the examination.g D. decrease intraocular pressure resulting from decrease production of a1ueous humor !1. !. 4ntraocular pressure is measured clinically by tonometer. !0. avoiding alcoholic drin%s+B limiting the use of tea and coffee C. (hat tonometer reading would be indicative of glaucoma? A. avoiding being excessively sedentary 1/.g $.g C. pressure of 1' mm. pressure of !0 mm. watching TG C. increase intraocular pressure resulting from the increased production of a1ueous humor . loc"age of he outflow of a1ueous humor y the dilation of the pupil $. wal%ing D. uring a visit to the emergency room+ a diagnosis of acute glaucoma is made. pressure of 10 mm. weeding her garden 2ituation. After returning home+ she experiences severe pain+ nausea and vomiting+ and blurred vision. ?atient also needs to be instructed to limit.$.

4 =olfactory> B. (hich cranial nerve transmits visual impulses? A. colored halos around lights $. medication for severe eye pain . atropine !'. pilocarpine C. 444 =oculomotor> . B. 4G =abducens> !#. 66 :optic. Antreated or uncontrolled glaucoma damages the optic nerve. severe pain in the eye C. C. (hich of the following drugs is a mydriatic? A.!!. dilated and fixed pupils D. (hat was the symptom that probably brought 7oy to the ophthalmologist initially? . restriction of fluids for the first !& hours 2ituation. opacity of the lens !&. 9laucoma is conservatively managed with miotic eye drops. 9laucoma may re1uire surgical treatment. Three of the following signs and symptoms result from optic nerve atrophyB which one does not? A. Mydriatic eye drops are contraindicated for glaucoma.7oy+ a '')year)old man+ is admitted to the hospital with wide)angle glaucoma !*. physostigmatine D. cough and deep)breathing 1h. neostigmine $. ?reoperatively+ the client would be taught to expect which of the following postoperatively? A. turn only to the unaffected side C.

seeing colored flashes of light !. redness and tearing of the eye .. pupil constriction increases outflow of a1ueous humor C. pilocarpine C. avoid exercise !. (hat is an example of a commonly used miotic? A. aceta8olamide = iamox> . increased pupil si8e relaxes the ciliary muscles . (hat is the rationale for using miotics in the treatment of glaucoma? A. decreasing vision $. the blood flow to the con"unctiva is increased #0. and put pressure on the lacrimal duct after instillation.. scopolamine !/. $. reduce fluid inta%e B. The teaching plan for 7oy would include which of the following? A. atropine B. add e$tra lighting in the home C. place the medication in the middle of the lower lid. wear dar% glassesIduring the day . they decrease the rate of a1ueous humor production B. extreme pain in eye C. Miotics are used in the treatment of glaucoma.!. 4nstill the drug to the outer angle of the eye+ have client tilt head bac% . (hen instilling eye drops for a client with glaucoma+ what procedure would the nurse follow? !.

ta%e all medications conscientiously .+ caffeine> C. paraly8e the power of accommodation . Carbonic anhydrase inhibitors are sometimes used in the treatment of glaucoma because they!. orient the client to time+ place+ and person D. ?reventive health teaching would best include which of the points? A. the use of contract lances in older clients is not advisable . spea% in a louder voice $. use touch fre1uently when providing care . dilate the pupil C. early surgical action may be necessary B.C. prevent constipation and avid heavy lifting and emotional excitement ##. (hich of the following actions would best minimi8e this problem? A. instill medication in middle eye+ have client blin% for better absorption #1. depress secretion of a a1ueous humor $. instill the drug at the innermost angleB wipe with cotton away from inner aspect . Teaching a client with glaucoma will not include which of the following? !. 9laucoma is a progressive disease that can lead to blindness. avoid stimulant =eg. all clients over /( years of age should have an annual tonometry e$am C. A client with progressive glaucoma may be experiencing sensory deprivation. 4t can be managed if diagnosed early. clients should see% early treatment for eye infections #&. increase the power of accommodation #!. ensure that a sedative is ordered C. vision can e restored only if the client remains under a physician)s care $.

Cf the following nursing actions+ which would have the highest priority? A. unless he is hypotensive C. a deviated septum C. #'. periodically chec" the position of the nasal pac"ing. $. (hich of the following medications would be used with in order to promote vasoconstriction and control bleeding? !. pilovarpine . minor trauma to the nose $. hypotension #*. advice 9ary to expectorate the blood in the nasopharynx gently and not to swallow it C. . lidocaine C. trendelenburg’s to control shoc% B. The physician decides to insert nasal pac%ing. cylospentolate #. ta%e rectal temperature+ because he must rely on mouth breathing and would be unable to %eep his mouth closed on the thermometer. side)lying+ to prevent aspiration . acute sinusitis D. a sitting position..2ituation.. 4t is unli%ely that 9ary’s history will include A. prone+ to prevent aspiration #. (hich of the following positions would be most desirable for 9ary? A. encourage 9ary to breath through his mouth+ because he may feel panic%y after the insertion.')9ary is seen in the emergency room with the diagnosis of epitaxis. ecause airway o struction can occur if the pac"ing accidentally slip out of place . epinephrine $.

After bleeding has been controlled+ 9ary ta%en to surgery to correct a deviated nasal septum. (hich of the following is li%ely complication of this surgery? A. loss of the ability to smell B. Ase sterile techni1ue $. infection . cocaine+ a fre1uent ingredient in nose drops+ may lead to psychological addiction C. use a sterile suction setup B. o serve for tachycardia &!. Apon his discharge+ the nurse instructs 9ary on the use of vasoconstrictive nose drops and cautions him to avoid too fre1uent+ and excessive use to these drugs+ which of the following provides the best rationale for this caution !. persistent vasoconstriction of the nasal mucosa can lead to alterations in the olfactory nerve 2ituation. ! re ound effect occurs in which stuffness worsens after each successive dose $. turn head to right to suction left bronchus C. $rix has tracheostomy. &1. (hen doing these two procedures at the same time+ the nurse would not do which of the ffA.#/. ina ility to reath through the nose C.$rix had redial and nec% surgery for cancer of the larynx. then the laryngectomy tu e . suction the nose first. suction for no longer then 10 to 1' seconds D. $rix re1uires both nasopharyngeal suctioning and suctioning through laryngectomy tube. these medications may be absorbed systematically+ causing severe hypotension . hemorrhage &0. (hen doing these two procedures at the same time+ the nurse would not do which of the ffA. (hen suctioning and suctioning through laryngectomy tube.

three months after surgery . inspection $. suction the laryngectomy tube first+ then the nose . $rix’s children are concerned about their own ris% of developing cancer. (hich physical examination techni1ue would be used first when assessing the abdomen? !. to prevent pain while swallowing B. (hich one is correct? A. light palpation C. long#term use of corticosteroids enhances the ody)s defense C. when he leaves the hospital B. A nasogastric tube is used to provide $rix with fluids and nutrient for approximately 10 days+ for which of the following reasons? A. lubricate the catheter with saline &#. to prevent contamination of the suture line C. family factors may influence an individual’s susceptibility to neoplasia B. 2exual differences influence an individuals susceptibility to specific neoplasm . The nurse is complaining the initial morning assessment on the client. to decrease need for swallowing . to prevent need for holding head up to ear &&.C. when the esophageal suture line is healed C. All but one of the following are facts that describe malignant neoplasia and must be considered by the nurse in her responses. when he regains all his strength &*. auscultation . (hen would $rix best begin speech rehabilitation? A. living in industriali8ed areas increase an individual’s susceptibility to a malignant neoplasm &'.

regularly assess respiratory status .. increased central venous pressure &/. uring the procedure+ instruction that will assist in insertion would be!. elevated creatinine '0. A client being treated for esophageal varices has a 2engsta%en)$la%emore tube inserted to control the bleeding. The most important assessment is for the nurse toA. elevated amylase . then fle$ his nec" for final insertion $. instruct the client to hold his chin down+ then bac% for insertion of the tube &. monitor 4G fluids for the shift C. The client has orders for a nasogastric =:9> tube insertion. decreased prothrombin formation $. (hich of the following results would the nurse expect to find? A. low al%aline phosphatase C. The most important pathophysiologic factor contributing to the formation of esophageal varices isA. after insertion into the nostril+ instruct the client to extend his nec% C. introduce the tube with the client’s head tilted bac%+ then instruct him to %eep his head upright for final insertion . decreased albumin formation by the liver C. percussion &.. portal hypertension . The nurse analy8es the results of the blood chemistry tests done on a client with acute pancreatitis. chec% that a hemostat is at the bedside $. instruct the client to tilt his head ac" for insertion into the nostril.. low glucose $.

. The nurse doing discharge planning will teach him that the action of cimetidine is toA. inhibit vagal nerve stimulation '&. chec% that the balloon is deflated on a regular basis '1. assisting in inserting an atrial pressure line C. reduce gastric acid output $. sigmoid colostomy with mucous fistula C. inserting an 4G '#. intestinal resection with end#to#end anastomosis . The nurse is admitting a client with Crohn’s disease who is scheduled for intestinal surgery. inserting a nasogastric tu e . protect the ulcer surface C. (hich surgical procedure would the nurse anticipate for the treatment of this conditionA. . ileostomy with total colectomy $. A female client complains of gnawing midepigastric pain for a few hours after meals. 2pecific tests are indicated to rule outA.e is being treated with a histamine receptor antagonists =cimetidine>+ antacids+ and diet. At times+ when the pain is severe+ vomiting occurs. peptic ulcer disease C. inhi it the production of hydrochloric acid :+Cl. pylorospasm '!. assisting in inserting a Miller)Abbott tube $. (hen a client has peptic ulcer disease+ the nurse would expect a priority intervention to beA.. chronic gastritis . cancer of the stomach B. A &0)year)old male client has been hospitali8ed with peptic ulcer disease.

left side. colonoscopy with biopsy and polypectomy ''. Dare you prepared for the test tomorrow?E C. sodium . An appropriate preoperative diet will includepreoperative diet will includeA. A client scheduled for colostomy surgery. fiber '*. roiled fish. The nurse %nows that the client is scheduled for diagnostic tests the following day. left side+ recumbent B. An important assessment 1uestion to as% the client isA. Dwould you li%e to go to the dayroom to watch TG?E $. Dhave you as%ed your physician to give you a sleeping pill tonight?E '. The client should be positioned on hisA. A client who has "ust returned home following ileostomy surgery will need a diet that is supplemented!. 2have you tal"ed with anyone a out the test tomorrow43 . ground hamburger+ rice+ and salad C. broiled chic%en+ ba%ed potato+ and wheat bread $. 3ollowing abdominal surgery+ a client complaining of Dgas painsE will have a rectal tube inserted.. stea%+ mashed potatoes+ raw carrots+ and celery '. and tea . s1uash. potassium $. vitamin $1! C. rice.. sims C. As the nurse is completing evening care for a client+ he observes that the client is upset+ 1uiet+ and withdrawn. right side+ semi)fowler’s ..

the irrigation cone is inserted in an upward direction in relation to the stoma *0. %<& inch $. left side+ semi)3owler’s '/. A client has a bile duct obstruction and is "aundiced. The nurse is teaching a client with a new colostomy how to apply an appliance to a colostomy. 3ollowing a liver biopsy+ the highest priority assessment of the client’s condition is to chec% forA. hemorrhage . pulmonary edema $. pain *!. provide tepid water for athing .! to . 1 inch *1. %((( ml is the usual amount of solution for the irrigation C. the solution temperature should be 100 deg. . use alcohol for bac% rubs . M inch . the solution container should be placed 10 inches above the stoma . maintain the client’s room temperature at . 3 B. 3 C. K inch C. %eep the client’s nails clean and short $. (hich intervention will be most effective in controlling the itching associated with his "aundice? A. (hich of the following statements is most correct regarding colostomy irrigations? A.. uneven respiratory pattern C.' deg.ow much s%in should remain exposed between the stoma and the ring of the appliance? !.

common following this operation $. This suggest that he has a history ofA. indicative of a need to use the incentive spirometer . shortness of breath B. renal failure C. cirrhosis **. in the right lower 1uadrant $.*#. The orders include :?C+ 4G therapy+ and bed rest. (hen a client is in liver failure+ which of the following behavioral changes is the most important assessment to report? A. fatigue . nausea *&. A female client had a laparoscopic cholecystectomy this morning. A client with a history of cholecystitis is now being admitted to the hospital for possible surgical intervention. expected after general anesthesia C. The nurse would explain to the client this symptom is!. lethargy C. The nurse ta%ing a nursing history from a newly admitted client learns that he has a enver shunt. hydrocephalus $. 2he is now complaining of right shoulder pain. in the upper 1uadrant *'. 4n addition to assessing for nausea+ vomiting and anorexia+ the nurse should observe for painA. peripheral occlusive disease D. radiating to the left shoulder D. unusual and will be reported to the surgeon . after ingesting food C.

?eritoneal reaction to acute pancreatitis results in a shift of fluid from the vascular space into the peritoneal cavity.. The assessment finding should be reported immediately should it develop in the client with acute pancreatitis isA. testing for . abdominal pain C. performing a glucometer test . abdominal pain C. begin C?7 */. peritonitis . call the physician . shortness of reath . decreased bowel sounds D.*. measuring the a dominal girth C. oliguria . decreased serum albumin $. The priority intervention isA. straining the urine *. 4f this occurs+ the nurse would evaluate forA. 3or a client with the diagnosis of acute pancreatitis+ the nurse would plan for which critical component of his care? A. monitoring vital signs B. After removing a fecal impaction+ the client complains of feeling lightheaded and the pulse rate is &&.. nausea and vomiting $.0.oman’s sign B. place in shoc" position C.

causes pancreatic islet cell exhaustion C. flushed chee"s. nausea+ vomiting and diarrhea . Addison’s disease . The non)insulin dependent diabetic who is obese is best controlled by weight loss because obesityA.. wea%ness+ lassitude+ irregular pulse+ dilated pupils . fre1uent urination+ flushed face+ pleural friction rub C. diabetes+ type 1 C. reduces pancreatic insulin production .00*. The nurse will %now this client understands if she says these symptoms areA. ehavioral changes $.1. 3ollowing brain surgery+ the client suddenly exhibits polyuria and begins voiding 1' to !0 FIday. thirst+ polyuria and decreased appetite B. diabetes+ type ! . acetone reath. weight gain+ normal breath and thirst .&. abdominal pain+ diminished deep tendon reflexes+ double vision . and increased thirst C. A person with a diagnosis of adult iabetes+ type !+ should understand the symptoms of a hyperglycemic reaction. 2pecific gravity of the urine is 1. reduces the number of insulin receptors $. lurred vision. wea"ness. A nursing assessment for initial signs of hypoglycemia will include!. The nurse will recogni8e these symptoms as the possible development of!. reduces insulin inding t receptor sites .!. Pallor.#. dia etes insipidus $.

./.. hypertension can lead to stro%e with residual paralysis .is physician has ordered short and long acting insulin. decreased calcium one deposits can lead to pathologic fractures $. maintain a dar% and 1uiet room . administer Pitressin Tannate as ordered . (hich of the following priority nursing implementation for a client with a tumor of the posterior lobe of the pituitary gland who has had a urine output of # F in the last hour with a specific gravity of 1. hypothermia related to decreased metabolic rate . tetany+ irritability+ dry s%in and sei8ures C. water retention+ moon face+ hirsutism and purple striae . fluid volume deficit related to polyuria .'.. energy loss. (hen administering two type of insulin+ the nurse would- . polyuria leads to dry s%in and mucous membrane that can brea%down . . edema causes stretched tissue to tear easily C. and cold intolerance . A client has a diagnosis of diabetes. une$plained weight gain. (hich of the following nursing diagnosis would be most appropriate for the client with decreased thyroid functionA...00!? A. measure and record vital signs each shift $. alteration in thought processes related to decreased neurologic function C. turn client every ! hours to prevent s%in brea%down C. hypertension+ diaphoresis+ nausea and vomiting $.*. alteration in growth and development related to increased growth hormone production $. The client hyperparathyroidism should have extremities handled gently because!. The 7: should assess for which of the following clinical manifestations in the client with Cushing’s syndrome? A.

4n an individual with the diagnosis of hyperparathyroidism+ the nurse will assess for which primary symptomA. The nursing assessment reveals the following clinical manifestations.respiratory rate . increased the use of RBA. withdraw long acting insulin+ in"ect air into regular insulin+ and withdraw insulin . withdraw the long acting insulin into the syringe before the short acting insulin B.0. continue with routine nursing care . A client with myxedema has been in the hospital for # days.Imin+ diminished breath sounds in the right lower lobe+ crac%les in the left lower lobe.1. continue with routine nursing care . draw up in two separate syringes+ then combine in one syringe . withdraw the short acting insulin into the syringe efore the long acting insulin C. initiate postural drainage . The most appropriate nursing intervention is to!. Certain physiological changes will result from the treatment for myxedem.!.A. initiate postural drainage . turning. fatigue+ muscular wea%ness $. increased the fre1uency of rest periods C. The symptoms that may indicate adverse changes in the body that the nurse should observe for areA. constipation . increased the fre1uency of rest periods C. cardiac arrhytmias C. tetany . deep reathing e$ercises $. increased respiratory excursion B.

The nurse explains to a client who has "ust received the diagnosis of type ! non) insulin dependent diabetes mellitus =:4 M> that sulfonylureas+ one group of oral hypoglycemic agents+ as act by!. ma%ing the insulin that is produce more available for use C. positive Chvoste%’s sign . uses a ball of a finger as the puncture site B. medicating with urinary antiseptics C.*. A client is scheduled for a voiding cystogram. moon face C. butterfly rash on the face B. (hich nursing intervention would be essential to carry put several hours before the test? A. lowering the blood sugar by facilitating the upta%e and utili8ation of glucose . stimulating the pancreas to produce or release insulin $. forcing fluids . bloated extremities . administering owel preparations . The nurse will %now the client is competent in performing her finger)stic% to obtain blood when sheA. A client has been admitted to the hospital with a tentative diagnosis of adrenocortical hyperfucntion. maintain :?C status $. The nurse is teaching a diabetic client to monitor glucose using a glucometer..&. altering both fat and protein metabolism . avoid using the thumbs as puncture sites . avoid using the fingers of her dominant hand as puncture sites .#. 4n assessing the client+ an observable sign the nurse would chart isA. uses the side of fingertip as the puncture site C.'.

on the inner thigh . temperature B. The best explanation of how the %idneys accomplish regulation of p. capillary refill . fever .. mgIdl. blurred vision $... pupillary reflex /0. is that theyA. The most common early sign of colchicines toxicity that the nurse assess for isA. on the lower a domen $. A client with a diagnosis of gout will beta%ing colchicines and allopurinol $4 to prevent recurrence... secrete ammonia C. A client’s laboratory results have been returned and the creatinine level is . After the lungs+ the %idneys wor% to maintain body p../. Conditions %nown to predispose to renal calculi formation include- . This finding would lead the nurse to place the highest priority on assessingA. secrete hydrogen ions and sodium $. e$change hydrogen and sodium in the "idney tu ules . inta"e andoutput C. anorexia C. under the thigh . decrease sodium ions+ hold on to the hydrogen ions+ and then secrete sodium bicarbonate /1. A retention catheter for a male client is correctly taped if it is!. diarrhea . on the umbilicus C.

evophed. urinary tract infection C. to prevent hypertension . ?olyuria B.*)year)old woman who has been in good health develops urinary incontinence over a period of several days and is admitted to the hospital for a diagnostic wor%up. fluid volume excess . the most appropriate nursing intervention+ based on physician’s orders+ for treating metabolic acidosis is toA.A. assess that height of 4G container is at least #0 inches above venipuncture site C. 4f the alarm sounds on the controller!. administer oral sodium bicarbonate to act as a buffer C. presence of an indwelling 3oley catheter /!. immo ility C. replace potassium ions immediately to prevent hypo%alemia $. glycosuria . ensure that drip cham er is full $. administer 6C cathecholamines :. 4G is attached to a controller to maintain the flow rate. renal failure B. evaluate the needle and 4G tubing to determine if they are patent and positioned appropriately /&. administer fluids to prevent dehydration /#. ensure that the drop sensor is properly placed on the drip chamber . 3or the system to be effective+ the nurse would- . dementia /'. A *0)year)old male client’s physician schedules a prostatectomy and orders a straight urinary drainage system to be inserted preoperatively. dehydration. A . The nurse would assess the client for other indicators ofA.

correct the hyperglycemia that occurs with acute renal failure .. After explaining the procedure to the client+ the nurse collects the first specimen. saved as part of the !& hours collection C. due to insertion techni1ue $. The physician has ordered a !& hours urine specimen. The most common cause of bladder infection in the client with a retention catheter is contaminationA. This specimen. coil the tubing above the level of the bladder $..A. of the urethralI catheter interface D. uring a retention catheter insertion or bladder irrigation+ the nurse must use!. of the internal lumen of the catheter //. clean e1uipment and maintain surgical asepsis C. chec" that the collection ag is vented and distensi le . clean e1uipment and techni1ue /. This specimen is the!. A client in acute renal failure receive an 4G infusion of 10 percent dextrose in water with !0 units of regular insulin. at the time of the catheter removal C. sterile e1uipment and wear sterile gloves $. discarded. position the collection bag above the level of the bladder C. determine that the tubing is less that # feet in length /*. tested+ then discarded . then collection egins $. placed in a separate container and later added to collection /. sterile e1uipment and maintain medical asepsis . The nurse understands that the rational for this therapy is toA.

cover him with a blan%et !. 1. chec% to see if he can move all of his extremities C.5ohn Fee is an 1. N5R>6N8 6C 2ituation. 4n directing emergency care until the ambulance arrives+ it is most important that the school nurse A. force potassium into cells to prevent arrhythmias 100. prevention of spinal shoc% .7 D7C7AB7R '((9 A7D6C!. A primary goal of nursing care when 5ohn is brought into the emergency room will be A. high ris% for fluid volume deficit !A#C!R7 Review !cademy for Nurses 7oom #01 #rd 3loor ? N 5 Fim $ldg. @'%#&(9 N.+ Cagayan de Cro City Tel. >5R86C!.B.less than body re1uirements . altered nutrition. No. A client with chronic renal failure is on continuous ambulatory peritoneal dialysis =CA? >. powerlessness B. high ris" for infection C. Tiano $rothers @alambaguhan 2ts. "eep him flat and immo ili*ed in a natural position . facilitate the intracellular movement of potassium C. (hich nursing diagnosis should have the highest priority? A. :(&&''. place a small ma%eshift pillow under his head $.)year old high school student who suffered an in"ury to his cervical spine in a football game. provide calories to prevent tissue catabolism and a8otemia .

5ohn is found to have a temperature of #*OC =/*. chec" all connections from the respirator C. chec% for signs of shoc% . notify the respiratory therapist to come immediately . notify the respiratory therapist B. &. remove the weights at least once a shift . notify his physician 2ituation. '. The most appropriate initial nursing measure for 5ohn in response to his hypothermia would be to !. massage the ac" of his head $. (hen suctioning 5ohn+ the nurse should .5ohn has a tracheostomy performed and is on assisted ventilation. maintenance of respiration C. place a hot)water bottle at his feet C. cover him with additional lan"ets $.Crutchfield tongs are used to apply traction to realign the spinal cord.B. The alarm on the ventilator sounds. #. maintenance of orientation provision for pain relief 2ituation. position him from side to side C. use a self)inflating bag to ventilate 5ohn *..O3>. encourage involvement in his own care 2ituation. The initial response by the nurse should be to 1uic%ly A. A nursing measure for "ohn while he is in cervical traction should be to !.

(ithin &. ut it is too soon to evaluate the e$tent of the in. suction him for at least #0 seconds with each catheter insertion C. hours he is noted to be having muscle spasms. spinal meningitis C. .is family becomes very excited when they notice these movements.. these movements are reflex activities that indicate that his spinal cord is intact 2ituation. pulmonary congestion D. ensure that he is a le to ta"e a reath etween insertions of the catheter $. These movements are a good sign that he is ma%ing progress C. at this stage.Mar% 7ichards has a compound fracture of the temporal bone. these movements are an indication that he is trying to move and that his will is very strong . (hich of the following actions by the nurse can be safely used to determine if the drainage contains cerebrospinal fluid =C23>? The nurse should A.ury or its permanent effects $. fecal impaction . /. 5ohn suddenly becomes diaphoretic+ his blood pressure rises to 1/0I110+ and he complains of a headache. 4 can understand your excitement.. swab the orifice of the ear with sterile applicator and send the specimen to the laboratory . (hich of the following choices would be the most appropriate response by the nurse? !. The nurse should assess the patient for signs of A. Apon admission 5ohn had a complete loss of motor ability. use clean techni1ue during the suction procedure . apply suction and gently rotate the catheter while inserting it into the bronchial bifurcation . muscle spasms are e$pected.!. The nurse notices bleeding from the orifice of the ear. increased intracranial pressure $.

Mr. 7ichards should be told that !. forcing fluids to restore hydration 1!. placing the patient in Trendelenburg’s position . he will experience a burning sensation as the dye is being in"ected C. local anesthetic is used before in"ecting air into the ventricles of the brain via the spinal canal 2ituation.E 6arly symptoms of 44? include A. pac%ing the ear with cotton balls to stop bleeding B. 7ichards should include A. uring the initial period after a head in"ury+ nursing intervention for Mr. awa"ening the patient every ' hours to determine his level of consciousness C. 1#. the procedure is noninvasive and he will not feel any pain $. elevated temperature and decerebrate posturing D. the procedure is done in the operating room under anesthesia . They include . (hile admitting Mr.Tonnie Miccio is a &#)year old divorced man who has been rushed to the emergency room with an acute gouty arthritis.B. test the C23 with a Tes)Tape and get a negative reading for sugar 10. widening pulse pressure and dilated pupils $. Miccio to the hospital+ the nurse should recogni8e those factors that can precipitate an acute attac%. lot the drainage with a sterile gau*e pad and loo" for a clear halo or ring around the spot of lood C. The nursing care plans states DCbserve for early signs of increased intracranial pressure =44?>. gently suction the ear an send the specimen to the laboratory . rising blood pressure and bradycardia C. and restlessness 11. $efore discharge+ a computeri8ed axial tomogram will be performed to rule out any intracranial or extracranial bleeding. vomiting. nausea.

The nurse should A. The nurse should recogni8e that this is A.1 mgI100 ml C. The expected outcome for colchicine is to A. give the patient the ! aspirin tablets . a psychogenic response to the severe pain 1*. relieve . emotional stress . *.The physician orders colchicines+ 1. detoxify purines in the liver 1. reduce uric acid levels B. Colchicine is the standard drug used to treat acute gout. increase blood flow to the %idney .0 mg every ! hours. %( mg<%(( ml 1'. excessive smo%ing B.0 mgI100 ml $. After receiving the third dose+ the patient complains of nausea+ vomiting+ and diarrhea. large alcohol inta"e C.. Miccio complains of severe pain in his toe and as%s the nurse for ! aspirin tablets. 1. A serum uric acid level is performed by the hospital laboratory. improper rest 1&. a transient side effect and give the next dose B. uring the night+ Mr.' mgI100 ml D.oint pain and inflammation C. an allergic response to the drug and notify the physician . 4n acute gout+ the uric acid level is approximately A.A. !. a sign of to$icity and withhold the medication C.

The nurse should A. mil". recogni8e this as a minor side effect that will subside $. Miccio develops a s%in rash. elevate the foot on a pillow C. as% the patient if he has been ta%ing any aspirin while ta%ing the allopurinol .$. About ! months after ta%ing the allopurinol+ Mr. (hich of the following foods are allowed? A. vegeta les. A teaching program for Mr. lower the plasma and urinary uric acid level $. stating that a low)purine diet should be followed while ta%ing allopurinol !1. relieve pain !0. produce diuresis . 2ome physicians prescribe an al%ali)ash diet to enhance the effect of the medications. cranberries+ cheese+ and whole grain cereals C. offer the patient a cup of tea 1. and most fruits . Miccio should include A. reduce inflammation of the affected "oints C.. restricting fluid inta%e to 1+000 mlIday C. The expected outcome for this drug is to !. e$plaining that acute gouty attac"s often occur during initiation of allopurinol therapy . eggs+ mil%+ prunes+ and plums 1/. liver+ shellfish+ and fats $. emphasi8ing that aspirin is contraindicated in patient’s ta%ing allopurinol $. After the acute attac% subsides+ the physician orders allopurinol =Lyloprim>+ #00 mgIday. notify the physician .

for # hours a day. (hen 6rin’s scoliosis was diagnosed after x)ray examination of her spine+ she was fitted with a Milwau%ee brace. only when you are lying flat+ either resting or sleeping B. be aware that concomitant use of colchicines with allopurinol causes this reaction !!. shower.E The nurse suspected scoliosis when she observed that 6rin’s shoulder on one side was elevated and her in the morning+ one in the afternoon+ and one in the evening 2ituation. head appeared aligned to the opposite side $. hip on the opposite side appeared prominent . on her bac% . (hich of the following would be the best response? A. arm on the same side appeared longer !#. flat and will e logrolled .6rin’s admission to the hospital for spinal fusion was necessary because hr scoliosis did not respond to the Milwau%ee brace. ?reoperative preparation for 6rin includes explaining that for ! wee%s after surgery she will be positioned A. 6rin replies+ DThe school health nurse told me that there may be a problem after all the girls in my class were as%ed to stand erect while she examined our bac%s. !&. recogni*e this is an indication to discontinue the drug . only for special occasions+ such as a party . sitting upright C.C. Cne day+ 5ennifer as%s her roommate+ 6rin+ how her scoliosis was first recogni8ed. or go swimming C. 6rin as%s the nurse when it could be removed each day. for % hour a day when you athe. on either side or prone $. leg on the same side appeared shorter C.

!.Girginia @ is a !') year old woman who wor%s as a lifeguard at the local beach. straighten her legs !. (hile assess Ms. wait 1 hour and supply pressure again $.. A diagnosis of complete transaction of the spinal cord at the third lumbar =F#> level is made. Fong)term goals for Ms. record 6rin’s expected response C. performing wheelchair ambulation $. report 7rin)s response to the surgeon 2ituation. @ include developing s%ills in A. the people who really care about you won’t even notice your cast $. a pretty hairstyle and some loose peasant louses will "eep you loo"ing feminine !*. shrug her shoulders $. 6rin replies+ D:o+ 4 don’t feel anything. bend her elbow D. (hen 6rin is told that after surgery she will wear a body cast for about 1 year+ she begins to sob. "ust ignore any comments that people ma%e D.E The nurse should then A. <ou’re mature enough to wait C. (hich of the following is the best response the nurse can ma%e? A. it only will be for a year.. as% 6rin if her toes feel cold D. 2he tells the nurse she will loo% li%e a football player+ not a girl. @ for neurologic function+ the nurse can expect she will be unable to A. tighten her abdominal muscles C.!'. Cn her way to wor% she is in an automobile accident and is rushed to the hospital by ambulance. activating an electric wheelchair . After surgery+ the nurse applies slight pressure to 6rin’s toes and as%s 6rin is he can feel her foot being touched.

To prevent the complication of urinary tract infections+ which of the following measures should be included in the nursing care plan? !.An open reduction with wiring of the lower "aw to the upper "aw has been done by the surgeon. 4n anticipating the postoperative needs o the patient+ which of the following actions has the priority for 5im? .C. hypertensive crisis #0. dropped prominence of the chee% on the affected side C. teeth unevenly lined up 2ituation. telling the patient to avoid fruit "uices such as plum+ prune+ and cranberry . encouraging e$tra fluid inta"e $. wal"ing with leg races and crutches . offering at least two servings of citrus fruit "uice per day C. spinal shoc" $. observing for symptoms of which of the following is the priority of care for Ms.5im+ a 1. bleeding in the external auditory canal $.)year old senior in high school+ has sustained a simple fracture of the mandible after falling from his motorbi%e. notifying the dietician to include a container of mil% at all meals 2ituation. @ in the acute stages of complete transaction of the lumbar cord? !. #!. respiratory insufficiency C. edema of the eyes and chee%s D. wal%ing without aids !/. Apon admission to the emergency room+ which of the following choices should the nurse expect to observe? A. autonomic hyperreflexia . #1.

The nurse should then !. inserting a gau8e wic% in the inside of the chee% ##. doing a neurologic chec% #'. (hile teaching 5im mouth care the nurse should A. tell him to use an astringent mouthwash to remove all the debris Mrs. place the patient in a flat position . apply ice pac%s to her head C. wearing supportive elastic hose . sit with the patient until the symptoms subside . #&. avoiding ladder distention $. Mrs. complains of severe headache and is extremely anxious. (hen there are lesions above T& and T*+ the patient may experience autonomic hyperreflexia. Marian . chec" the patency of the urinary catheter $. placing paper and pencil at the bedside $. The nurse chec%s her blood pressure and finds it is !10I110. is a '0)year old woman who has a spinal cord lesion at the fourth thoracic =T&> vertebra. changing the patient’s position hourly C. . This condition can be prevented by !. providing a tracheostomy set for tracheostomy care C. explain to him that mouth care should not be done until the wires are removed . show him how to use moistened gau8e sponges to clean his mouth and tongue B.A. demonstrate how an oral irrigation can e performed y inserting the catheter along the inside of the mouth etween the teeth and the chee" C. taping a wire cutter to the head of the ed .

C. completely flat in bed B. The preliminary diagnosis is rupture of an intervertebral dis%. #*. she would gently roll the patient toward her while fle$ing her "nees #. C should be reminded that if she is turning on her side+ it is best if she A. ?roper body mechanics may have prevented this in"ury to Ms. 4f she had adhered to the correct method of turning a patient from the supine position to the left side+ she would have crossed the patient’s right arm over chest+ and crossed the right leg over the left leg. fle$es the uppermost "nee toward the side to which she is turning. apart at the right side of the bed+ she would turn the patient by gently pushing at the shoulder and center of the bac% C.ead elevated with several pillows+ and several pillows under her %nees #. apart at the left side of the ed.. apart at the left side of the bed+ she would gently roll the patient toward her while %eeping her legs straight D. together at the patient’s right side+ she would gently turn the patient by pushing at the shoulder and sacral areas $. and then rolls over . 4nstructions for Ms. After moving a particularly heavy patient+ she suddenly develops severe pain in the lumbosacral area that radiates down her right leg.orothy C+ 7:+ age #'+ is at wor%. head elevated with several pillows+ and her legs flat . and "nees and feet elevated with pillows C. crosses her arms. grasps a chair leg by the side of the bed+ and slowly pulls herself over+ flexing the uppermost %nee $. . Ms. Then+ while standing with her feet A. %eeps her legs extended while crossing them to the side to which she is turning+ and then uses her arms to help turn the upper portion of her body C.. head elevated on a pillow. C’s recuperation at home should include the use of a bed board+ firm mattress+ and rest in which of the following positions? A.2ituation.

she has a feeling of euphoria C. &0. Care after this procedure should include . 2he is admitted to the hospital for further treatment and diagnostic tests. $ecause of her nursing bac%ground+ Ms. prochlorpea8ine =Compa8ine> D. diphenoxylate hydrochloride =Fomotil> C.. administer it immediately efore or after eating $. administer it at least ! hours after eating . there is a decrease in muscle spasms .After a wee% of bed rest at home+ Ms. &!. administer it at specific time intervals+ without regard to meals &1. avoid administering it with dairy products C. crosses her arms+ crosses her legs while they are extended to the side toward which she is turning+ and then rolls over #/. The physician gives Ms. ?lanning for the administration of this medication should include directions to !. To diminish adverse responses to this treatment+ the nurse should re1uest an order for A. C’s condition remains about the same. 2he feels drowsy+ and is sleeping more $. C is placed on bed rest and in pelvic traction. dioctyl sodium sulosuccinate :Colace. C a prescription for methocarbamol =7obaxin>. acetylsalicylic acid =aspirin> $. there is an increase in the %nee)"er% reflex 2ituation. C will %now that the mediation is having the desired effects if which of the following occurs? A. A myelogram is performed on Mrs. C with a water)soluble contrast medium. ?henylbuta8one =$uta8olidin> is ordered for Ms. C. 4n addition to the order for phenylbuta8one+ Ms.

. perform a dominal#strengthening e$ercise . not allowing anything by mouth and %eeping the bed flat C. and e$plain that the pain is to e e$pected ecause of the edema that results from the surgery $. The nurse should !. sit up for at least part of he day C. sleep in prone position $. C has a laminectomy. administer the analgesics as ordered+ but re1uest that the physician chec% the patient immediately C. administer the analgesics as ordered+ and tell Ms.. A white blood count is ordered+ and the report comes bac% at . evidence of leu%openia C. C it will give her relief shortly &&. encouraging fluid inta"e and raising the head of the ed to %9 to -( degrees &#. administer analgesics as ordered. limiting fluid inta%e and elevating the head of the bed to 1' to #0 degrees $. C is encouraged to do which of the following? A.OC =100O3>. 7ehabilitation will be facilitated if Ms.+'00ImmP. &'. ?ostoperatively+ she complains that the pain is no different now than it was before surgery. only slightly elevated . The nurse should recogni8e this as being consistent with rheumatoid arthritis because it is !. 2 is noted to have a rectal temperature of #. Apon admission+ Mrs. withhold the analgesic and notify the physician . 2he has a tentative diagnosis of rheumatoid arthritis. Ms.Martha 2 is a !. perform full trun% range)of)motion exercises 2ituation. indicative of a generali8ed infectious process .A. within normal limits $. encouraging fluid inta%e and %eeping the bed flat D.)year old patient who has experienced increasing generali8ed stiffness+ especially in the morning+ fatigue+ general malaise+ and swelling and pain in the finger "oints.

assist her to accept the fact that rheumatoid arthritis is a log)term illness &. 2amuel that analgesics of choice would be A. an elevated erythrocyte sedimentation rate and negative C)reactive protein B. (hich of the following blood)analysis tests would be consistent with diagnosis of rheumatoid arthritis? A. proppoxyphene hydrochloride = arvon> &/. prevent deformity and reduce inflammation $. provide for comfort and relief of pain . 2 adapt to her chronic illness and plan is to . a low erythrocyte sedimentation rate and positive C)reactive protein &.. an elevated erythrocyte sedimentation rate and positive C#reactive protein C. prevent the spread of the inflammation to other "oints C. C. fre1uent periods of ed rest C. 2 during this initial acute phase of rheumatoid arthritis should be to !. a low erythrocyte sedimentation rate and negative C)reactive protein . fre1uent periods of active exercises B.. encouragement to perform activities of daily living independently '0. uring the acute phase of Mrs. acetylsalicylic acid :aspirin. uring hospitali8ation+ the nurse should explain to Mrs. acetaminophen =Tylenol> . The primary goal of nursing care for Mrs. codeine B. rest for he affected "oints only . The nurse understands that the main nursing goal in helping Mrs.&*. 2’s illness+ which of the following measures would be the most appropriate? A.

The nursing team recogni8es that the role of the nurse therapist is to . you must have some medication to help you gain control . (henever Mrs. while exercising her fingers '!. only when other measures are not effective C. arthritic pain will lessen if you try to grin and bear it '#. provide the care she is unable to give herself B. upon arising and again at bedtime .E (hich response by the nurse is the most therapeutic? A. 2 is discharged+ the nursing staff refers her to a nurse therapist who will assist her in dealing with the anxiety over her arthritis and the changes it has made in her life.A. 6 will teach you some rela$ing e$ercises so you won)t e so tense C. between meals to promote its absorption '&. 2 is discharged+ she is instructed to ta%e aspirin at home. arrange for her after)care with the home health aide '1. 4 will have someone stay with you so you won’t harm yourself B. after exercising her hands C. provide guidance so that she will not repress her illness C. on a regular asis throughout the day $. Mrs. (hen Mrs. 2 feels pain from her arthritis+ she tells the nurse she feels not only the pain but that her Dwhole body feels threatened. 4t is important that she be told to ta%e the drug !. instead of exercising her fingers . 2 is given instructions for using paraffin for her hands. The nurse should include the fact that the dips will be most effective if they are performed !. efore e$ercising her hands $. plan for social contacts so that she will not feel alone . (hen Mrs.

. ''. 2he has experienced severe right hip pain that has not responded to treatment for several years+ and has had increasing difficulty moving about because of damage to the right hip "oint. 2 by !. 2’s ability to perform the exercises . 2’s right hip+ %nee+ and foot to gradually increase range of motion to the right hip. The nurse can best assist Mrs.A. swelling of the operative sites C. the avoidance of aspirin for & days prior to surgery '*. performing the exercises for Mrs. 2 . lead groups in therapy for those with similar problems . 2 should include !. wor% in con"unction with a psychiatrist B. 2 experiences pain C. pain and tenderness in the calf . observing Mrs. (hich of the following should the nurse consider to be most significant if noted when chec%ing Mrs. ?reoperative teaching for Mrs. orthostatic hypotension '. provide individual nursing psychotherapy C. The physical therapist orders exercises of Mrs. isometric e$ercises of the 1uadriceps and gluteal muscles $. administering an analgesic efore the e$ercises $. pain in the operative site $.Twenty years after Mrs. the need to flex the involved hip postoperatively to maintain mobility . instructions on the necessity for %eeping the right leg perfectly straight after surgery C. 2 was first diagnosed with rheumatoid arthritis+ she is admitted for a right total hip replacement. stopping the exercises if Mrs. give family nursing psychotherapy 2ituation. 2 # days postoperatively? A.

Mrs. adduction of her right leg $. learn to deal realistically with your disa ility *0. Mrs. bearing any weight on her right leg .'. prevent further loss of your ability to function D. (hen the rehabilitation therapist tells Mrs. 2 plan for her rehabilitation. 2 as%s the nurse if her new "oint will function normally. particularly if you perform your e$ercise faithfully . 2 as%s the nurse+ D(hat do 4 have to do in therapy?E (hich reply by the nurse most accurately describes the tas% of the patient in rehabilitation? To A.. the new . the prone position in bed '/. 2 1uestions the nurse on the meaning of this phrase. 2 that the outcome of her therapy depends on Dthe ability of the nursing staffE as well as on her motivation+ Mrs. the new "oint won’t function as well as a normal "oint+ but it will be better than the arthritic "oint C. follow the directions of the rehabilitation therapist C. assist the patient in esta lishing therapy priorities and goals *1. regain some function that was lost C. Mrs. supervise the patient’s therapy appointments and exercise program D. follow the instructions of the rehabilitation team $.oint will function almost as well as a normal . 2 should be instructed to avoid !. the new "oint will be stronger than the old one $. The nurse can best answer this by saying that A.oint. abduction of hr right leg C. The nurse should reply that Dthe nurse’s role in rehabilitation is to A. The nurse and Mrs. ma%e the patient as comfortable as possible $.

*!. The fracture is then reduced+ and a 2teinmann pin for . lower than his heart . e applied to the lim in the position in which it is found C. nothing+ because he is sufficiently immuni8ed against tetanus C. Fee is ta%en to the operating room and the wound caused by the fracture of the femur is cleansed and debrided. a full tetanus immuni8ation program $. be applied while the limb is in good alignment B. The nurse should recogni8e that this information is important because it means that he should receive A.ection .Mr.. an additional ooster in. Fee is being transported in the ambulance to the hospital+ he should be positioned with the affected limbs !. Fee is a !0)year)old patient who sustains a compound fracture of the right shaft of the femur and a simple fracture of the ulna in a motorcycle accident.Mr. (hile Mr. extend from the fracture site upward *#. (hile ta%ing a history from the patient+ the nurse determines that his last booster in"ection for tetanus immuni8ation was ' years ago. human tetanus immune globulin 2ituation. slightly abducted *&. elevated $. extend from the fracture site downward . in a flat position C. 4t is important that the splint A. the doctor will be able to assess your limitations in * wee%s and then explain them to you 2ituation. (hile serving as a member of a first aid s1uad+ Mary G+ 7:+ reaches the scene of the motorcycle accident and administers emergency treatment+ which includes the application of a splint.

4n dealing with the weights that are applying the traction+ the nurse should !. pad the edges of the cast *. hold them up if the patient is shifting position in bed C. massage of pressure areas **. The most important nursing measure in the immediate postoperative period will be A. A closed reduction of the ulna is performed+ and a cast is applied. After Mr. remove them if the patient is being moved up in bed . cleansing of the area around the 2teinmann pin C. careful o servation of vital signs .s%eletal traction is inserted. cannot turn or sit up $. To maintain proper alignment and immobili8ation of the femur+ the physician has ordered s%eletal traction with a Thomas splint. The initial action of the nurse should be to A. (hile caring for Mr.. lighten them for short periods if the patient complains of pain . can turn but cannot sit up D. notify his physician immediately . *'. chec" his fingers C. encouragement of isometric exercises $. Fee+ the nurse should explain to him that he A. administer analgesics as ordered B. Fee returns to his room+ he complains of pain in his right arm. allow them to hang freely in place $. can turn and can sit up *. cannot turn but can sit up C..

with a warm solution C. $ecause of the nature of Mr. Fee should show an increase in blood pressure and signs of confusion and increased restlessness+ the nurse should suspect A. impending shoc% C. .*/.1. the groin area for pressure $. pulmonary congestion . at e1ual time intervals . fat em oli . Fee’s wound and the insertion of a 2teinmann pin+ it is especially important that the nurse observe for !. Fee has a Thomas %nee splint in place. his s%in for sings of decubiti . foot drop C.!. The wound is incised and drained+ and neomycin irrigations are ordered four times a day. anxiety . 4n addition to the usual measures for a patient in traction+ it will be important that the nurse observe !. Mr. 4t is important that these irrigations be performed !. Mr. Fee develops an acute locali8ed osteomyelitis. for at least ' minutes . for signs of hypostatic pneumonia .0. 4f Mr. for constipation C. fecal impaction . a concussion $.e is placed on intravenous antibiotic therapy. a foul odor $. with strict aseptic techni1ues $.

> will have to be prescribed .oints. Mrs. once the symptoms of 2F6 subside+ the medication will be discontinued gradually $. (hile doing as nursing history on Mrs. Alfredo+ the nurse should recogni8e that the most common initial symptoms of 2F6 are daily maintenance dose is ' mgIday. The nursing care plan states+ DCbserve for signs of 7aynaud’s phenomenon. . Alfredo 1uestions the nurse about family planning and birth control. oral contraceptives can precipitate an acute e$acer ation of your condition $. is aggravated y smo"ing C. hematuria+ increased blood pressure+ and edema C.oints .#. (hich of the following choices should the nurse include in her answer? !. 4ntrauterine devices are the recommended brithcontrol measures C. Mrs. painful muscles and . studies indicate that the corticosteroids produce fetal damage . is relieved by application of cold compresses to the hands .&. 4n the instructions to Mrs. if adrenal atrophy occurs+ adrenocorticotropic hormone =ACT.Maria Alfredo is a #0)year old married woman who has systemic lupus erythematosus =2F6>. . a weight gain ! pounds per wee% should be reported to the physician C. petechiae in the s%in+ nosebleeds+ and pallor $.*. Afredo is instituted on long)term prednisone therapy. and inflammation of . occurs as a side effect of prednisone B. stiffness. tachycardia+ tremors+ and loss of weight D. Alfredo+ the nurse should emphasi8e that A.'.E The nurse should recogni8e that this phenomenon A.2ituation. there are no contraindications for pregnancy+ as long as the disease is being treated . the maintenance dose will e the lowest dose that controls symptoms .

recommended that she increase her dose of prednisone until her temperature is normal C. . C)reactive protein =C7?> . once the symptoms are controlled+ the corticosteroids will be discontinued $. if hair loss occurs+ it is irreversible C. the lupus erythematosus =F6> factor $. a low)potassium+ low)protein diet is recommended . is the priority care .0. overe$posure to the sun can produce an e$acer ation of symptoms ./. The nurse should A.... recommended that she come to the office to e e$amined y the physician . tell the patient that if she ta%es the prednisone with mil%+ blac%+ tarry stools will be avoided C. reassure the patient that this is a minor side effect of prednisone $. The test that is positive in over /' percent of all patients with 2F6 is the blood test for A. Although many abnormal laboratory findings are found in 2F6+ there is no one specific diagnostic test. The nurse should A.. Alfredo planned by the nurse should include emphasis on which of the following? A. notify the physician ecause lac". The teaching program for Mrs. Mrs. the rheumatoid factor C. Alfredo calls the physician’s office and complains that she has chills+ a fever+ and a cough. tarry stools can e an indication of leeding peptic ulcer . Alfredo tells the nurse that she has had blac%+ tarry stools. Mrs. antinuclear anti odies :!N!. tell the patient that she will as% the physician to prescribe aluminum hydroxide D.. advise that she remain in bed+ drin% extra fluids+ and ta%e aspirin every & hours $.

promotes rest . acute infection can precipitate an attac% .&. nystagmus+ arthralgia+ and vertigo $. encouraging the patient to wal% $. placing the patient in Trendelenburg’s position 2ituation.#. ? includes helping her to recogni8e that A. After a neurological wor%)up she is diagnosed as having multiple sclerosis.4rene ? is being treated in the emergency room for an acute attac% of Meniere’s syndrome .. The main goal of nursing care for Mrs. Meniere’s syndrome is psychogenic and is brought on by stress B. and tinnitus . a labyrinthectomy is the preferred treatment for relieving symptoms and restoring hearing . The nurse should recogni8e that the triad of symptoms associated with Meniere’s syndrome is A. nausea+ vomiting+ and arthralgia C.1. Alfredo to call for an appointment when she is feeling better 2ituation. placing the patient in a semi)3owler’s position C.!. :ursing intervention during an acute attac% includes A.Mrs. C during the acute phase of the disease should be to !. +aving the patient lie flat . . syncope+ headache+ and hearing loss D. vertigo. tell Mrs. C+ #0 years old+ has symptoms of diplopia+ fatigue+ slight vertigo+ and a lac% of coordination. hearing loss. ?atient teaching for Mrs. most patients can e successfully treated with a low#salt diet and diuretics C.

the future will ta%e care of itselfB let’s concentrate on the present .*. is probably the result of an underlying mental disorder $.. Mrs. Mrs. prevent constipation C. indicates that Mrs. acute episodes li"e this are followed y remissions. limiting her activities to those that are absolutely necessary 2ituation.I A diagnosis of idiopathic epilepsy has been made.$. The physician has ordered an electroencephalogram =669> and phenytoin sodium = ilantin>+ #00 mgIday . C’s condition improves+ it is most important that she be given guidance in A. may e a result of pathology and involvement of the lim ic system in the disease . C is note d to be having mood swings. which may last a long time . maintain normal functioning . health history includes two grand mal sei8ures. developing a program of exercise B. indicates that Mrs. 2he is attending the neurological out)patient clinic for the first time. . As Mrs. encourage activities of daily living . learning to handle stressful situations C. see%ing vocational rehabilitation .'.. 4 %now you are worried+ but it is too soon to predict what will happen C. C’s intellectual capacity has been compromised .$arbara is a !#)year)old woman who lives with her mother+ sister+ and brother in a private residence. each individual is very differentB we cannot tell what will happen $. C 1uestions the nurse concerning the usual course of multiple sclerosis. C is having difficulty accepting her diagnosis C. (hich would be the best reply by the nurse? A. 4n deciding what approach to use with her+ the nursing staff should recogni8e that this A.

The nurse should !./. forcing fluids helps to reduce the incidence of sei8ures . during the hyperventilation portion of the test. persons with idiopathic epilepsy have a lower intelligence level B. The nurse should recogni8e that .. . reassure Bara ara that this is a harmless side effect of phenytoin sodium :Dilantin. moderate use of alcohol is permitted C. the incidence of sei8ures is related to hyperglycemia /1.ealth teaching for $arbara includes ensuring that she understands that !. the test measures mental status as well as electrical brain waves C. recommend that $arbara go to the laboratory for a serum ilantin concentration test ... uring a follow)up clinic visit+ $arbara tells the nurse that her urine has had a reddish)brown color. A long)term goal for $arbara is to minimi8e the gingival hyperplasia associated with ilantin therapy. a common characteristic of idiopathic epilepsy is committing acts of violence . tell $arbara that this is a sign of hepatic toxicity C. notify the physician that $arbara has hematuria /!. (hile doing a nursing history on $arbara+ the nurse should recogni8e that A. grand mal sei*ures do not cause mental deterioration C. she may e$perience di**iness . she will be unconscious during the test /0. $. idiopathic epilepsy is a form of mental illness . To prepare $arbara for 669+ the nurse should explain that A. proper prophylactic medication can control the incidence of sei*ures $. during the test she will experience small electric shoc%s that feels li%e pin pric%s $.

+ot and cold sensations.> (hat warning symptoms should the nurse tell $arbara to be aware of? !. another anticonvulsant will be prescribed if it occurs $. 3amily members should be instructed about caring $arbara during a grand mal sei8ure. a regular plan of good oral hygiene is essential .A. The nurse should tell $arbara’s family that after a sei8ure she will be in a confused state and will need some supervision. giving orange "uice before the clonic stage begins D. Muscle twitching+ lapse of consciousness+ anxiety+ and gastrointestinal problems C. gastrointestinal pro lems. The nurse should recogni8e this as !. an$iety. 4mmediate care during a sei8ure should include A. The nurse explains to $arbara that safety precautions can be ta%en by those who have warning symptoms before the sei8ure. a desired therapeutic serum level $. increased tonicity of muscles and autonomic behavior /*. the physician will reduce the dosage at the first sign of hyperplasia C. below the desired therapeutic level C. above the recommended serum level . and mood changes $. 4t is most important for the caring one to be calm because the confused state of the epileptic is considered to be . restraining $arbara’s arms and legs $. $arbara’s serum concentration level ilantin is 1' QgIml. a toxic serum level /&. vitamin C should be ta%en daily with the ilantin /#. turning Bar ara)s head to the side /'. =These symptoms are not part of the sei8ure+ as the aura is. tingling in a local region+ anxiety+ and lapse of consciousness . forcing the mouth open to insert an airway C.

(hile doing a nursing history on Ms. 2he has been referred to the neurology clinic by her physician.E (hich of the following choices would be the nurse’s best responseI A.Ms. a helpless state+ with intellectual deterioration+ difficulty in communication+ and regression to the infantile state /. spastic wea%ness of the limbs+ intention tremors+ and incontinence C. nystagmus+ ataxia+ and tinnitus //. when one slowly learns to cope with the devastating insults to one)s psychological and physical integrity C. <es+ one may learn to induce sei8ures as a way of getting attention from others D. a gross impairment in social and intellectual functioning with crude+ tactless+ and impulsive behavior . 7+ the nurse should expect her to complain of which of the following symptoms? A. passive tremors+ cogwheel rigidity+ and drooling $... $arbara as%s the nurse if it is true that there is an Depileptic personality. an adaptive period. 7+ the nurse should emphasi8e that . /. ptosis. Cne mood swings and a feeling of general inade1uacy and fatigue that result in a decrease of interest B. and fatigue . diplopia. 7+ a #')year old woman+ has myasthenia gravis.A. :o+ deviation in personality is caused by restrictions imposed by society C. the person may ta"e on a sic" role if mismanaged at home or in the community 2ituation. the person must be aware that anxiety over anticipation of a sei8ure may cause personality problems $. 4n preparing a teaching plan for Ms.

7 tells the nurse that each time she ta%es the medication she feels nauseated. a mem er of the family should e taught how to use suction for emergency use . hydrocortisone C. Ms.0 mgIday. 7espiratory distress is common in people with myasthenic crisis? Mar%ed improvement of respirations occurs after the administration of intravenous A. edrophonium chloride :Tensilon. The medication used to treat cholinergic crisis !. hydrocortisone 10!. edrophonium chloride =Tensilon> is the drug of choice in the treatment of myasthenia gravis 100. not to ta%e the medication until she notifies the physician Mr. 7 to A. aminophylline . atropine sulfate $. . 9o+ who has had ?ar%insosn’s disease for & years+ visits his wife daily during her hospital stay. The nurse should tell Ms. crush the tablet before ta%ing it B. physical activity should be planned for the late afternoon early evening C. neostigmine =?rostigmin> C. atropine sulfate D. ta"e the ta let with food or mil" C. The physician has prescribed pyridostigmine =Mestinon>+ illness is being treated with levodopa =F)dopa>. dia8epam =Galium> $. .A. 101. ta%e the tablet on an empty stomach . the anticholinesterase medications cause fewer side effects when ta%en on an empty stomach $.

. . restful environment $. maintain "oint range of motion C. 9o visits his wife+ he is observed to be wal%ing rather slowly. ?lanning for Mr. provide a 1uiet. exhibiting a long)range side effect of F)dopa B.owever+ he complains that he feels di88y whenever he tries to stand up from a lying position. 9o is A.10#. The nurse can help him to be more comfortable by !. e$hi iting a symptom that is characteristic of stage 66 Par"inson)s disease C. explaining that this is a side effect of his medication+ and encouraging increased inta%e of fluids 2ituation. 9o responds to treatment+ and his condition gradually improves.Mr.e develops tachycardia+ a respiratory rate of &0+ and appears extremely anxious. suggesting that he is probably dressing too warmly for the hospital environment . 9o’s care should include measures to !. 10'. tell him that his doctor will be notified of this symptom . decrease social isolation . discussing this pro lem and how he handles it. opening the windows and providing as much ventilation as possible while he is visiting C. The nurse should recogni8e that Mr.e is hospitali8ed with a diagnosis of par%insonian crisis. . beginning to experience atrophy of the cerebral cortex and cellular changes . improve his nutritional status 10*. (hen Mr. The nurse should A. probably doing this on purpose as a way of 10&. Mr. and discussing hygiene measures with him $. explain that this is "ust part of his illness $. go has a sudden exacerbation of symptoms.

should be cautioned against overfatigue C.e states that he his glad that he will be able to continue wor%ing. should e encouraged to e active $. 9o tells the nurse that someone told him that people with ?ar%inson’s disease develop early senility. his information is false+ because ?ar%inson’s disease does not cause any changes in the individual’s intellectual capacities C. needs to recogni8e that his situation is uni1ue 10/. he does not have to worry about senility because he is responding so well to treatment . and it is only in the late stages that any mental changes might ta"e place $. is being unrealistic about his future . Mr. discuss his feelings about his wife’s hospitali8ation 10. (hich of the following is the best initial action by the nurse in response to this complaint? A. An appropriate initial response would be based on the nurse’s recognition that he !. . Par"inson)s disease progresses very slowly over a period of years. 9o discusses his wor% as an accountant with the nurse. give him more time and encouragement to dress himself C. suggest that for the present he wear only the hospital gown . tell him he needs assistance+ and gradually help him B.C. encourage him to change his position slowly .. Mr. listen to his refusal+ but give him assistance as needed 10. 9o has problems in dressing himself as a result of tremors+ but he refuses all assistance.. Mr. although ?ar%inson’s disease does cause mental confusion+ this condition is clinically different from senility . 4n response+ the nurse should explain that !.