Which normal nervous system changes of aging put the geriatric person at higher risk of

falls (select all that apply)?

A. Memory deficit
B. Sensory deficit
C. Motor function deficit
D. Cranial and spinal nerves
E. Reticular activation system
F. Central nervous system changes

ANS
B. Sensory deficit
C. Motor function deficit
F. Central nervous system changes
An older person is at a higher risk for falls because the changes in the nervous system
decrease the sensory function that leads to poor ability to maintain balance and a widened
gait. The motor function deficit decreases muscle strength and agility. The central nervous
system changes in the brain lead to a diminished kinesthetic sense or position sense.
Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation
system do not contribute to the increased risk of falls.

20. A result of stimulation of the parasympathetic nervous system is (select all that apply):

A. constriction of the bronchi.

B. dilation of skin blood vessels.
C. increased secretion of insulin.
D. increased blood glucose levels.
E. relaxation of the urinary sphincters.

ANS
A. constriction of the bronchi.
B. dilation of skin blood vessels.
C. increased secretion of insulin.
E. relaxation of the urinary sphincters.
Stimulation of the parasympathetic nervous system results in constriction of the bronchi,
dilation of blood vessels to the skin, increased secretion of insulin, and relaxation of the
urinary sphincter. Stimulation of the sympathetic nervous system results in increased
blood glucose levels.

15. Which assessments will the nurse make to monitor a patient's cerebellar function
(select all that apply)?
a. Assess for graphesthesia.
b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Check ability to push against resistance.
e. Determine ability to sense heat and cold.

ANS: B,C
*The cerebellum is responsible for coordination and is assessed by looking at the patient's
gait and the finger-to-nose test. The other assessments will be used for other parts of the
neurologic assessment.

47. The nurse is monitoring a patient for increased ICP following a head injury. Which of the following
manifestations indicate an increased ICP (select all that apply)

a. fever
b. oriented to name only
c. narrowing pulse pressure
d. dilated right pupil > left pupil
e. decorticate posturing to painful stimulus

A, B, D, E
The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil,
changes in motor response such as posturing, and fever, which may indicate pressure on the
hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and
bradycardia.

60. The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The
nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which
complications (select all that apply)?

A. Vision loss
B. Cerebral edema
C. Pituitary dysfunction
D. Parathyroid dysfunction
E. Focal neurologic deficits

A,B,C,E
Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including
vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to
dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure
(ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the
pituitary gland.
64. The nurse is providing care for a patient who has been admitted to the hospital with a head injury
and who requires regular neurologic and vital sign assessment. Which assessments will be components
of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)?

A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function

B,D,E
The three dimensions of the GCS are eye opening, best verbal response, and best motor response.
Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

83. Nursing management of a patient with a brain tumor includes (select all that apply):

a. discussing with the patient methods to control inappropriate behavior.

b. using diversion techniques to keep the patient stimulated and motivated.
c. assisting and supporting the family in understanding any changes in behavior.
d. limiting self-care activities until the patient has regained maximum physical functioning.
e. planning for seizure precautions and teaching the patient and the caregiver about anti seizure drugs.

Correct answers: c, e
Rationale: Nursing interventions should be based on a realistic appraisal of the patient's condition and
prognosis after cranial surgery. The nurse should provide support and education to the caregiver and
family about the patient's behavioral changes. The nurse should be prepared to manage seizures and
teach the caregiver and family about antiseizure medications and how to manage a seizure. An overall
goal is to foster the patient's independence for as long as possible and to the highest degree possible.
The nurse should decrease stimuli in the patient's environment to prevent increases in intracranial
pressure.

3. The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For
which medications might the nurse expect to provide discharge instructions (select all that
apply)?

A. Clopidogrel (Plavix)
B. Enoxaparin (Lovenox)
C. Dipyridamole (Persantine)
D. Enteric-coated aspirin (Ecotrin)
E. Tissue plasminogen activator (tPA)

ANS:
A. Clopidogrel (Plavix)
C. Dipyridamole (Persantine)
D. Enteric-coated aspirin (Ecotrin)
Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot
formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid),
combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral
warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to
treat ischemic stroke not prevent TIAs or strokes.

26. Common psychosocial reactions of the stroke patient to the stroke include (select all
that apply)

a. depression.
b. disassociation.
c. intellectualization.
d. sleep disturbances.
e. denial of severity of stroke.

ANS: A, D, E
Rationale: The patient with a stroke may experience many losses, including sensory,
intellectual, communicative, functional, role behavior, emotional, social, and vocational
losses. Some patients experience long-term depression, manifesting symptoms such as
anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy
required to perform previously simple tasks can result in anger and frustration. Frustration
and depression are common in the first year after a stroke. A stroke is usually a sudden,
extremely stressful event for the patient, caregiver, family, and significant others. The
family is often affected emotionally, socially, and financially as their roles and
responsibilities change. Reactions vary considerably but may involve fear, apprehension,
denial of the severity of stroke, depression, anger, and sorrow.

39. A 27-year-old patient who has been treated for status epilepticus in the emergency department will
be transferred to the medical nursing unit. Which equipment should the nurse have available in the
patient's assigned room (select all that apply)?

a. Side-rail pads
b. Tongue blade
c. Oxygen mask
d. Suction tubing
e. Urinary catheter
f. Nasogastric tube
ANS: A, C, D
The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to
clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk
for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of
a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or
abdominal distention. A urinary catheter is not required unless there is urinary retention.

40. A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which
nursing interventions will be included in the plan of care (select all that apply)?

a. Use an elevated toilet seat.

b. Cut patient's food into small pieces.
c. Provide high-protein foods at each meal.
d. Place an armchair at the patient's bedside.
e. Observe for sudden exacerbation of symptoms.

ANS: A, B, D
Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An
armchair should be used when the patient is seated so that the patient can use the arms to assist with
getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein
foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without
acute exacerbations.

42. A patient is diagnosed with cluster headaches. The nurse knows that which characteristics are
associated with this type of headache (select all that apply)?

a. Family history
b. Alcohol is the only dietary trigger
c. Abrupt onset lasting 5 to 180 minutes
d. Severe, sharp, penetrating head pain
e. Bilateral pressure or tightness sensation
f. May be accompanied by unilateral ptosis or lacrimation

ANS: b, c, d, f. Cluster headaches have only alcohol as a dietary trigger and have an abrupt onset lasting
5 minutes to 3 hours with severe, sharp, penetrating pain. Cluster headaches may be accompanied by
unilateral ptosis, lacrimation, rhinitis, facial flushing or pallor and commonly recur several times each
day for several weeks, with months or years between clustered attacks. Family history and nausea,
vomiting, or irritability may be seen with migraine headaches. Bilateral pressure occurring between
migraine headaches and intermittent occurrence over long periods of time are characteristics of
tension-type headaches.
49. The patient is diagnosed with complex focal seizures. Which characteristics are related to complex
focal seizures (select all that apply)?

a. Formerly known as grand mal seizure

b. Often accompanied by incontinence or tongue or cheek biting
c. Psychomotor seizures with repetitive behaviors and lip smacking
d. Altered memory, sexual sensations, and distortions of visual or auditory sensations
e. Loss of consciousness and stiffening of the body with subsequent jerking of extremities
f. Often involves behavioral, emotional, and cognitive functions with altered consciousness

ANS: C, D, F
Complex focal seizures are psychomotor seizures with automatisms such as lip smacking. They cause
altered consciousness or loss of consciousness producing a dreamlike state and may involve behavioral,
emotional, or cognitive experiences without memory of what was done during the seizure. In
generalized tonic-clonic seizures (previously known as grand mal seizures) there is loss of consciousness
and stiffening of the body with subsequent jerking of extremities. Incontinence or tongue or cheek
biting may also occur.

55. Priority Decision: The nurse finds a patient in bed having a generalized tonic-clonic seizure. During
the seizure activity, what actions should the nurse take (select all that apply)?

a. Loosen restrictive clothing.

b. Turn the patient to the side.
c. Protect the patient's head from injury.
d. Place a padded tongue blade between the patient's teeth.
e. Restrain the patient's extremities to prevent soft tissue and bone injury.

ANS: A, B, C.
The focus is on maintaining a patent airway and
preventing patient injury. The nurse should not place objects in the patient's mouth or restrain the
patient.

83. When establishing a diagnosis of MS, the nurse should teach the patient about what diagnostic
studies (select all that apply)?

A. EEG
B. CT scan
C. Carotid duplex scan
D. Evoked response testing
E. Cerebrospinal fluid analysis
ANS: B, D, E
There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid
analysis, and MRI along with history and physical examination are used to establish a diagnosis for MS.
EEG and carotid duplex scan are not used for diagnosing MS.

19. The spouse of a male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am just
exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take
next (select all that apply)?

a. Suggest that a long-term care facility be considered.

b. Offer ideas for ways to distract or redirect the patient.
c. Suggest that the spouse consult with the physician for antianxiety drugs.
d. Educate the spouse about the availability of adult day care as a respite.
e. Ask the spouse what she knows and has considered about dementia care options.

ANS:
b. Offer ideas for ways to distract or redirect the patient.
d. Educate the spouse about the availability of adult day care as a respite.
e. Ask the spouse what she knows and has considered about dementia care options.
The stress of being a caregiver can be managed with a multicomponent approach. This includes respite
care, learning ways to manage challenging behaviors, and further assessment of what the spouse may
already have considered. The patient is in the early stages and does not need long-term placement.
Antianxiety medications may be appropriate but other measures should be tried first.

34. When providing community health care teaching regarding the early warning signs of Alzheimer's
disease, which signs should the nurse advise family members to report (select all that apply)?

A) Misplacing car keys

B) Losing sense of time
C) Difficulty performing familiar tasks
D) Problems with performing basic calculations
E) Becoming lost in a usually familiar environment

ANS:
B) Losing sense of time
C) Difficulty performing familiar tasks
D) Problems with performing basic calculations
E) Becoming lost in a usually familiar environment
Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time,
and becoming lost in a usually familiar environment are all part of the early warning signs of Alzheimer's
disease. Misplacing car keys is a normal frustrating event for many people.
41. The patient is having some increased memory and language problems. What diagnostic tests will be
done before this patient is diagnosed with Alzheimer's disease (select all that apply)?

A) Urinalysis
B) MRI of the head
C) Liver function tests
D) Neuropsychologic testing
E) Blood urea nitrogen and serum creatinine

ANS:
A) Urinalysis
B) MRI of the head
C) Liver function tests
D) Neuropsychologic testing
E) Blood urea nitrogen and serum creatinine
Because there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause
manifestations of dementia, testing must be done to eliminate any other causes of cognitive
impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain
tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal
dysfunction, and neuropsychologic testing to assess cognitive function.

43. What manifestations of cognitive impairment are primarily characteristic of delirium (select all that
apply)?

a. Reduced awareness
b. Impaired judgments
c. Words difficult to find
d. Sleep/wake cycle reversed
e. Distorted thinking and perception
f. Insidious onset with prolonged duration

ANS: A, D, E. Manifestations of delirium include cognitive impairment with reduced awareness, reversed
sleep/wake cycle, and distorted thinking and perception. The other options are characteristic of
dementia.

56. The sister of a patient with AD asks the nurse whether prevention of the disease is possible. In
responding, the nurse explains that there is no known way to prevent AD but there are ways to keep the
brain healthy. What is included in the ways to keep the brain healthy (select all that apply)?

a. Avoid trauma to the brain.

b. Recognize and treat depression early.
c. Avoid social gatherings to avoid infections.
d. Do not overtax the brain by trying to learn new skills.
e. Daily wine intake will increase circulation to the brain.
f. Exercise regularly to decrease the risk for cognitive decline

ANS: A, B, F. Avoiding trauma to the brain, treating depression early, and exercising regularly can
maintain cognitive function. Staying socially active, avoiding intake of harmful substances, and
challenging the brain to keep its connections active and create new ones also help to keep the brain
healthy.

61. The health care provider is trying to differentiate the diagnosis of the patient between dementia and
dementia with Lewy bodies (DLB). What observations by the nurse support a diagnosis of DLB (select all
that apply)?

a. Tremors
b. Fluctuating cognitive ability
c. Disturbed behavior, sleep, and personality
d. Symptoms of pneumonia, including congested lung sounds
e. Bradykinesia, rigidity, and postural instability without tremor

ANS: B, E. Dementia with Lewy bodies (DLB) is diagnosed with dementia plus two of the following
symptoms: (1) extrapyramidal signs such as bradykinesia, rigidity, and
postural instability but not always a tremor, (2) fluctuating cognitive ability, and (3) hallucinations. The
extrapyramidal signs plus tremors would more likely indicate Parkinson's disease. Disturbed behavior,
sleep, personality, and eventually memory are characteristics of frontotemporal lobe degeneration
(FTLD).

62. Delegation Decision: The RN in charge at a long-term care facility could delegate which activities to
unlicensed assistive personnel (UAP) (select all that apply)?

a. Assist the patient with eating.

b. Provide personal hygiene and skin care.
c. Check the environment for safety hazards.
d. Assist the patient to the bathroom at regular intervals.
e. Monitor for skin breakdown and swallowing difficulties.

ANS: A, B, D. All caregivers are responsible for the patient's safety. Basic care activities, such as those
associated with personal
hygiene and activities of daily living (ADLs) can be delegated to unlicensed assistive personnel (UAP). The
RN will perform ongoing assessments and develop and revise the plan of care as needed. The RN will
assess the patient's safety risk factors, provide education, and make referrals.
The licensed practical nurse (LPN) could check the patient's environment for potential safety hazards.
81. The spouse of a 67-year-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I
am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse
to take next (select all that apply)?

a. Suggest that a long-term care facility be considered.

b. Offer ideas for ways to distract or redirect the patient.
c. Teach the spouse about adult day care as a possible respite.
d. Suggest that the spouse consult with the physician for antianxiety drugs.
e. Ask the spouse what she knows and has considered about dementia care options.

ANS: B, C, E
The stress of being a caregiver can be managed with a multicomponent approach. This includes respite
care, learning ways to manage challenging behaviors, and further assessment of what the spouse may
already have considered for care options. The patient is in the early stages and does not need long-term
placement. Antianxiety medications may be appropriate, but other measures should be tried first.

93. Social effects of a chronic neurologic disease include (select all that apply)

a. divorce.
b. job loss.
c. depression.
d. role changes.
e. loss of self-esteem.

ANS: a, b, c, d, e
Rationale: Social problems related to chronic neurologic disease may include changes in roles and
relationships (e.g., divorce, job loss, role changes); other psychologic problems (e.g., depression, loss of
self-esteem) also may have social effects.

128. A 27-year-old patient who has been treated for status epilepticus in the emergency department will
be transferred to the medical nursing unit. Which equipment should the nurse have available in the
patient's assigned room (select all that apply)?

a. Side-rail pads
b. Tongue blade
c. Oxygen mask
d. Suction tubing
e. Urinary catheter
f. Nasogastric tube
ANS: A, C, D
The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to
clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk
for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of
a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or
abdominal distention. A urinary catheter is not required unless there is urinary retention

129. A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which
nursing interventions will be included in the plan of care (select all that apply)?

a. Use an elevated toilet seat.

b. Cut patient's food into small pieces.
c. Provide high-protein foods at each meal.
d. Place an armchair at the patient's bedside.
e. Observe for sudden exacerbation of symptoms.

ANS: A, B, D
Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An
armchair should be used when the patient is seated so that the patient can use the arms to assist with
getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein
foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without
acute exacerbations.

82. Which nursing actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)
who is part of the team caring for a patient with Alzheimer's disease (select all that apply)?

a. Develop a plan to minimize difficult behavior.

b. Administer the prescribed memantine (Namenda).
c. Remove potential safety hazards from the patient's environment.
d. Refer the patient and caregivers to appropriate community resources.
e. Help the patient and caregivers choose memory enhancement methods.
f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.

ANS: B, C
LPN/LVN education and scope of practice includes medication administration and monitoring for
environmental safety in stable patients. Planning of interventions such as ways to manage behavior or
improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse
(RN)-level education and scope of practice
33. In which order will the nurse take these actions when caring for a patient with left leg fractures after
a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.)
____________________

a. Obtain x-rays.
b. Check pedal pulses.
c. Assess lung sounds.
d. Take blood pressure.
e. Apply splint to the leg.
f. Administer tetanus prophylaxis.

ANS:
C, D, B, E, A, F
The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be
followed by checking the neurovascular status of the leg (before and after splint application).
Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The
tetanus prophylaxis is the least urgent of the actions.

19. A patient with osteomyelitis is treated with surgical debridement with implantation of
antibiotic beads. When the patient asks why the beads are used, the nurse answers (select
all that apply)

a."The beads are used to directly deliver antibiotics to the site of the infection."
b."There are no effective oral or IV antibiotics to treat most cases of bone infection."
c."This is the safest method of delivering long-term antibiotic therapy for a bone infection."
d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections."
e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV
antibiotics."

ANS:
A."The beads are used to directly deliver antibiotics to the site of the infection."
D."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections."
Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized
tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-
impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid
in combating the infection.

22. Which individuals would be at high risk for low back pain (select all that apply)?

a.A 63-year-old man who is a long-distance truck driver

b.A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb
c.A 28-year-old female yoga instructor who is 5 ft, 6 in and weighs 130 lb
d.A 30-year-old male nurse who works on an orthopedic unit and smokes
e.A 44-year-old female chef with prior compression fracture of the spine

ANS: A, B, D, E
Risk factors associated with low back pain include a lack of muscle tone and excess body
weight, stress, poor posture, cigarette smoking, pregnancy, prior compression fractures of
the spine, spinal problems since birth, and a family history of back pain. Jobs that require
repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged periods
of sitting are also associated with low back pain. Low back pain is most often caused by a
musculoskeletal problem. The causes of low back pain of musculoskeletal origin include (1)
acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3)
osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5)
herniation of an intervertebral disc. Health care personnel are at high risk for the
development of low back pain. Lifting and moving patients, excessive time being stooped
over or leaning forward, and frequent twisting can result in low back pain.

37. During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would
expect the patient to report (Select all that apply.)

a. sleep disturbances.
b. multiple tender points.
c. urinary frequency and urgency.
d. cardiac palpitations and dizziness.
e. multijoint pain with inflammation and swelling.
f. widespread bilateral, burning musculoskeletal pain.

Answer: A, B, C, F
These symptoms are commonly described by patients with FMS. Cardiac involvement and
joint inflammation are not typical of FMS.

1. In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that
the joints are damaged by (select all that apply)

a. bony ankylosis following inflammation of the joints

b. the deterioration of cartilage by proteolytic enzymes
c. the development of Heberden's nodes in the joint capsule
d.. increased cartilage and bony growth at the joint margins
e. invasion of pannus into the joint causing a loss of cartilage

Correct answers: A, E
Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in
complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint
changes from chronic inflammation begin when the hypertrophied synovial membrane
invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly
vascular granulation tissue) forms within the joint. It eventually covers and erodes the
entire surface of the articular cartilage. The production of inflammatory cytokines at the
pannus-cartilage junction further contributes to cartilage destruction. The pannus scars
and shortens supporting structures such as tendons and ligaments, ultimately causing joint
laxity, subluxation, and contracture.

6. When caring for a patient with systemic sclerosis, the nurse knows it is important to
instruct the patient related to (select all that apply)

a. avoiding the consumption of high-purine foods

b. strategies for good dental hygiene and mouth care
c. protecting the extremities from hot and cold temperatures
d. maintaining joint function and preserving muscle strength
e. performing mouth excursion (yawning) exercises on a daily basis

Correct answers: B, C, D, E
Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by
fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels,
synovium, skeletal muscle, and internal organs. The nurse should include the following in
the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and
gingival problems); protection of hands and feet from cold exposure and possible burns or
cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures
(they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint
movement occurs); use of assistive devices as appropriate and organization of activities to
preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open
mouth) (helps maintain temporomandibular joint function).

osteoarthritis (OA) of the hip. Which of the following points would the nurse include in this
review of the disorder (select all that apply)?

A. OA cannot be successfully treated with any current therapy options.

B. OA is an inflammatory disease of the joints that may present symptoms at any age.
C.Joint degeneration with pain and disability occurs in the majority of people by the age of
60.
D. OA is more common with aging, but usually it remains confined to a few joints and does
not cause crippling.
E.OA can be prevented from progressing when well controlled with a regimen of exercise,
diet, and medication.
Correct answer:
D. OA is more common with aging, but usually it remains confined to a few joints and does
not cause crippling.
E.OA can be prevented from progressing when well controlled with a regimen of exercise,
diet, and medication.
OA occurs with greater frequency with increasing age, but it usually remains confined to a
few joints and can be managed with a combination of exercise, diet, and medication. OA can
lead to significant disability.

37. Teaching that the nurse will plan for the patient with SLE includes
a. ways to avoid exposure to sunlight
b. increasing dietary protein and carbohydrate intake
c. the necessity of genetic counseling before planning a family
d. the use of no pharmacologic pain interventions instead of analgesics
A. ways to avoid exposure to sunlight

1. Myopia is present in 25% of Americans. Which characteristics are associated with

myopia (select all that apply)?

a. Excessive light refraction

b. Abnormally short eyeball
c. Unequal corneal curvature
d. Corrected with concave lens
e. Image focused in front of retina

ANS: A, D, E. Myopic people may have abnormally long eyeballs, not abnormally short ones,
which occurs in hyperopia. Unequal corneal curvature results in astigmatism.

4. What surgical choices are available for correction of a refractive error (select all that
apply)?

a. LASIK
b. Contact lenses
c. Corrective lenses
d. Photorefractive keratectomy (PRK)
e. Surgical implantation of intraocular lens

ANS: A, D, E. Refractive errors are the most common visual problem and treatment may
include nonsurgical corrections such as corrective glasses and contact lenses. Surgical
therapy includes LASIK, PRK, LASEK, and intraocular
lens implants.
10. Endophthalmitis can be a complication of intraocular surgery or penetrating ocular
injury. What manifestations are expected when the nurse assesses a patient with this
disorder (select all that apply)?

a. Ocular pain
b. Photophobia
c. Eyelid edema
d. Reddened sclera
e. Bleeding conjunctiva
f. Decreased visual acuity

ANS: A, B, F. There are also headaches, reddened and swollen conjunctiva, and corneal
edema. Eyelid edema, reddened sclera, and bleeding conjunctiva do not occur with
endophthalmitis.

14. For the patient with a retinal break, what extraocular techniques may be used with
sclera buckling to seal the break
by creating an inflammatory reaction that causes a chorioretinal adhesion or scar (select all
that apply)?

a. Cryopexy
b. Vitrectomy
c. Pneumatic retinopexy
d. Laser photocoagulation
e. Penetrating keratoplasty

AND: A, D. Vitrectomy is an intraocular procedure but it may

be used with sclera buckling. Pneumatic retinopexy
is an intraocular procedure that may be used with
photocoagulation or cryotherapy. Penetrating keratoplasty
is used for corneal scars or opacities and removes the
cornea.

19. Which characteristics of glaucoma are associated with only primary open-angle
glaucoma (POAG) (select all
that apply)?

a. Gradual loss of peripheral vision

b. Treated with iridotomy or iridectomy
c. Causes loss of central vision with corneal edema
d. May be caused by increased production of aqueous humor
e. Treated with cholinergic agents such as pilocarpine (Pilocar)
f. Resistance to aqueous outflow through trabecular meshwork
ANS: A, D, F. The other answers are associated with primary angleclosure
glaucoma (PACG).

20. Which characteristics of glaucoma are associated with only primary angle-closure
glaucoma (PACG) (select all
that apply)?

a. Caused by lens blocking papillary opening

b. Treated with trabeculoplasty or trabeculectomy
c. Causes loss of central vision with corneal edema
d. Treated with β-adrenergic blockers such as betaxolol (Betoptic)
e. Causes sudden, severe eye pain associated with nausea and vomiting
f. Treated with hyperosmotic oral and IV fluids to lower intraocular pressure

ANS: A, C, E, F. The other answers are associated with primary

open-angle glaucoma (POAG).

23. What characteristics describe the care of a patient with chronic otitis media (select all
that apply)?

a. It is most commonly treated with antibiotics.

b. It is an infection in the inner ear that may lead to headaches.
c. Impairment of the eustachian tube is most commonly associated with effusion.
d. Formation of an acoustic neuroma may destroy the structures of the middle ear or
invade the dura of the brain.
e. The patient who has had a myringotomy with placement of a tympanostomy tube should
be instructed to avoid
getting water in the ear.

ANS: C, E. Antibiotics are used to treat acute otitis media. Both

acute and chronic otitis media occur in the middle ear. A
cholesteatoma may destroy structures in the middle ear or
invade the dura of the brain.

26. What makes up the triad of symptoms that occur with inner ear problems (select all
that apply)?

a. Vertigo
b. Nausea
c. Tinnitus
d. Sensorineural hearing loss
e. Inflammation of the ear canal

ANS: A, C, D. Vertigo, tinnitus, and sensorineural hearing loss

are the triad of symptoms that occur with inner ear
problems.

29.What characteristics of hearing loss are associated with conductive loss (select all that
apply)?

a. Presbycusis
b. Speaks softly
c. Related to otitis media
d. Result of ototoxic drugs
e. Hears best in noisy environment
f. May be caused by impacted cerumen

ANS: B, C, E, F. The remaining answers are characteristics of

sensorineural hearing loss.

30. What characteristics of hearing loss are associated with sensorineural loss (select all
that apply)?

a. Hearing aid is helpful

b. Related to otitis media
c. Caused by noise trauma
d. Linked with otosclerosis
e. Associated with Meniere disease

ANS: A, C, E. The remaining answers are characteristics of

conductive hearing loss.

Which assessments will the nurse make to monitor a patient's cerebellar function (select all that
apply)?

a. Assess for graphesthesia.

b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Check ability to push against resistance.
e. Determine ability to sense heat and cold.
ANS: B, C
The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and
the finger-to-nose test. The other assessments will be used for other parts of the neurologic
assessment