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1) A child is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment
of scoliosis. Which assessment is most important in the immediate postoperative period?

Options:

A) Capillary refill, sensation, and motion in all extremities

B) Pain level

C) Ability to turn using the logroll technique

D) Ability to flex and extend the feet

Correct Answer is: A

Explanation : When the spinal column is manipulated during surgery, altered neurovascular
status is a possible complication; therefore, neurovascular checks including circulation,
sensation, and motion should be checked at least every 2 hours. Level of pain is an important
postoperative assessment, but circulatory status is most important. Assessment of flexion and
extension of the lower extremities is a component of option 1, which includes checking motion,
Logrolling is performed by nurses.

2) A pediatric nurse clinician is discussing the pathophysiology related to childhood leukemia


with a class of nursing students .Which statement made by a nursing student indicates a lack of
understanding of the pathophysiology of this disease?

Options:

A) The presence of a Reed-Sternberg cell is found on biopsy

B) Normal bone marrow is replaced by blast cells

C) Red blood cell production is affected

D) The platelet count is decreased

Correct Answer is: A


Explanation : Reed-Sternberg cell is a giant binucleated or multinucleated macrophage that is
characteristic of Hodgkins disease.

3) A 4-year-old child is admitted to the hospital for abdominal pain.The mother reports that the
child has been pale and excessively tired and is bruising easily.On physical
examination,lymphadenopathy and hepatosplenomegaly are noted.Diagnostic studies are being
performed on the child because acute lymphocytic leukemia is suspected.The nurse understands
that which diagnostic study will confirm this diagnosis?

Options:

A) A platelet count

B) Bone marrow biopsy

C) A lumber puncture

D) White blood cell count

Correct Answer is: B

Explanation : Bone marrow biopsy is a investigation for acute lymphocytic leukemia.

4) A nurse instructs the parents of a child with leukemia regarding measures related to
monitoring for infection.Which statement if made by a parent indicates a need for further
instructions?

Options:

A) I will take a rectal temperatures daily

B) I will perform proper hand-washing techniques

C) I will inspect the skin daily for redness

D) I will inspect the mouth daily for lesions

Correct Answer is: A

Explanation : Option 2,3 & 4 are the important measures to be followed for the infection.
17) A child is receiving vincristine. Understanding the side effects of vincristine, the nurse plans a
diet for the child that is:

Options:

A) Low in fat

B) High in iron

C) High in fluids

D) Low in residue

Correct Answer is: C

Explanation : Constipation from the side effect of an a dynamic ileus can be prevented with high-
fiber foods and liberal fluids. These will keep the stool bulky and soft, promoting evacuation.

20) Developmentally, a gross motor skill the nurse should expect a 3-year-old child to perform is:

Options:

A) Riding alone on a small bicycle

B) Skipping and hopping on alternate feet

C) Standing on one foot for a few seconds

D) Jumping rope by lifting both feet simultaneously

Correct Answer is: C

Explanation : This can be expected; usually it is accomplished by 3 years of age

21) Because a newborn is diagnosed with Down syndrome, a nurse would anticipate that the
infant is at high risk for developing

Options:

A) altered thermoregulation
B) generalized infections

C) feeding problems

D) pathologic jaundice

Correct Answer is: C

Explanation : Inadequate drainage and pooling of mucus in the nose can interfere with feeding.
When eating solid, the child may gag on the food because of the mucus in the oral pharynx. The
protruding tongue interferes with feeding, espeically of solid foods.

22) A child is to receive 15 ml of an antibiotic solution intravenously during a 20-minute period.


The intravenous apparatus delivers 60 drops/ml. To administer the medication within the
prescribed time period, the child should receive how many drops per minute?

Options:

A) 15

B) 30

C) 45

D) 60

Correct Answer is: C

Explanation : Flow Rate = Volume x calibration -------------------------- Time (minutes) Rate = 15 ml x


60 gtts/ml ---------------------- 20 minutes Rate = 900 gtts ------------ 20 min Rate = 45 gtts/min

23) A two-year-old child is receiving chelation therapy for acute lead poisoning. In order to
monitor for drug toxicity, a nurse would closely evaluate which of the following laboratory
values?

Options:

A) Hemoglobin

B) Blood urea nitrogen


C) Unconjugated bilirubin

D) Platelets

Correct Answer is: B

Explanation : Chelation should not be performed in the absence of adequate urine flow.
Impending renal failure due to drug toxicity is noted by the appearance of protein in the urine,
rising blood urine nitrogen and rising serum creatinine levels.

24) An infant who weighs 11 Ib (5 kg) is to receive 750 mg of an antibiotic in a 24 hour period.
The liquid antibiotic comes in a concentration of 125 mg/5 ml. If the antibiotic is to be given
three times each day, how many milliliters would the nurse administer with each dose?

Options:

A) 2

B) 5

C) 6.25

D) 10

Correct Answer is: D

Explanation : The nurse would first calculate how much antibiotic should be given for the dose:
750 mg = x mg ------------ ------- 24 hr 8 hr 24 x = 6100 X = 250 mg/dose Now calculate the number
of milliliters needed per dose: Dose Desired ------------------- X Dose on Hand Vehicle = number of
ml/dose 250 mg ---------- X 5 ml = number of m1/dose 1250 mg ----------- = 10 m1/dose 125 mg
125 mg

26) Which of the following instructions regarding mouth care should be given to the parent of a
four-year-old child who is receiving cancer chemotherapy?

Options:

A) Brush your child's teeth twice each day using a firm-bristled toothbrush

B) Avoid using alcohol-based mouth washes to rinse your child's mouth


C) Floss your child's teeth daily with a gortex flossing string

D) Have your child refrain from eating foods that have a high sugar content

Correct Answer is: B

Explanation : Oral ulcers greatly compound anorexia and may be a side effect of chemotherapy.
Helpful interventions include rinsing the mouth with normal saline or sodium bicarbonate
mouth washes, and using local anesthetics such as Chloraseptic lozenges or nonprescription
medications without alcohol.

27) A client who is suspected to have lung cancer is scheduled for a computed tomography (CT)
scan as part of his initial workup. The nurse knows, the reason for this test is:

Options:

A) The CT is far superior to magnetic resonance imaging for evaluating lymph node metastasis

B) The CT is useful for distinguishing small differences in tissue density and detecting nodal
involvement

C) The CT is noninvasive and readily available

D) The CT can distinguish a malignant from a nonmalignant adenopathy

Correct Answer is: B

Explanation : CT scanning is the standard noninvasive method used in a workup for lung cancer
because it can distinguish small difference in tissue density and in detecting nodal involvement.
CT is comparable to magnetic resonance imaging in evaluating lymph node metasis. CT is
noninvasive and usually available, but these are not the main reasons for its use. The CT can
distinguish malignancy in some situation only.

28) A client with a family history of cancer, wants to know the single most important risk factor
for cancer. The nurse should discuss:

Options:

A) Lifestyle choices
B) Age

C) Family history

D) Infections

Correct Answer is: B

Explanation : Because more than 50% of cancer occur in people who are older than 65 years of
age, the single most important factor in determining the risk would be age.

29) An environmental factor that increases the risk of cancer is:

Options:

A) Gender

B) Nutrition and infection

C) Age

D) Immunologic status

Correct Answer is: B

Explanation : Environmental factor includes place of residence, nutrition, occupation, personal


habits, latrogenic factors, and physical environment. Gender, immunologic status, and age are
individual factors.

30) Prevalance of cancer is defined as:

Options:

A) The likelihood cancer will occur in a lifetime

B) The number of persons with cancer at a given point of time

C) All cancer cases more than 5 years old

D) The number of new cancers in a year


Correct Answer is: B

Explanation : The word prevalence in a statistical setting is defined as the number of cases of a
disease present in a specified population at a given time.

31) Following a course in radiation therapy, the client is experiencing radiodermatitis. The most
effective method of treating the skin is to:

Options:

A) Wash the area with soap and warm water

B) Apply a cream or lotion to the area

C) Avoid applying creams or lotions to the area

D) Leave the skin alone until it is clear

Correct Answer is: C

Explanation : Irradiated areas are very sensitive; all creams and lotions, which would serve to
irritate the skin, should be avoided. The area should be washed with lukewarm water; a mild
soap may be used, but most physicians prefer using clear water.

33) The treatment of choice for malignant melanoma of the eye is:

Options:

A) Radiation

B) Cryosurgery

C) Enucleation

D) Chemotherapy

Correct Answer is: C

Explanation : Malignant melanoma of the eye is an intraocular tumor that metastasizes rapidly;
therefore, enucleation (removal of the eye) is the treatment of choice. Radiation, cryosurgery
and chemotherapy are only palliative at best.
34) In cancer therapy, alkylating drugs are used as chemotherapeutic agents. The nurse knows
that these drugs stop cancer growth by:

Options:

A) Interrupting the production of necessary cellular metabolites

B) Damaging DNA in the cell nucleus

C) Creating a hormonal imbalance

D) Destroying messenger RNA

Correct Answer is: B

Explanation : Alkylating agents affect production of DNA, which is turn disrupts cell growth and
division.

35) The main goal of chemotherapeutic drugs in the treatment of the leukemic client is to:

Options:

A) Decrease intervals between exacerbations

B) Assist the client into remission

C) Prevent all future relapses

D) Increase the positive effects of radiation

Correct Answer is: B

Explanation : The main goal is to get the client into remission. Medications are usually
discontinued after remission.

36) Client teaching regarding external radiation therapy includes:

Options:

A) Leave skin markigns between treatments


B) Schedule treatments monthly

C) Fast prior to the treatment

D) Remain isolated after treatments

Correct Answer is: A

Explanation : Skin markings are utilized by the radio-therapist to delineate the exact area of the
body to be irradiated. Treatments are completed daily in a series and do not require fasting or
any form of isolation.

37) Antineoplastic drugs are dangerous because they affect both normal and cancer tissue.
Normal cells that divide and proliferate rapidly are more at risk. Which of the following areas of
the body would be least at risk?

Options:

A) Bone marrow

B) Nervous tissue

C) Lining of the GI tract

D) Hair follicles

Correct Answer is: B

Explanation : Nervous tissue is least at risk, because nervous tissue cells do not have rapid cell
division. Bone marrow, hair follicles, and the lining of the GI tract are the cells that are most
vulnerable, because they have rapid cell division and proliferation similar to cancer cells.

38) The nurse is evaluating a central line before administering the client's chemotherapy. A
priority nursing check is:

Options:

A) Phlebitis and infection

B) Dale of the dressing change


C) Systemic sepsis

D) Mechanical problems with the central line

Correct Answer is: A

Explanation : Phlebitis and infection are common complications of chemotherapy delivery.


Checking the IV site and surrounding area for signs of infection and phlebitis is a priority nursing
action.

39) When a nurse is assessing a client with a radiation implant, the nurse finds it dislodged. The
nurse cannot immediately locate the implant. The first nursing action is to:

Options:

A) Search for the implant in the bed covers and place it in a lead container

B) Pick up the source with a foot-long applicator

C) Call the physician and bar all visitors from the room

D) Notify the radiation safety team

Correct Answer is: C

Explanation : The first nursing action is to bar all visitors from the room and notify the physician.
It is important not to contaminate yourself by searching for the implant. The physician will notify
the radiation team and make decisions about reimplanting the radiation source in the client

40) In which of the following stages carcingogenesis is irreversible?

Options:

A) Progression stage

B) Initiation stage

C) Promotion stage

D) Regression stage
Correct Answer is: A

Explanation : Progression is the change in a tumor from the preneoplastic state or low degree of
malignancy to a rapid growing tumor, which cannot be reversed. Promotion is reversible.
Initiation is at first reversible (through repair of damaged DNA) and later irreversible. Regression
is not a recognized stage of carcinogenesis.

41) A client is diagnosed to have a type of skin caner, which has the poorest prognosis because it
metastasizes so rapidly and extensively via the lymph system. This cancer is:

Options:

A) Basal cell epithelioma

B) Squamous cell epithelioma

C) Malignant melanoma

D) Sebaceous cyst

Correct Answer is: C

Explanation : Malignant melanoma has the poorest prognosis. Basal cell epithelioma and
squamous cell epithelioma are both superficial, easily excised, and slow growing tumors. A
sebaceous cyst is a benign (nonmalignant) growth.

42) The most common route for the administration of chemotherapy drugs is IV route, because it
provides for better absorption. When a client is receiving drugs via this route one of the most
important assessments the nurse will perform is for the complication(s) of:

Options:

A) Infection and phlebitis

B) Catheter clotting

C) Malposition of the needle

D) Sepsis
Correct Answer is: A

Explanation : Infection and phlebitis are two of the most common complications of receiving
chemotherapy drugs via IV. Cathether clotting, malposition of the needle and sepsis are
complications seen with central venous catheter insertion used for continuous infusions.

43) A client is receiving chemotherapy with a combination of antineoplastic agents. A nursing


observation that is considered a side effect of chemotherapy is:

Options:

A) Gingivitis and oral ulcers

B) Slow slurred speech

C) Increased leukoctes on EBC

D) Sinus dysrhythmias with bradycardia

Correct Answer is: A

Explanation : A common side effect of chemotherapy medications is stomatitis. It may be


manifested as inflammation of the gums and ulcerations in the mouth.

44) The nurse is evaluating a client's reaction to external radiation. A common nursing
observation is:

Options:

A) A sudden weight loss

B) Abnorml skin pigmentation

C) Vertigo when sitting up quickly

D) Urinary retention and infection

Correct Answer is: B

Explanation : Due to the skin receiving radiation, eythema, desquamation, and abnormal
pigmentation may develop during radiation.
45) Many screening methods are available for prevention of cancer. The most important one for
the client to be aware of is:

Options:

A) Magnetic Resonance Imaging (MRI)

B) Breast self-examination

C) Risk assessment

D) Sigmoidoscopy

Correct Answer is: B

Explanation : Breast self-examination (BSE) is the most important primary prevention method,
which the client should be taught about. It is performed every month (whereas a mammogram is
done, every year after age 50), and many breast lumps are first found by the woman when she is
examining her breasts. MRI would be done for diagnosis. Risk assessment and sigmoidoscopy are
also important preventive measures, but in priority fall below a BSE.

46) An iatrogenic cause of cancer is:

Options:

A) Ionizing radiation from radon

B) Ionizing radiation from uranium ore

C) X-rays used to treat a tumor

D) Ultraviolent radiation from the sun

Correct Answer is: C

Explanation : Only treatment related X-rays are iatrogenic. The other are agents that occur in the
physical environment naturally.

47) A nurse has been instructed to place an IV line in a patient that has active TB and HIV. The
nurse should where which of the following safety equipment?

Options:

A) Sterile gloves, mask, and goggles

B) Surgical cap, gloves, mask, and proper shoewear

C) Double gloves, gown, and mask

D) Goggles, mask, gloves, and gown

Correct Answer is: D

Explanation : All protective measures must be worn, it is not required to double glove.

48) What is another name for the neoplastic disorder of the bone marrow in which there is an
overproduction of white blood cells?

Options:

A) bone density deficiency

B) leukemia

C) cystic fibrosis

D) arthritis

Correct Answer is: B

Explanation : Leukemia is a potentially fatal disease

49) A nurse has just finished assisting the physician in placing a central intravenous (IV line.
Which of the following is a priority nursing intervention?

Options:

A) Obtain a temperature to monitor for infection

B) Monitor the blood pressure (BP) to asses for fluid volume overload
C) Label the dressing with the date and time of catheter insertion

D) Prepare the client for a chest X-ray

Correct Answer is: D

Explanation : A major risk associated with central line placement is the possibility of a
pneumothorax developing from an accidental puncture of the ling. Assessing the results of a
chest X-ray is one of the best methods to determine if this complication has occurred and to
verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation
would not likely occur immediately after placement. Although BP assessment is always
important in assessing a client’s status after an invasive procedure, fluid volume overload is not a
concern until IV fluids are started. Labeling the dressing site is important but is not the priority.

50) A client diagnosed with leukemia asks the nurse questions about preparing a living will. The
nurse informs the client that the initial step in preparing this document is to:

Options:

A) Consult with the American Cancer society

B) Talk to the hospital chaplain

C) Contact a lawyer

D) Discuss the request with the physician

Correct Answer is: D

Explanation : The client should discuss the request for a living will with the physician. The client
should also discuss this desire with the family. Wills should be prepared with legal counsel and
should identify the executor of the estate, address disturbance and use of property, and the
specific plans for burial. Although options 1 and 2 may be helpful, their contact would not be the
initial step. The lawyer would be contacted following discussion with the physician and family.

51) The nurse receives in transfer from the post-anesthesia care unit a client who has had
skeletal traction applied in the operating room. The nurse takes immediate action to correct
which problem noted with the traction setup?

Options:
A) Weights are resting against the foot of the bed

B) Knots are secured tightly

C) Ropes are centered in the wheel grooves of the pulleys

D) Ropes are free of frays or shredding

Correct Answer is: A

Explanation : The traction setup is checked to ensure that the ropes are in the grooves of the
pulleys, ropes are not frayed, knots are tied securely, and weights are hanging freely from the
ropes. Problems with any of these can interfere with maintenance of proper traction. If any
problems are noted, they should be fixed immediately.

52) A client is being treated in the emergency room for a fractured tibia. The skin is not broken,
but the nurse can see n the X-ray viewer that the bone is completely fractured across the shaft
and has small splintered pieces around it. The nurse interprets that this client’s fracture is a:

Options:

A) Compound fracture

B) Simple fracture

C) Greenstick fracture

D) Comminuted fracture

Correct Answer is: D

Explanation : A comminuted fracture is a complete fracture across the shaft of a bone, with
splintering of the bone into fragments. A compound fracture, also called an open fracture, is one
in which the skin or mucous membrane has been broken, and the wound extends to the depth
of the fractured bone. A simple fracture is a fracture of the bone across its entire shaft with
some possible displacement but without breaking the skin. A greenstick fracture is an
incomplete fracture, which occurs through part of the cross section of a bone. One side of the
bone is fractured, and the other side is bent.

53) Following a thorough assessment, the nurse determines the need to place a vest restraint on
a client. The client tells the nurse that he does not want the vest restraint applied. The best
nursing action is to:

Options:

A) Apply the restraint anyway

B) Contact the physician

C) Medicate the client with a sedative and then apply the resistant

D) Compromise with the client and use wrist restraints

Correct Answer is: B

Explanation : The use of restraints needs to be avoided if possible. If the nurse determines that a
restraint is necessary, this should be discussed with the family, and an order needs to be
obtained from the physician. The nurse should explain carefully to the client and family about
the reasons why the restraint is necessary, the type of restraint selected, and the anticipated
duration of restraint. If the nurse applied the restraint on a client who was refusing such, the
nurse could be charged with battery. Compromising with the client is unethical.

54) A cooling blanket is prescribed for a child with a fever. A nurse caring for the child has never
used this type of equipment, and the charge nurse provides instructions and observes the nurse
using the cooling blanket. The charge nurse intervenes if the nurse:

Options:

A) Places the cooling blanket on the bed and covers it with a sheet

B) Checks the skin condition of the child before, during , and after the use of the cooling blanket

C) Keeps the child uncovered to assist in reducing the fever

D) Keeps the child dry while on the cooling blanket to prevent the risk of frostbite

Correct Answer is: C

Explanation : While on a cooling blanket, the child should be covered lightly to maintain privacy
and reduce shivering. Options 1, 2, and 4 are important interventions to prevent shivering
frostbite, and skin breakdown.
55) The nurse in a well baby clinic is providing safety instructions to the mother of a 1-month-old
infant. Which safety instruction is most appropriate at this age?

Options:

A) Cover electrical outlets

B) Remove hazardous objects from low places

C) Lock all poisons

D) Never shake the infant’s head

Correct Answer is: D

Explanation : The age-appropriate instruction that is most important is to instruct the mother
not to shake or vigorously jiggle the baby’s head. Options 1, 2 and 3 are most important
instructions to provide to the mother as the child reaches the age of 6 months and begins to
explore the environment.

56) A nurse is taking a history from a client suspected of having testicular cancer. Which of the
following data will be most helpful in determining risk factors for this type of cancer?

Options:

A) Number of sexual partners

B) Age and race

C) Number of children

D) Marital status

Correct Answer is: B

Explanation : Two basic but important risk factors for testicular cancer are age and race. The
disease occurs most frequently in Caucasian males between the ages of 18 and 40 years. Other
risk factors include a history of undescended testis and a family history of testicular cancer.
Marital status and number of children do not pose a risk factor for males and testicular cancer.
57) A home car nurse visits a child with Reye’s syndrome and plans to provide instruction to the
mother regarding care of the child. The nurse instructs the mother to:

Options:

A) Increase the stimuli in the environment

B) Give the child frequent, small meals if vomiting occurs

C) Avoid daytime naps so the child will sleep at night

D) Check the child’s skin and eyes every day for a yellow discoloration

Correct Answer is: D

Explanation : Checking for jaundice will assist in identifying the presence of liver complications
that are characteristic of Reye’s syndrome. If vomiting occurs in Reye’s syndrome, it is caused by
cerebral edema, is a sign of increased intracranial pressure, and needs to be reported.
Decreasing stimuli and providing rest decreases stress on the brain tissue. Options 1 and 3 do
not promote a restful environment for the child.

58) A 7-year-old child is hospitalized with a fracture of the femur and is placed in traction. In
meeting the growth and development needs of the child, the nurse most appropriately selects
which of the following play activities for the child?

Options:

A) A coloring book with crayons

B) A finger-painting set

C) A large puzzle

D) A board game

Correct Answer is: D

Explanation : The school-aged child becomes organized with more direction with play activities.
Such activities include collections drawing, construction, dolls, pets, guessing games, board
games, riddles, hobbies, competitive games, and listening to the radio or television. Options 1
and 2 are most appropriate for a preschooler. Option 3 is most appropriate for a toddler.
59) A clinic nurse is performing an assessment on a 12-month-old infant. The nurse determines
that the infant’s is demonstrating the highest level of developmental achievement if the 12-
month-old is able to:

Options:

A) Produce cooling sounds

B) Produce babbling sounds

C) Obey simple commands

D) Begin to use simple words

Correct Answer is: D

Explanation : Simple words such as “mama” and the use of gestures to communicate begins
between 9 and 12 months of age. A 1-to 3-month-old infant will produce cooing sounds.
Babbling is common in a 3-to-4-month-old infant. Between 8 and 9 months, the infant begins to
understand and obey simple commands such as “wave bye-bye.” Using single-consonant
babbling occurs between 6 and 8 months.

60) The parents of a male newborn infant who is uncircumcised request information on how to
clean the newborn’s penis. The nurse tells the parents to:

Options:

A) “Retract the foreskin and cleanse the glans when bathing the infant.”

B) “Avoid retraction of the foreskin to clean the penis because this may cause adhesions.”

C) “Retract the foreskin no farther than it will easily go and replace it over the glans after
cleaning.”

D) “Retract the foreskin and cleanse with every diaper change.”

Correct Answer is: B

Explanation : In male newborn infants, prepuce is continuous with the epidermis of the gland
and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother
should be told to allow separation to occur naturally, which usually occurs between 3 years old
and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently
at this time for cleaning once a week. Options 1, 3, and 4 identify an action that addresses
retraction of the foreskin.

61) The nurse prepares a teaching plan about the administration of ear drops for the parents of a
6-year-old child. The nurse tells the parents that when administering the drops, they should:

Options:

A) Pull the ear up and back

B) Wear gloves

C) Hold the child in a sitting position

D) Position the child so that the affected ear is facing downward

Correct Answer is: A

Explanation : To administer ear drops in a child older than 3 years of age, the ear is pulled
upward and back. The ear is pulled down and back in children younger than 3 years of age.
Gloves do not need to be worn by the parents, but handwashing before and after the procedure
needs to be performed. The child needs to be in a side-lying position with the affected ear facing
upward to facilitate the flow of medication down the ear canal by gravity.

62) A nurse is developing a teaching plan for a client who will be receiving phenelzine sulfate
(Nardil). The nurse plans to tell the client to avoid:

Options:

A) Aged cheeses

B) Cheeries and blueberries

C) Digitalis preparations

D) Vasodilators

Correct Answer is: A


Explanation : Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of
antidepressant medications. An individual on an MAOI must avoid aged cheeses, alcoholic
beverages, avocados, bananas, and caffeine drinks. There are also other food items to avoid,
including chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy
sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain
antidepressants. The client should also avoid antihistamines, antihypertensive medications,
levodopa (L-Dopa), and meperidine (Demerol).

63) A nurse demonstrates to a mother how to correctly take an axillary temperature to


determine if the child has a fever. Which action by the mother would indicate a need for further
teaching?

Options:

A) She selects a thermometer with a slender tip.

B) She holds the thermometer in the axilla for one minute.

C) She records the actual temperature reading and route.

D) She places the thermometer in the center of the axilla

Correct Answer is: B

Explanation : Taking an axillary temperature of at least 5 minutes a most accurate. Options 1, 3,


and 4 are correct steps for taking axillary temperature.

64) A nurse is teaching the client taking cyclosporine (Sandimmune) after renal transplant about
the medication. The nurse tells the client to be especially alert for:

Options:

A) Signs of infection

B) Hypotension

C) Weight loss

D) Hair loss
Correct Answer is: A

Explanation : Cyclosporine is an immunosuppressant medications used to prevent transplant


rejection. The client should be especially alert for signs and symptoms of infection while taking
this medication, and report them to the physician if experienced. The client is also taught about
other side effects of the medications, including hypertension, increased facial hair, tremors,
gingival hyperplasia, and gastrointestinal complaints.

65) Cyclophosphamide (Cytoxan) is prescribed for the client with breast cancer, and the nurse
provides instructions to the client regarding the medication. Which statement by the client
indicates a need for further instructions?

Options:

A) “I need to avoid contact with anyone who recently received a live virus vaccine.”

B) “If I lose my hair, it will grow back.”

C) “If I develop a sore throat, I should notify the physician.”

D) “I need to limit my fluid intake while taking this medication.”

Correct Answer is: D

Explanation : Hemorrhagic cystitis is an adverse reaction associated with this medication. The
client needs to be instructed to consume copious amounts of fluid during therapy. Avoiding
contact with anyone who recently received alive virus vaccine is important because
cyclophosphamide produces immunosuppression, placing the client at risk for infection. Hari will
grow back, although it may have a different color and texture. A sore throat may be an indication
of an infection and needs to be reported to the physician.

66) A nurse is caring for a child who is a victim of child abuse and has determined that the child
uses repression to cope with past life experiences. The nurse implements a plan of care that
includes:

Options:

A) Placing the child on medications that will help forget the incidents

B) Having the child talk about the abuse in detail during the first therapy session

C) Encouraging the child to use play therapy to act out past experiences
D) Telling the child to let the past go and concentrate on the present and future

Correct Answer is: C

Explanation : Play therapy is a nonthreatening avenue through which the child can use artwork,
dolls, or puppets to act out frightening life experiences. Options 1 and 4 devalue the child and
force the child to further repress harmful past experiences rather than facing them and moving
on. Option 2 would be extremely threatening to the child and nontherapeutic.

67) A client has terminal cancer and is using narcotic analgesics for pain relief. The client is
concerned about becoming addicted to the pain medication. The home care nurse allays the
client’s anxiety by:

Options:

A) Explaining to the client that is fears are justified but should be of no concern in the final stages
of care

B) Encouraging the client to hold off as long as possible between doses of pain medication

C) Telling the client to take lower doses of medications even though the pain is not well
controlled

D) Explaining to the client with addiction rarely in the individuals who are taking medication to
relieve pain

Correct Answer is: D

Explanation : Clients who are on narcotics often have well-founded fears about addiction, even
in the face of pain. The nurse has a responsibility to provide correct information about the
likelihood of addiction while still maintaining adequate pain control. Addition is rare for
individuals who are taking medications to relieve pain. Allowing the client to be in pain, 1 is only
partially correct in that it acknowledges the client’s fear.

68) A nurse is caring for a client with cancer who has a nursing diagnosis of Disturbed Body
Image related to alopecia. The nurse plans to teach the client about which of the following
related to this nursing diagnosis?

Options:
A) Proper dental hygiene with the use of a foam toothbrush

B) The importance of rinsing the mouth after eating

C) The use of wigs, which are often covered by insurance

D) The use of cosmetics to hide drug induced rashes

Correct Answer is: C

Explanation : The temporary or permanent thinning or loss of hair, known as alopecia, is


common in clients with cancer receiving chemotherapy. This often causes a body image
disturbance that can be easily addressed by the use of wigs, hats, or scarves. Options 1, 2, and 4
are all unrelated to alopecia.

69) A clinic nurse reads the chart of a client who was seen by the physician and notes that the
physician has documented that the client has Lyme disease stage III. On assessment of the client,
which clinical manifestation would the nurse expect to note?

Options:

A) A generalized skin rash

B) A cardiac dysrhythmia

C) Enlarged and inflamed joints

D) Palpitations

Correct Answer is: C

Explanation : Stage III develops within a month to several months after initial infection. It is
characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which
can persist for several years after the initial infection. Cardiac and neurological dysfunction
occurs in stage II. A rash occurs in stage I.

70) A nurse is caring for a child diagnosed with rubeola (measles). The nurse notes that the
physician has documented the presence of Koplik spots. Based on this documentation, which of
the following would the nurse expect to note on assessment of the child?
Options:

A) Petechiae spots that are reddish and pinpoint on the soft palate

B) Whitish vesicles located across the chest

C) Small, blue-white spots with a red base found on the buccal mucosa

D) Pinpoint petechiae noted on both legs

Correct Answer is: C

Explanation : Koplik spots appear approximately 2 days before the appearance of the rash. These
are small, blue-white spots with a red base found on the buccal mucosa. The spots last
approximately 3 days, after which time they slough off. Options 1, 2, and 4 are incorrect.

71) A nurse is performing on assessment on a child who is to receive a measles, mumps, and
rubella (MMR) vaccine. The nurse notes that the child is allergic to eggs. Which of the following
would the nurse anticipate to be prescribed for this child?

Options:

A) Administration of diphenhydramine (Benadryl) and acetaminophen (Tylenol) before the


administration of the MMR vaccine

B) Administration of a killed measles vaccine

C) Eliminating this vaccine from the immunization schedule

D) Administration of epinephrine (Adrenalin) before the administration of the MMR.

Correct Answer is: B

Explanation : Live measles vaccine is produced by chick embryo cell culture, so the possibility of
an anaphylactic hypersensitivity in children with egg allergies should be considered. If there is a
question of sensitivity, Children should be tested before the administration of MMR vaccine. If a
child tests positive for sensitivity, the child measles vaccine may be given as an alternative.

72) A nurse is preparing a plan of care for a child with leukemia who is scheduled to receive
chemotherapy. Which intervention will the nurse include in the plan of care?
Options:

A) monitor rectal temperatures every 4 hours

B) Monitor mouth and anus each shift for signs of breakdown

C) Provide meticulous mouth care several times daily using an alcohol-based mouthwash and a
toothbrush

D) Encourage the child to consume fresh fruits and vegetables to maintain nutritional status

Correct Answer is: B

Explanation : When the child is receiving chemotherapy, the nurse should avoid taking rectal
temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary
temperatures should be taken to prevent alterations in skin integrity. Meticulous mouth care
should be performed, but the nurse should avoid alcohol-based mouthwash and should use a
softbristled toothbrush. The nurse should assess the mouth and anus each shift for ulcers,
erythema, or breakdown. Bland, nonirritating foods and liquids should be provided to the child.
Fresh fruits and vegetables need to be avoided because they can harbor organisms.
Chemotherapy can cause neurtropenia, and the child should be maintained on a low-bacteria
diet if the white blood cell count is low.

73) A nurse is providing care to the client following a bone biopsy. Which action would the nurse
take as part of aftercare for this procedure?

Options:

A) Keep the area in a dependent position

B) Monitor vital signs once per day

C) Monitor the site for swelling, bleeding, or hematoma formation

D) Administer intramuscular narcotic analgiesics

Correct Answer is: C

Explanation : Nursing care after bone biopsy includes monitoring the site for swelling, bleeding,
or hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital
signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more
severe pain usually indicates that complications arising.
74) A child is brought to the emergency room after being bitten in the arm by a neighbourhood
dog. The nurse performs a focused assessment, cleanses the wound as prescribed, and
continues to perform a thorough assessment on the child. Which of the following is the priority
question for the nurse to ask the mother of the child?

Options:

A) “Did the dog have rabies?”

B) “Are the child’s immunizations up-to-date?”

C) “How old is the dog?”

D) “Did the dog have all of its recommended shots?”

Correct Answer is: B

Explanation : When a bite occurs, the injury site of the bite should be cleansed carefully and the
child should be given tetanus prophylaxis if immunizations are not up-to-date. Option 2 is the
priority consideration. Options 1, 3, and 4 identify information that may have to be obtained, but
are not the priority questions. Additionally, the mother may not have the answers to these
questions.

75) The nurse manager on a surgical unit is holding a meeting with the nursing team to discuss
management’s decision to reduce staffing on the unit. During the discussion, one of the staff
nurses stands up and yells at the nurse manager, using profanity and threatening “to take this
decision further.” To defuse this situation, which of the following would be the best step for the
nurse manager to take?

Options:

A) Tell the nurse that she is suspended for her behavior.

B) Call a break in the meeting and talk to the nurse privately.

C) Ask the rest of the staff if they are also feeling the same way.

D) Try to defuse the situation by telling the nurse to act professionally.

Correct Answer is: B


Explanation : When an individual is verbally acting out and others are present, it is advisable to
isolate the acting-out individual by either removing him or her from the audience or removing
the audience. By doing this, it gives the acting-out individual an opportunity to regain control of
rational thinking without embarrassment in front of peers. It also avoids the audience from
encouraging or coaching the individual and escalating the situation further.

76) The nurse manager on a surgical unit is holding a meeting with the nursing team to discuss
management’s decision to reduce staffing on the unit. During the discussion, one of the staff
nurses stands up and yells at the nurse manager, using profanity and threatening “to take this
decision further.” The nurse manager speaks to the nurse privately in her office. The nurse is still
speaking to the manager with a raised voice. The manager realizes she must set some limits on
this nurse behaviour. Which of the following statements would indicate that the manger can
effectively set limits?

Options:

A) “Settle down or I will call someone in and take you out of the office.”

B) “Start acting professionally or things will be lot worse for you.”

C) “That is enough or I will have you escorted out of the building.”

D) “Please lower your voice or you will not be able to return to the meeting.”

Correct Answer is: D

Explanation : When setting limits on behaviour, it is important to be clear about which behaviour
you are addressing. It is important to tell the acting-out person what the consequences of not
changing the behaviour will be. The consequences need to be reasonable, enforceable, and
consistent.

77) The nurse manager on a surgical unit is holding a meeting with the nursing team to discuss
management’s decision to reduce staffing on the unit. During the discussion, one of the staff
nurses stands up and yells at the nurse manager, using profanity and threatening “to take this
decision further.” The nurse manager knows that setting limits on unacceptable behaviour
should include consequences that are appropriate, enforceable and which of the following?

Options:

A) Consistent.
B) Courteous.

C) Concurrent.

D) Consensual.

Correct Answer is: A

Explanation : To be effective, limits that are set on unacceptable behaviour should be consistent
and should be all of the qualities mentioned in the stem of the question.

78) A nurse’s niece is unexpectedly admitted to the pediatric unit of the hospital where the
nurse works. The nurse is working in the emergency department and accesses her niece’s
computer chart. When telling a coworker what she is doing, the coworker’s best response would
be?

Options:

A) “That is very caring of you to follow up on your niece’s treatment.”

B) “Did you realize that accessing her chart is a breach of confidentiality?”

C) “I have a pediatric background; I can tell you more about her diagnosis.”

D) “I would be interested in hearing how her treatment progresses because her condition is
unique.”

Correct Answer is: B

Explanation : Accessing medical records of clients that are not assigned to the nurse or for which
the nurse has no professional reason to access is considered a breach of confidentiality.

79) A nurse is assessing the casted extremity of a client for signs of infection. Which of the
following findings is indicative of infection?

Options:

A) Coolness and pallor of the skin

B) Presence of a “hot spot” on the cast


C) Diminished distal pulse

D) Dependent edema

Correct Answer is: B

Explanation : Signs and symptoms of infection under a casted area include odor or purulent
drainage from the cast, or the presence of “hot spots,” which are areas on the cast that are
warmer than others. The physician should be notified if any of these occur. Signs of impaired
circulation in the distal extremity include coolness and pallor of the skin, diminished arterial
pulse, and edema.

80) A nurse obtains a fingerstick glucose reading of 425 mg/dL on a client who has recently
started on total parenteral nutrition (TPN). What nursing action is mot appropriate at this time?

Options:

A) Stop the TPN

B) Decrease the flow rate of the TPN

C) Administer insulin

D) Notify the physician

Correct Answer is: D

Explanation : Hyperglycemia is a complication of TPN, and the nurse reports abnormalities t the
physician. Options 1,2 and 3 are not done without a physician’s order.

81) What method would the nurse use to most accurately assess the effectiveness of a weight
loss diet for an obese client?

Options:

A) Checking daily weights

B) Checking serum protein levels

C) Doing daily calorie counts


D) Monitoring daily intake and output

Correct Answer is: A

Explanation : The most accurate measurement of weight loss is daily weighing of the client at the
same time of the day, in the same clothes, and using the same scale. Options 2,3 and 4 measure
nutrition and hydration status.

82) Which assessment is most important for the nurse of make before advancing a client from
liquid to solid food?

Options:

A) Food preferences

B) Appetite

C) Presence of bowel sounds

D) Chewing ability

Correct Answer is: D

Explanation : It may be necessary to modify a client’s diet to a soft or mechanical chopped diet if
the client has difficulty chewing. Food preferences should be ascertained on admission
assessment. Appetite will affect the amount of food eaten, but not the type of diet ordered.
Bowel sounds should be present before introducing any diet, including liquids.

83) A nurse is checking postoperative orders and planning care for a 110-pound child after spinal
fussion. Morphine sulfate, 8 mg subcutaneously every 4 hours prn for pain, is prescribed. The
pediatric drug reference states that the safe dose is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours.
From this information, the nurse determines that:

Options:

A) The dose is too low

B) The dose is too high

C) The dose is within the safe dosage range


D) There is not enough information to determine the safe dose

Correct Answer is: C

Explanation : Use the formula to determine the dosage parameters. Convert pounds to kilograms
by dividing by 2.2. 110 1bs. Divided by 2.2 = 50 kg Dosage parameters: 0.1 mg/kg/dose x 50 kg =
5 mg 0.2 mg/kg/dose x 50 kg = 10 mg Dosage is within the safe dosage range.

84) Following assessment and diagnostic evaluation, it has been determined that the client has
Lyme disease, stage II. The nurse assesses the client for which of the following that is most
indicative of this stage?

Options:

A) Erythematous rash

B) Neurological deficits

C) Headache

D) Lethargy

Correct Answer is: B

Explanation : Stage II of Lyme disease develops within 1 to 6 months in most untreated


individuals. The most serious problems in this stage include cardiac conduction defects and
neurological disorders such as Bell’s plasy and paralysis. These problems are not usually
permanent. Flulike symptoms (headache and lethargy) and a rash appear in stage I.

85) A physician tells a nurse that a client can be given droperidol (Inapsine) for the relief of
postoperative nausea. The nurse anticipates that the physician will order the medication by
which of the following routes?

Options:

A) Oral

B) Intravenous

C) Subcutaneous
D) Intranasal

Correct Answer is: B

Explanation : Droperidol may be administered by the intramuscular (IM) or intravenous (IV)


routes. The IV route is the route used when relief of nausea is needed. The IM route may be
used when the medication is used as an adjunct to anesthesia. Options 1, 3, and 4 are not routes
of administration of this medication.

86) A child is hospitalized with a diagnosis of lead poisoning, and chelation therapy is prescribed.
The nurse caring for the child would prepare to administer which of the following medications?

Options:

A) Activated charcoal

B) Sodium bicarbonate

C) Ipecac syrup

D) Dimercaprol (BAL)

Correct Answer is: D

Explanation : Dimercaprol (BAL) is a chelating agent that is used to treat lead poisoning. Sodium
bicarbonate may be used in salicylate poisoning. Ipecac may be prescribed by the physician to
induce vomiting in certain poisoning situations. Activated charcoal is used to decrease
absorption in certain poisoning situations.

87) A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain
tumor. The nurse anticipates that the physician will prescribe which of the following before the
procedure?

Options:

A) An antihistamine

B) A corticosteroid

C) A sedative
D) An antibiotic

Correct Answer is: C

Explanation : An MRI is a noninvasive diagnostic test that visualizes the body’s tissues, structure,
and blood flow. The client is positioned on a padded table and moved into a cylinder-shaped
scanner. Relaxation techniques or a sedative are used before the procedure to reduce
claustrophobic effects. There is no useful purpose for administering an antihistamine,
corticosteroid, or antibiotic.

88) A nurse is preparing to access an implanted vascular port to administer chemotherapy. The
nurse:

Options:

A) Anchors the port with the dominant hand

B) Palpates the port to locate the center of the septum

C) Places a warm pack over the area for several minutes to alleviate possible discomfort

D) Cleans the area with alcohol, working from the outside inward

Correct Answer is: B

Explanation : Before accessing an implanted vascular port, the nurse must palpate the port to
locate the center of the septum. The port should then be anchored with the nondominant hand.
Cool compresses over the site can help alleviate pain upon entry. The site should be cleansed
with alcohol, Working from the inside out to prevent introducing germs into the access site.

89) A nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of
anxiety. The nurse assigns priority to which assessment finding?

Options:

A) Tearful, withdrawn, oriented times four, isolated

B) Blood pressure 160/100 mmHg; pulse 120 beats per minute; respirations 18 breaths per
minute
C) Temperature 99.4 F, affect bland

D) First clenched, pounding table, fearful

Correct Answer is: D

Explanation : Anxiety symptoms may take a physical harm form, and if these symptoms occur,
they are of priority. Tearfulness, withdrawn, isolated, and elevated vital signs are abnormal
findings. However, these findings are not life-threatening, although they should be monitored.

90) A nurse caring for a client with a neurological disorder is planning care to maintain
nutritional status. The nurse is concerned about the client’s swallowing ability. Which of the
following food items would the nurse plan to avoid in this client’s diet?

Options:

A) Cheese casserole

B) Scrambled eggs

C) Mashed potatoes

D) Spinach

Correct Answer is: D

Explanation : In general, flavorful, warm, or well-chilled food with texture stimulate the swallow
reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually effective. Raw vegetables,
chunky vegetables such as diced beets, and stringy vegetables such as spinach, corn, and peas
are foods commonly excluded from the diet of client with a poor swallow reflex.

91) A client who has fallen from a ladder and fractured three ribs has arterial blood gas (ABG)
results of pH 7.38, Pco2 38 mmHg, Pco2 86 mmHg, Hco3 23 mEq/L. The nurse interprets that the
client’s ABGs indicate which of the following?

Options:

A) Normal results

B) Metabolic alkalosis
C) Metabolic acidosis

D) Respiratory acidosis

Correct Answer is: A

Explanation : Normal ABG results include a pH of 7.35 to 7.45, a Pco2 of 35 to 45 mmHg, Po2 of
80 to 100, and a Hco3 of 22 to 27 mmHg. The client’s results fall in the normal range.

92) A 1000-mL intravenous (IV) solution of normal saline 0.9% is prescribed for the client. The
nurse understands that this type of IV solution:

Options:

A) Is isotonic with the plasma and other body fluids

B) Is hypertonic with the plasma and other body fluids

C) Affects the plasma osmolarity

D) Is the same solution as sodium chloride 0.45%

Correct Answer is: A

Explanation : Sodium chloride 0.9% (not sodium chloride 0.45%) is the same solution as normal
saline 0.9%. This solution is isotonic (not hypertonic), and isotonic solutions are frequently used
for IV infusion because they do not affect the plasma osmolarity.

93) An emergency room nurse prepares to treat a child with acetaminophen (Tylenol) overdose.
The nurse reviews the physician’s orders, expecting that which of the following will be
prescribed?

Options:

A) Vitamin K (AquaMephyton)

B) Protamine sulfate

C) Succimer (Chemet)

D) N-acetylcysteine (NAC)
Correct Answer is: D

Explanation : N-acetylcysteine (NAC) is the antidote for acetaminophen overdose. It is


administered orally with juice or soda or via a nasogastric tube. Vitamin K is the antidote for
warfarin (Coumadin). Protamine sulfate is the antidote for heparin. Succimer (Chemet) is used in
the treatment of lead poisoning.

94) A nurse caring for a client with late-stage salicylate poisoning who is experiencing metabolic
acidosis reviews the results of the clients blood chemistry profile. The nurse anticipates that
which laboratory value is related to the client’s acid-base- disturbance?

Options:

A) Sodium: 145 mEq/L

B) Magnesium: 2.0 mEq/

C) Potassium: 5.2 mEq/L

D) Phosphorus: 2.3 mEq/L

Correct Answer is: C

Explanation : The client with late-stage salichlate poisoning is at risk for metabolic acidosis
because of the effects of acetylsalicylic acid in the body. Clinical manifestations of metabolic
acidosis include hyperpnea with Kussmaul’s respirations, headache, nausea, vomiting, diarrhea,
fruity smelling breath caused by improper fat metabolism, central nervous system depression,
twitching, convulsions, and hyperkalemia. The other laboratory values listed are within the
normal reference ranges.

95) A nurse is caring for a client with a nasogastric tube that is attached to low suction. The
nurse assesses the client for symptoms of which acid-base disorder?

Options:

A) Metabolic acidosis

B) Metabolic alkalosis

C) Respiratory acidosis
D) Respiratory alkalosis

Correct Answer is: B

Explanation : Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis
because of the loss of hydrochloric acid, which is a potent acid in the body. Thus, this situation
results in an alkalotic condition. The respiratory system is not involved.

96) A nurse is reviewing the client’s most recent blood gas results, and the results indicate a pH
of 7.43, Pco2 of 31 mmHg, and Hco3 of 21 mEq/L. The nurse interprets there results as indicative
of which acid-base imbalance.

Options:

A) Uncompensated metabolic alkalosis

B) Compensated metabolic acidosis

C) Uncompensated respiratory acidosis

D) Compensated respiratory alkalosis.

Correct Answer is: D

Explanation : The normal pH is 7.35 to 7.45, the normal Pco2 is 35 to 45 mmHg, and the normal
Hco3 is 22 to 27 mEg/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory
condition, and opposite effect will be seem between the pH and the Pco2. In a metabolic
condition, the pH and the bicarbonate move in the same direction. Because the pH is within the
normal range of 7.35 to 7.45, compensation has occurred.

97) A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets
that this client is most at risk of developing which type of acid-base imbalance?

Options:

A) Respiratory acidosis

B) Respiratory alkalosis

C) Metabolic acidosis
D) Metabolic alkalosis

Correct Answer is: C

Explanation : Diabetes mellitus can lead to metabolic acidosis. When the body does not have
sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body
utilize all available glucose. The body then breaks down glycogen and fat for fuel. The by-
products of fat metabolism are acidotic and can lead to the condition known as diabetic
ketoacidosis. Options 1, 2, and 4 are incorrect.

98) A nurse is reviewing the record of a client with a disorder involving the inner ear. Which of
the following would the nurse most likely expect to note documented as an assessment finding
in this client?

Options:

A) Complaints of itching in the affected ear

B) Complaints of severe pain in the affected ear

C) Complaints of burning in the ear

D) Complaints of tinnitus

Correct Answer is: D

Explanation : Tinnitus is the most common complaint of clients with ear disorders, especially
disorders involving the inner ear. Symptoms of tinnitus can range from mild ringing in the ear
that can go unnoticed during the day to a loud roaring in the ear that can interfere with the
client’s thinking process and attention span. The assessment findings noted in options 1, 2, and 3
are not specifically noted in the client with an inner ear disorder.

99) A nurse has just administered a purified protein derivative (PPD) skin test to a client who is at
low risk for developing tuberculosis. The nurse determines that the test is positive if which of the
following occurs?

Options:

A) An induration of 15 mm
B) A large area of erythema

C) The presence of a wheal

D) Client complains of constant itching

Correct Answer is: A

Explanation : An induration of 15 mm or more is considered positive for clients in low-risk


groups. Erythema is not a positive reaction. The presence of a wheal would indicate that the skin
test was administered appropriately. Itching is not an indication of a positive PPD.

100) A nurse is performing an otoscopic examination on a client with a suspected diagnosis of


mastoiditis. The nurse would expect to note which of the following if this disorder was present?

Options:

A) A thick and immobile tympanic membrane

B) A pearly colored tympanic membrane

C) A mobile tympanic membrane

D) A transparent tympanic membrane

Correct Answer is: A

Explanation : Otoscopic examination in a client with mastoiditis reveals a red, dull, thick and
immobile tympanic membrane with or without perforation. Options 2, 3 and 4 indicate normal
findings in an otoscopic examination.

101) A nurse is planning to give a tepid tub bath to a child who has hyperthermia. The nurse
plans to:

Options:

A) Obtain isopropyl alcohol to add to the bath water

B) Warm the water to the same body temperature of the child

C) Have cool water available to add to the bath water


D) Allow 5 minutes for the child to soak in the bath water

Correct Answer is: C

Explanation : Adding cool water to an already warm bath allows the water temperature to slowly
drop. The child is able to gradually adjust to the changing water temperature and will not
experience chilling. Alcohol is toxic and contraindicated for tepid sponge or tub baths. To achieve
the best cooling results, the water temperature should be at least 2 degrees lower than the
child’s body temperature. The child should be in a tepid tub bath for 20 to 30 minutes to achieve
maximum results.

102) A client receiving total parenteral nutrition (TPN) via a central venous intravenous (IV) line is
scheduled to receive an antibiotic by the IV route. Which action by the nurse is appropriate
before hanging the antibiotic solution?

Options:

A) Ensure a separate IV access for the antibiotic

B) Turn of the TPN for 30 minutes before administering the antibiotic

C) Check with the pharmacy regarding compatibility of the antibiotic and the TPN solution

D) Flush the central line with 60 mL of normal saline before hanging the antibiotic

Correct Answer is: A

Explanation : The TPN line is used only for the administration of the TPN solution. Any other IV
medication must be administered though a separate IV access site. Therefore, options 2, 3, and 4
are incorrect actions.

103) A client with acquired immunodeficiency syndrome (AIDS) who has cytomegalovirus
retinitis (CMV) is receiving ganciclovir sodium (Cytovene). The nurse implements which of the
following in the care of this client?

Options:

A) Monitors blood glucose levels for elevation

B) Administers the medication on an empty stomach only


C) Tells the client to use a soft toothbrush and an electric razor

D) Applies pressure to venipuncture sites for 2 minutes

Correct Answer is: C

Explanation : Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side
effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding, and
implements the same precautions that are used for a client receiving anticoagulant therapy.
Thus, venipuncture sites should be held for approximately 10 minutes. The medication does not
have to be taken on an empty stomach. The medication may cause hypoglycemia, but not
hyperglycemia.

104) A nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has
repositioned the client’s head in a flexed-forward position. The client has been asked to begin
swallowing, and as the nurse starts to slowly advance the NG tube with each swallow, the client
begins to gag. Which nursing action would least likely result in proper tube insertion and
promote client relaxation?

Options:

A) Continuing to advance the tube to the desired distance

B) Pulling the tube back slightly

C) Checking the back of the pharynx using a tongue blade and flashlight

D) Instructing the client to breathe slowly

Correct Answer is: A

Explanation : As the NG tube is passed through the oropharynx, the gag reflex is stimulated,
which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil
around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the
tube may enter the larynx, advancing the tube may position it in the trachea. Slow breathing
helps the client relax to reduce the gag response. The tube may be advanced after the client
relaxes.

105) A nurse is caring for an infant with spina bifida (meningomyelocele type) who had the
gibbus (sac on the back containing cerebrospinal fluid, the meninges, and the spinal cord)
surgically removed. The nurse plans which of the following in the postoperative period to
maintain the infant’s safety?

Options:

A) Elevating the head with the infant in the prone position

B) Covering the back dressing with a binder

C) Placing the infant in a head-down position

D) Strapping the infant in a baby seat sitting up

Correct Answer is: A

Explanation : Elevating the head will decrease the chance of cerebrospinal fluid collecting in the
cranial cavity. The infant needs to be prone for several days to decrease the pressure on the
surgical site on the back. Binders and a baby seat should not be used because of the pressure
they would exert on the surgical site.

106) The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk
of compounding the injury most effectively most effectively by

Options:

A) Logrolling the client on a soft mattress.

B) Keeping the client on a stretcher.

C) Placing the client on a Stryker frame.

D) Logrolling the client on a firm mattresses.

Correct Answer is: C

Explanation : Spinal immobilization is necessary after spinal cord injury to prevent further
damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame,
which allows the nurse to turn the client to prevent complications of immobility, while
maintaining alignment of the spine. If a Stryker frame is not available, a firm matters with a
bedboard under it should be used.
107) The nurse is evaluating the neurological signs of the male client in spinal shock following
spinal cord injury. Which of the following observations by the nurse indicates that spinal shock
persists?

Options:

A) Hyperreflexia

B) Inability to elicit a Babinski’s reflex

C) Reflex emptying of the bladder

D) Positive reflexes

Correct Answer is: B

Explanation : Resolution of spinal shock is occurring when there is return of reflexes (especially
flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex
emptying of the bladder, and a positive Babinaski’s reflex.

108) The nurse is assessing the client who is experiencing seizure activity. The nurse understands
that it is unnecessary to determine information about which of the following items as part of
routine assessment of seizures?

Options:

A) What the client ate in the 2 hours preceding seizure activity

B) Changes in pupil size or eye deviation

C) Duration of the seizure

D) Seizure progression and type of movements

Correct Answer is: A

Explanation : Typically, seizure assessment includes the time the seizure began, part(s) of the
body affected, the type of movements and progression of the seizure, changes in pupil size, eye
deviation or nystagmus, client condition during the seizure, and postictal status.
109) The nurse is planning to institute seizure precautions for a client who is being admitted
from the emergency department. Which of the following measures would the nurse avoid in
planning for the client’s safety?

Options:

A) Padding the side rails of the bed

B) Having intravenous equipment ready for insertion of an intravenous catheter

C) Placing an airway, oxygen, and suction equipment at the bedside

D) Putting a padded tongue blade at the head of bed.

Correct Answer is: D

Explanation : Seizure precautions may vary from agency to agency, but they generally have some
commonalities. Usually an airway, oxygen, and suctioning equipment are kept available at the
bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The
client has an intravenous access in place to have a readily accessible route if anticonvulsant
medications must be administered. The use of padded tongue blades. Forcing a tongue blade
into the mouth during a seizure activity. Risks include blocking the airway from improper
placement, chipping the client’s teeth, and subsequent risk of aspirating tooth fragments. If the
client has an aura before the seizure, it may give the nurse enough time to place an oral airway
before seizure activity begins.

110) The nurse is caring for the client who begins to experience seizure activity while in bed
.Which of the following actions by the nurse would be contradicted?

Options:

A) Positioning the client to the side if possible, with head flexed forward

B) Loosening restrictive clothing.

C) Restraining the client’s limbs

D) Removing the pillow and raising padded side rails

Correct Answer is: C

Explanation : Nursing actions during a seizure include providing for privacy, loosening restrictive
clothing, removing the pillow and raising side rails in bed, and placing the client on one side with
the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage.
The limbs are never restrained because the strong muscle contractions could cause the client
harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the
floor of possible, protects the head from injury, and moves furniture that may injure the client.
Other aspects of care are as described for the client who is in bed.

111) The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The
nurse determines that the client has an adequate understanding if the client states

Options:

A) Good oral hygiene is needed, including brushing and flossing.

B) The morning dose of the medication should be taken before a serum drug level is drawn.

C) The medication dose may be self-adjusted depending on side effects.

D) Alcohol is not contraindicated while taking this medication

Correct Answer is: A

Explanation : Typical anticonvulsant medication instructions include taking the dose daily to keep
the blood level of the drug constant and having a serum drug level before taking the morning
dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with the
physician before taking over-the-counter medications, to avoid activities where alertness and
coordination are required until medication effects are known, to provide good oral hygiene, and
to obtain regular dental care. The client should also wear a Medic-Alert bracelet.

112) The nurse is planning care for the client with hemi paresis of the right arm and leg. The
nurse incorporates in the care plan to place objects.

Options:

A) within the client’s reach on the left side.

B) Just out of the client’s reach on the left side.

C) within the client’s reach on the right side.

D) Just out of the client’s reach on the right side.


Correct Answer is: A

Explanation : Hemiparesis is a weakness of the face, arm, and leg on one side. The client with
one-sided hemiparesis benefits from having objects placed on the unaffected side and within
reach. Other helpful activities with hemiparesis include range of motion exercise to the
unaffected side.

113) The client with cerebrovascular accident has residual dysphasia. When a diet order is
initiated, the nurse avoids doing which of the following?

Options:

A) Thickening liquids to the consistency of oatmeal

B) Allowing plenty of time for chewing and swallowing.

C) Placing food on the unaffected side of the mouth.

D) Giving the client thin liquids.

Correct Answer is: D

Explanation : Before the client with dysphagia is started in a diet, the gag and swallow reflexes
must returned. The client is assisted with meals as needed and is given ample time to chew and
swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid
aspiration.

114) The nurse has instructed the family of a client with cerebrovascular accident who as
homonymous hemianopsia about measures to help the client overcome the deficit. The nurse
determines that the family understands the measures to use if they stated to.

Options:

A) Approach the client from the impaired field of vision.

B) Discourage the client from wearing eyeglasses.

C) Place objects in the client’s impaired field of vision.

D) Remind the client to turn the head to scan the lost of visual field.
Correct Answer is: D

Explanation : Homonymous hemianopsia is loss of one half of the visual field. The client with
homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse
also should approach the client from the intact side. The nurse instructs the client to scan the
environment to overcome the visual deficit and does client teaching from within the intact field
of vision. The nurse encourages the use of personal eyeglasses, if they are available.

115) The nurse is assessing the adaptation of the client to changes in functional status after a
cerebrovascular accident. The nurse assesses that the client is adapting most successfully if the
client?

Options:

A) Has difficulty with using modified feeding utensils.

B) Experiences bouts of depression and irritability.

C) Consistently uses adaptive equipment in dressing self.

D) Gets angry with family if they interrupt a task.

Correct Answer is: C

Explanation : Clients are evaluated as coping successfully with lifestyle changes after a
cerebrovascular accident if they make appropriate lifestyle alterations, use the assistance of
others, and have appropriate social interactions. Options 1, 3 and 4 are not adaptive behaviors.

116) A nursing student is caring for a client with a cerebrovascular accident who is experiencing
unilateral neglect. The nurse would intervene if the student planned to use which of the
following strategies to help the client adapt to this deficit?

Options:

A) Approach the client from the unaffected side.

B) Tell the client to scan the environment

C) Move the commode and chair to the affected side.


D) Place the bedside articles on the affected side.

Correct Answer is: A

Explanation : Unilateral neglect is an unawareness of the paralyzed side of the body, which
increases the client’s risk for injury. The nurse’s role is to refocus the client’s attention to the
affected side. The nurse moves personal care items and belongings to the affected side, as well
as the bedside chair and commode. The nurse teaches the client to scan the environment to
become aware of that half of the body and approaches the client from the affected side to
increase awareness further.

117) The nurse is trying to communicate with a client with cerebrovascular accident and aphasia.
Which of the following actions by nurse would be least helpful to the client?

Options:

A) Looking directly at the client attempts at speech.

B) Allowing plenty of time for the client to respond.

C) Speaking to the client at lower rate.

D) Completing the sentences that the client cannot finish.

Correct Answer is: D

Explanation : Clients with aphasia after cerebrovascilar accident often fatigue easily and have a
short attention span. General guidelines when trying to communicate with the aphasic client
include speaking more slowly and allowing adequate response time, listening to and watching
attempts to communicate, and trying to put the client at ease with a caring and understanding
manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a
response, and letting family members provide all the responses for the client.

118) The client with diplopia has been taught to use an eye patch to promote better vision and
prevent injury. The nurse determines that the client has correct understanding of the use of the
patch if the client states to.

Options:

A) Wear the patch for 1 hour for a time


B) Wear the patch continuously, alternating eyes each week.

C) Use the patch only when the vision is especially troublesome.

D) Wear the patch continuously, alternating eyes each day.

Correct Answer is: D

Explanation : Placing an eye patch over one in the client with diplopia removes the second image
and restores more normal vision. The patch is alternated each day to maintain the strength of
the extra ocular muscle of the eyes.

119) A client receives a dose of edrophonium (Tensilon) intravenously. The client shows
improvement in muscle strength for a period of time following the injection. The nurse
interprets that this finding is compatible with?

Options:

A) Amyotrophic lateral sclerosis.

B) Muscular dystrophy.

C) Myasthenia gravis.

D) Multiple sclerosis

Correct Answer is: C

Explanation : Myasthenia gravis often can be diagnosed based on clinical signs and symptoms.
The diagnosis can be confirmed by injecting the client with a dose of edrophonium (Tensilon).
This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more
acetylcholine binds onto receptors. If the muscle is strengthened for 3 to 5 minutes after this
injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine
(Prostigmin) also may be used because the client lasts for 1 to 2 hours, giving a better analysis.
For either medication, atropine sulfate should be available as the antidote.

120) The client with myasthenia gravis is having difficulty speaking. The speech is dysarthritic
and has a nasal tone. The nurse would avoid using which of the following communication
strategies when working with this client?
Options:

A) Asking yes and no questions when able.

B) Encouraging the client to speak quickly.

C) Repeating what the next client said to verify the message.

D) Using a communication board when necessary.

Correct Answer is: B

Explanation : The client has speech that is nasal and dysarthritic because of cranial nerve
involvement of the muscles governing speech. The nurse listen attentively and verbally verifies
what the client has said, asks questions requiring a yes or no response, and develops alternative
communication methods (letter board, picture board, pen and paper, flash cards). Encouraging
the client to speak quickly is unsuccessful and counterproductive.

121) The client with myasthenia gravis has a Risk for ineffective Airway clearance and risk for
ineffective Breathing pattern. The nurse would keep which of the following available at the
client’s bed side?

Options:

A) Pulse oximeter and a cardiac monitor.

B) Ambu bag and suction equipment.

C) Incentive Spiro meter and cough pillow

D) Oxygen and metered-dose inhaler.

Correct Answer is: B

Explanation : The client with myasthenia gravis may experience episode of respiratory distress if
excessively fatigues or if the client develops myasthenic crisis or cholinergic crisis. For this
reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside.

122) The client has experienced an episode of myasthenic crisis. The nurse would assess
whether the client has precipitating factors such as?
Options:

A) Increased intake of fatty foods.

B) Excess medication.

C) Too little exercise.

D) Omitted doses of medication.

Correct Answer is: D

Explanation : Myasthenic crisis often is caused by undermedicaltion and responds to the


administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine
(Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and
responds to withholding of medications. Too little exercise and fatty food intake are incorrect.
Overexertion and overeating possibly could trigger myasthenic crisis.

123) The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and
cholinergic crisis. The nurse tells the client that this is most effectively done by?

Options:

A) Doing muscle strengthening exercises.

B) Doing all chores early in the day while less fatigued.

C) Eating large, well-balanced meals.

D) Taking medications on time to maintain therapeutic blood vessels.

Correct Answer is: D

Explanation : Clients with myasthenic gravis are taught to space out activities over the day to
conserve energy and restore muscle strength. Taking medications correctly to maintain blood
levels that are not too low or too high is important. Muscle strengthening exercises are not
helpful and can symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional
stress.

124) The home health nurse is visiting the client with myasthenia gravis and is discussing
methods to minimize the risk of aspiration during meals because of decreased muscle strength.
Which of the following suggestions would the nurse avoid giving to the client?

Options:

A) Cut food into very small pieces, chewing thoroughly.

B) Lift the head while swallowing liquids

C) Swallow when the chain is tipped slightly downward to the chest.

D) Sit straight up in chair while eating.

Correct Answer is: B

Explanation : The client avoids swallowing any type of food or drink with the head lifted upward,
which could actually cause aspiration by opening the glottis. The client should be advised to sit
upright while eating, not to talk with food in the mouth (glottis is open), cut food into very small
pieces, chew thoroughly, and tip the chin downward to swallow.

126) The client with Parkinson’s disease has a nursing diagnosis of risk for fall related to an
abnormal gait documented in the nursing care plan. The nurse assesses the client expecting to
observe which type of gait?

Options:

A) Shuffling and propulsive.

B) Broad based and waddling.

C) Accelerating with walking on toes.

D) Unsteady and staggering.

Correct Answer is: A

Explanation : The parkinsonian gait is characterized by short, accelerating, shuffling steps. The
client leans forward with the head, hips, and knees flexed, and had difficulty starting and
stopping. A dystrophic gait is broad and waddling. A festinating gait is accelerating with walking
on toes. An ataxic gait is staggering and unsteady.
127) The client with Parkinson’s disease is embarrassed about the symptoms of the disorder, and
is bored and lonely. The nurse would plan which of the following approaches as most
therapeutic in assisting the client to cope with the disease?

Options:

A) Assist the client with activities of daily living as much as possible.

B) Encourage and praise perseverance in exercising and performing activities of daily living.

C) Cluster activities at the end of the day when the client is most bored.

D) Plan only a few activities for the client during the day

Correct Answer is: B

Explanation : The client with Parkinson’s disease tends to become withdraw and depressed and
should become an active participant in personal care to prevent this. Activities should be
planned throughout the day to inhibit daytime sleeping and boredom. The nurse gives the client
encouragement and praises the client for perseverance. Exercise helps prevent progression of
the disease, and self-care improves self-esteem.

128) The nurse has given instructions to the client with Parkinson’s disease about maintaining
mobility. The nurse determines that the client understood the directions if the client stated to?

Options:

A) Rock back and 4th to start movement with bradykinesia.

B) Sit in soft, deep chairs.

C) Buy clothes with many buttons to maintain finger dexterity.

D) Exercise in the evening to combat fatigue.

Correct Answer is: A

Explanation : The client with Parkinson’s disease should exercise in the morning when energy
levels are highest. The client should avoid sitting in soft, deep chairs because they are difficult to
get up from. The client can rock back and forth to initiate move meant. The client should buy
clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self.
129) The nurse has given suggestions to the client with trigeminal neuralgia about strategies to
minimize episodes of pain. The nurse determines that the client needs reinforcement of
information if the client made which of the following statements?

Options:

A) ’ll have to start chewing on the unaffected side.”

B) “I’ll try to eat my food either very warm or very cold.”

C) “I will wash my face with cotton pads.”

D) “I should rinse my mouth some times if tooth brushing is painful.”

Correct Answer is: B

Explanation : Facial pain can be minimized by using cotton pads to wash the face and using room
temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet,
and take in foods and beverages at room temperature. If tooth brushing triggers pain,
sometimes an oral rinse after meals is helpful instead.

130) The client with Bell’s palsy asks the nurse what caused the problem to occur. The nurse’s
response is based on an understanding that the cause is?

Options:

A) Primarily genetic in origin and is triggered by exposure to meningitis.

B) Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem.

C) Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia.

D) Primarily genetic in origin and is triggered by exposure to neurotoxins.

Correct Answer is: B

Explanation : Bell’s palsy is a one-side facial paralysis from compression of the facial nerve. The
exact cause is unknown. Possible cause includes vascular ischemia, infection, exposure to viruses
such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these items.
131) The client with an onset of Bell’s palsy is upset and crying about the change in the facial
appearance. The nurse plans to support the client emotionally by telling the client that?

Options:

A) This is a temporary problem, with treatment similar to that for migraine headaches.

B) This is similar to a cerebrovascular accident, but all symptoms will reverse without any
treatment.

C) This is not a cerebrovascular accident, and many clients recover in 3 to 5 weeks.

D) This is caused by a small tumor, which can be removed easily.

Correct Answer is: C

Explanation : Clients with Bell’s palsy should be reassured that they have not experienced a
cerebrovascular accident and that symptoms often disappear spontaneously in 3 to 5 weeks. The
client is given supportive treatment for symptoms. Bell’s palsy usually is not caused by a tumor,
and the treatment is not similar to that for migraine headaches.

132) The nurse is reinforcing information given to the Bell’s palsy about medications that may be
used to decrease edema of nervous tissue. The nurse gives the client specific information about
which of the following medications?

Options:

A) Ibuprofen (Motrin).

B) Prednisone (Deltas one).

C) Acetylsalicylic acid (Aspirin)

D) Dexamethanose (Decadron).

Correct Answer is: B

Explanation : Bell’s palsy may be treated with prednisone. The medication reduces inflammation
and edema, allowing return of normal circulation to the nerve. The medication may reduce the
severity of the palsy, reduce the pain, and preserve substantial, if not all, nerve function. Options
1, 2 and 3 are incorrect.
133) The nurse has given the client with Bell’s palsy instructions on preserving muscle tone in the
face and preventing denervation. The nurse determines that the client needs additional
information if the client stated to?

Options:

A) Massage the face with a gentle upward motion.

B) Use a device for electrical stimulation of the face.

C) Expose the face to cold and drafts.

D) Wrinkle the fore head, the blow out the cheeks, and whistle.

Correct Answer is: C

Explanation : Prevention of muscle atrophy with Bell’s palsy is accomplished with the use of
facial massage, facial exercises, and electrical stimulation of the nerves. Exposures to cold or
drafts is avoided flow and provide comfort.

134) The client is admitted to the hospital with a diagnosis of Gullian-Barre syndrome. The nurse
inquires during the nursing admission interview if the client has a history of

Options:

A) Seizures or trauma to the brain.

B) Respiratory or gastrointestinal infection during the previous month.

C) Meningitis during the last 5 years

D) Back injury or trauma to the spinal cord.

Correct Answer is: B

Explanation : Guillian-Barre syndrome is a clinical syndrome of unknown origin that involves


cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal
infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the
syndrome has been triggered by vaccination or surgery.
135) The client with Gullian-Barre syndrome has ascending paralysis and is intubated and
receiving mechanical ventilation. Which of the following strategies would the nurse inquires
during the nursing admission interview if the client has a history of?

Options:

A) Providing intravenously administered sedatives, reducing distractions, and limiting visitors.

B) Providing information, giving (+) ve feed back, and encouraging relaxation.

C) Giving client full control over care decisions and restricting visitors.

D) Providing (+) ve feedback and encouraging active range of motion.

Correct Answer is: B

Explanation : The client with Guillian-Barre syndrome experiences fear and anxiety from the
ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by
providing accurate information about the client’s condition, giving expert care, giving positive
feedback to the client, and encouraging relaxation and distraction. The family can become
involved with selected care activities and provide diversion for the client as well.

136) . The nurse is admitting a client with Gullian-Barre syndrome to the nursing unit. The client
has an ascending paralysis to the level of the waist. Knowing the complications of the disorder,
the nurse brings which of the following items into the client’s room?

Options:

A) E.C.G monitoring electrodes and intubation tray.

B) Nebulizer and pulse oximeter.

C) Flash light and incentive Spiro meter.

D) Blood pressure cuff and flashlight.

Correct Answer is: A

Explanation : The client with Guillian-Barre syndrome is at risk for respiratory failure because of
ascending paralysis. An intubation tray should be available for use. Another complication of this
syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiogram monitoring.
Because the client is immobilized, the nurse should assess for deep vein thrombosis and
pulmonary embolism routinely.

137) The nurse is evaluating the respiratory outcomes for the client with Gullian-Barre
syndrome. The nurse would evaluate that which of the following is the least optimal outcome for
the client?

Options:

A) Oxygen saturation 98%.

B) Adventitious breath sounds.

C) Vital capacity with in normal range.

D) Spontaneous breathing.

Correct Answer is: B

Explanation : Satisfactory respiratory outcomes include clear breath sounds on auscultation,


spontaneous breathing, normal vital capacity, and normal arterial blood gases and pulse
oximetry.

138) The client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the
client for possible precipitating risk factors. Which of the following factors, if stated by the client,
would the nurse assess as being unrelated to the exacerbation?

Options:

A) Ingestion of more fruits and vegetables

B) Inability to sleep well.

C) A recent bout of the flu

D) A stressful week at work

Correct Answer is: A

Explanation : The onset or exacerbation of multiple sclerosis is preceded by number of different


factors, including emotional stress, fatigue, infection, physical injury, and pregnancy. No methods
of primary prevention are known. Intake if fruit and vegetables is an unrelated item.
139) The client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic
gait. Based on this information, the nurse would formulate which of the following nursing
diagnoses for the client?

Options:

A) Activity intolerance.

B) Impaired tissue integrity.

C) Self care deficit.

D) Impaired physical mobility.

Correct Answer is: D

Explanation : Impaired Physical Mobility has been defined by the North American Nursing
Diagnosis Association as “a state in which the individual experiences a limitation of ability for
independent physical movement.” The client’s muscle weakness, muscle spasticity, and ataxic
gait meet the defining characteristics impairment is listed as a related factor or defining
characteristic.

140) The nurse is planning care for the client with a neurogenic bladder caused by multiple
sclerosis. Which of the following plans for fluid administration of at least 2000 mL/day would be
most helpful to this client?

Options:

A) 400 to 500 mL with each meal, 500 to 600mL in the evening before bed time.

B) 400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon and evening.

C) 400 to 500 mL with each meal, additional fluids in the morning but not after mid day.

D) 400 to 500 mL with each meal, 200to 250 mL at midmorning, mid afternoon, and late
afternoon.

Correct Answer is: D

Explanation : Spacing fluid intake over the day helps the client with a neurogenic bladder to
establish regular times for successful voiding. Omitting intake after the evening meal minimizes
incontinence or the need to empty the bladder during the night.

141) A client’s cannot close the right eye. It can be explained by no conduction of:

Options:

A) The 3rd cranial nerve

B) The 4th cranial nerve

C) The 7th cranial nerve

D) The 2nd cranial nerve

Correct Answer is: C

Explanation : Lesions affecting the seventh cranial (facial) nerve cause paralysis of the eyelids.
The optic nerve is concerned with vision; lesions result in visual field defects and loss of visual
acuity. The oculomotor nerve is concerned with papillary constriction and eye movement’s
lesions result in ptosis strabismus, an diplopia. The trochlear nerve is concerned with eye
movements; lesions result in diplopia, strabismus, and head tilt to the affected side.

142) An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for
analysis. The nurse assesses for which of the following values that should be negative if the CSF
is normal?

Options:

A) Protein

B) Glucose

C) White blood cells

D) Red blood cells

Correct Answer is: D

Explanation : The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The
client may have small levels of white blood cells (0 to 5 cells). Protein (15 to 45 mg/dL) and
glucose (45 to 80 mg/dL) are normally present in CSF.

143) A nurse is caring for a client following craniotomy who has a supratentorial incision. The
nurse places a sign above the client’s bed stating that the client should be maintained in which
of the following positions?

Options:

A) Semi-Fowler’s

B) Dorsal recumbent

C) Prone

D) Supine

Correct Answer is: A

Explanation : Following supratentorial surgery (Surgery above the brains tentorium), the client’s
head is usually elevated 30 degrees to promote venous outflow through the jugular veins.
Options 2, 3, and 4 are incorrect positions following this surgery.

144) A 24 year old female is admitted to the ER for confusion. This patient has a history of a
myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following
would you most likely suspect?

Options:

A) Diverticulosis

B) Hypercalcaemia

C) Hypocalcaemia

D) Irritable bowel syndrome

Correct Answer is: B

Explanation : Hypercalcaemia can cause polyuria, severe abdominal pain, and confusion
145) A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to
use a quad cane. Which of the following is the most appropriate gait sequence?

Options:

A) Place the cane in the patient’s left upper extremity, encourage cane, then right lower
extremity, then left upper extremity gait sequence.

B) Place the cane in the patient’s left upper extremity, encourage cane, then left lower extremity,
then right upper extremity gait sequence.

C) Place the cane in the patient’s right upper extremity, encourage cane, then right lower
extremity, then left upper extremity gait sequence.

D) Place the cane in the patient’s right upper extremity, encourage cane, then left lower
extremity, then right upper extremity gait sequence.

Correct Answer is: A

Explanation : The cane should be placed in the patient’s strong upper extremity, and left
arm/right foot go together, for normal gait.

146) A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The
nurse should do which of the following first?

Options:

A) Check the patient’s chest x-ray results.

B) Retake vitals including blood pressure.

C) Perform a neurological screen on the patient.

D) Request the physician on-call assess the patient.

Correct Answer is: B

Explanation : Dizziness can be a sign of hypotension, that may a contraindication with Morphine.

147) A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and
breathing is independent. What should the nurse document to most accurately describe the
client's condition?

Options:

A) Comatose, breathing unlabored

B) Glascow Coma Scale 8, respirations regular

C) Appears to be sleeping, vital signs stable

D) Glascow Coma Scale 13, no ventilator required

Correct Answer is: B

Explanation : Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a
standard reference for assessing or monitoring level of consciousness. Any score less than 13
indicates a neurological impairment. Using the term comatose provides too much room for
interpretation and is not very precise.

148) An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has
had a blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted
increased lethargy. Which assessment finding should the nurse report immediately to the
provider?

Options:

A) Slurred speech

B) Incontinence

C) Muscle weakness

D) Rapid pulse

Correct Answer is: A

Explanation : Slurred speech. Changes in speech patterns and level of conscious can be indicators
of continued intracranial bleeding or extension of the stroke. Further diagnostic testing may be
indicated.

149) A client with myasthenia gravis is admitted to the hospital, and the nursing history reveals
that the client is taking pyridostigmine (Mestinon). The nurse assesses the client for side effects
of the medication land asks the client about the presence of:

Options:

A) Muscle cramps

B) Mouth ulcers

C) Feelings of depression

D) Unexplained weight gain

Correct Answer is: A

Explanation : Mestinon is an acetylcholinesterase inhibitor. Muscle cramps and small muscle


contractions are side effects and occur as a result of overstimulation of neuromuscular
receptors. Options 2, 3, and 4 are not associated with this medication.

150) A client with myasthenia gravis is experiencing prolonged periods of weakness, and the
physician orders an edrophonium (Tensilon) test. A test dose is administered and the client
becomes weaker. The nurse interprets this test result as:

Options:

A) Normal

B) Positive

C) Myasthenia crisis

D) Cholinergic crisis

Correct Answer is: D

Explanation : A Tensilon test may be performed to determine whether increasing weakness in a


previously diagnosed myasthenic client is a result of cholinergic crisis (overmedication with
anticholinesterase drugs) or myasthenic crisis (under medication with cholinesterase inhibitors).
Worsening of the symptoms after the test dose of medication is administered indicates a
cholinergic crisis.
151) A nurse is caring for a client with a head injury and is monitoring the client for decerebrate
posturing. Which of the following is characteristic of this type of posturing?

Options:

A) Extension of the extremities after a stimulus

B) Flexion of the extremities after a stimulus

C) Upper extremity flexion with lower extremity extension

D) Upper extremity extension with lower extremity flexion

Correct Answer is: A

Explanation : Decerebrate posturing which can occur with upper brain stem injury, is the
extension of the extremities after a stimulus. Options 2, 3, and 4 are incorrect descriptions of
this type of posturing.

152) A nurse is caring for a client who had a craniotomy (Supratentorial surgery). When assessing
the client for the major postoperative complication following craniotomy, the nurse monitors for:

Options:

A) Restlessness

B) Bleeding

C) Hypotension

D) Bradycardia

Correct Answer is: A

Explanation : The major postoperative complication following craniotomy (supratentorial


surgery) is increased intracranial pressure (ICP) from cerebral edema, hemorrhage, or
obstruction of the normal flow of cerebrospinal fluid (CSF). Symptoms of increased ICP include
severe headache, deteriorating level of consciousness, restlessness, irritability, and dilated or
pinpoint pupils that are slow to react or nonreactive to light. Without prompt recognition and
treatment, herniation syndromes develop and death can occur. Options 2, 3, and 4 are not
associated with increased ICP.
153) A nurse is caring for a client admitted to the hospital after sustaining a head injury. The
nurse appropriately positions the client:

Options:

A) With the head elevated on a pillow

B) In Left Sims’ position

C) In reverse Trendelenburg

D) With the head of the bed elevated 30 to 45 degrees

Correct Answer is: D

Explanation : The client with a head injury is positioned to avoid extreme flexion or extension of
the neck and to maintain the head in the midline, neutral position. The client is logrolled when
turned to avoid extreme hip flexion. The head of the bed is elevated 30 to 45 degrees. All of
these measures are used to enhance venous drainage, which helps prevent increased
intracranial pressure (ICP).

154) A nurse is planning care for a client with a T-3 spinal cord injury. The nurse includes which
intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?

Options:

A) Assess vital signs and observe for hypotension, tachycardia, and tachypnea

B) Teach the client that this condition is relatively minor with few symptoms

C) Assist the client to develop a daily bowel routine to prevent constipation

D) Administer dexamethasone (Decadron) as per physician’s order

Correct Answer is: C

Explanation : Autonomic dysreflexia (hyperreflexia) is a potentially life-threatening condition and


may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of
pain receptors in the skin. A daily bowel program eliminates this trigger. A client with autonomic
dysreflexia would be hypertensive and bradycardic. Removal of the stimuli results in prompt
resolution of the signs and symptoms. Option 4 is unrelated to this specific condition.

155) A nurse has developed a plan of care for a client with a diagnosis of anterior cord
syndrome. Which intervention would the nurse include in the plan of care?

Options:

A) Asses the client’s sensation of vibration

B) Remind the client to change positions slowly

C) Assess the client’s sensation of touch

D) Teach the client about loss of motor function and decreased pain sensation

Correct Answer is: D

Explanation : Clinical findings related to anterior cord syndrome include loss of motor function
and decreased pain sensation below the level of injury. The syndrome does not affect sensations
of touch, motion, position, and vibration.

156) A nurse is caring for a client with a thoracic spinal cord injury. As part of the nursing care
plan, the nurse monitors for spinal shock. In the event that spinal shock occurs, the nurse
anticipates that the most likely intravenous (IV) fluid to be prescribed would be:

Options:

A) 5% dextrose in water

B) Dextran

C) 5% dextrose in 0.9% normal saline

D) 0.9% normal saline

Correct Answer is: D

Explanation : Normal saline 0.9% is an isotonic solution that primarily remains in the
intravascular space, increasing intravascular volume. This IV fluid would increase the client’s
blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is
usually sufficient. Additionally, Dextran has potentially serious side effects. Dextrose 5% in water
is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for
shock. Dextrose 5% in normal saline 0.9% is hypetonic and indicated for shock resulting from
hemorrhage of burns.

157) During the admission assessment, the nurse asks the client to run the heel of one foot
down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg
being tested and concludes that the client has an alteration in the area of:

Options:

A) Muscle strength and flexibility

B) Balance and coordination

C) Sensation and reflexes

D) Bowel and bladder function

Correct Answer is: B

Explanation : In this situation, the nurse is performing one test of cerebellar function and is
testing for ataxia. Alterations in the cerebellar function and is testing for ataxia. Alterations in the
cerebellar function are noted by alterations in balance and coordination. Options 1, 3, and 4 are
not associated with this assessment technique.

158) A nurse is monitoring the intracranial pressure (ICP) of a client with a head injury and notes
that the cerebrospinal fluid pressure (CSF) is averaging 25 mmHg. The nurse analyzes these
results as:

Options:

A) Normal

B) Compensated, indicating adequate brain adaptation

C) Borderline in elevation, indicating the initial stage of decompensation

D) Increased, indicating a serious compromise in cerebral perfusion.

Correct Answer is: D


Explanation : The normal CSF pressure is 5 to 15 mmHg. A pressure of 25 mmHg is increased

159) A nurse is caring for a client with multiple myeloma who is receiving intravenous hydration
at 100 mL per hour. Which assessment finding would indicate a positive response to the
treatment plan?

Options:

A) Weight increase of 1 kilogram

B) White blood cell count of 6,000 mm3

C) Respirations of 18 breaths per minute

D) Creatinine of 1.0 mg/dL

Correct Answer is: D

Explanation : Renal failure is a concern in the client with multiple myeloma. In multiple myeloma,
hydration is essential to prevent renal damage resulting from precipitation of proteins in the
renal tubules and from excessive calcium and uric acid in the blood. Creatinine is the most
accurate measure of renal status. Options 2 and 3 are unrelated to the issue of hydration. Weight
gain is not a positive sign when concerned with renal status.

160) A nurse is caring for a client with a spinal cord injury who has spinal shock. The nurse
performs an assessment on the client, knowing that which assessment will provide the best
information about recovery from spinal shock?

Options:

A) Blood pressure

B) Pulse rate

C) Reflexes

D) Temperature

Correct Answer is: C

Explanation : Areflexia characterizes spinal shock. Therefore, reflexes would provide the best
information about recovery. Vital sign changes (options 1, 2, and 4) are not consistently affected
by spinal shock. Because vital signs are affected by many factors, they do not give reliable
information about spinal shock recovery. Blood pressure would provide good information about
recovery from other types of shock, but not spinal shock.

161) A client was admitted to the nursing unit with a closed head injury 6 hours ago. After
report, the nurse finds that the client has vomited, is confused, and complains of dizziness and
headache. Which of the following is the most important nursing action?

Options:

A) Administer an antiemetic

B) Change the client’s gown and bed linens

C) Reorient the client to surroundings

D) Notify the physician

Correct Answer is: D

Explanation : The client with a closed head injury is at risk of developing increased intracranial
pressure (ICP). This is evidenced by symptoms such as headache, dizziness, confusion, weakness,
and vomiting. Because of the implications of the symptoms, the most important nursing action is
to notify the physician. Other nursing actions that are appropriate include physical care of the
client and reorientation to surroundings.

162) A client is being bought into the emergency department after suffering a head injury. The
first action by the nurse is to determine the client’s:

Options:

A) Respiratory rate and depth

B) Pulse and blood pressure

C) Level of consciousness

D) Ability to move extremities


Correct Answer is: A

Explanation : The first action of the nurse is to ensure that the client has an adequate airway and
respiratory status. In rapid sequence the client’s circulatory status is evaluated (option 2),
followed by evaluation of the neurological status (options 3 and 4).

163) A client with a spinal cord injury is at risk of developing foot drop. The nurse uses which of
the following as the most effective preventive measure?

Options:

A) Heel protectors

B) Posterior splints

C) Pneumatic boots

D) Foot board

Correct Answer is: B

Explanation : The most effective means of preventing foot drop is the use of posterior splints or
high-top sneakers. A foot board prevents plantar flexion, but also places the client more at risk
for developing pressure ulcers of the feet. Pneumatic boots prevent deep vein thrombosis, but
not foot drop. Heel protectors protect the skin, but do not prevent foot drop.

164) A nurse is performing an assessment on a client who has a suspected spinal cord injury.
Which of the following is the priority nursing assessment?

Options:

A) Pupillary response

B) Respiratory status

C) Mobility level

D) Pain level

Correct Answer is: B


Explanation : All of these assessments would be performed on a client with a suspected spinal
cord injury. However, respiratory status is the priority.

165) A nurse is caring for a client who is newly diagnosed with a spinal cord injury. The nurse
would anticipate that the most likely medication to be prescribed would be:

Options:

A) Propranolol (Inderal)

B) Dexamethasone (Decadron)

C) Furosemide (Lasix)

D) Morphine sulfate

Correct Answer is: B

Explanation : The most likely medication to be prescribed for a client with a newly diagnosed
spinal cord injury is dexamethasone (Decadron). This medication is a short-acting glucocorticoid
and would be administered to reduce traumatic edema. The use of propranolol (a beta-blocker),
furosemide (a diuretic), or morphine sulfate (an opioid analgestic) would not be indicated based
on the information in this question.

166) A nurse is caring for a client with Parkinson’s disease who is taking benztropine mesylate
(Cogentin) orally daily. The nurse does which of the following to asses for a side effect of the
medication?

Options:

A) Checks papillary response

B) Checks the partial thromboplastin time (PTT)

C) Monitors intake and output

D) Monitors the prothrombin time (PT)

Correct Answer is: C

Explanation : Urinary retention is a side effect of benztropine mesylate. The nurse needs to
monitor the client’s intake and output and observe for dysuria, distended abdomen, infrequent
voiding of small amounts, and overflow incontinence. Options 1, 2, and 4 are unrelated to the
side effects of this medication.

167) A client recovering from a craniotomy complains of a “runny nose.” The most important
nursing action is to:

Options:

A) Provide the client with soft tissues

B) Tell the client to use soft tissues to soak up the drainage

C) Monitor the client for signs of a cold

D) Notify the physician

Correct Answer is: D

Explanation : If the client has sustained a craniocerebral injury or is recovering from a


craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic area is
critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its presence indicates a
serious breach of cranial integrity. Any suspicious drainage should be reported immediately.

168) A nurse reviews the physician’s orders for a client with Guillain-Barre syndrome. Which
order written by the physician should the nurse question?

Options:

A) Assess vital signs frequently

B) Provide a clear liquid diet

C) Perform passive ranger of motion exercises three times daily

D) Obtain bilateral calf measurements daily

Correct Answer is: B

Explanation : Clients with Guillain-Barre syndrome have dysphagia. Clients with dysphagia are
more likely to aspirate clear liquids than thick or semi-solid foods. Because clients with Guillain-
Barre syndrome are at risk for hypotension or hypertension, bradycardia, and respiratory
depression, frequent monitoring of vital signs is required. Passive range of motion exercises can
help prevent contractures, and assessing calf measurements can help detect deep vein
thrombosis, for which these clients are at risk.

169) A client with myasthenia gravis arrives at the emergency room and crisis is suspected. The
physician plans to administer edrophonium (Tensilon) to differentiate between myasthenic and
cholinergic crisis. The nurse prepares to administer which medication if the client is in
cholinergic crisis?

Options:

A) Atropine sulfate

B) Morphine sulfate

C) Pyridostigmine bromide (Mestinon)

D) Isoproterenol (Isuprel)

Correct Answer is: A

Explanation : Clients with cholinergic crisis have experienced over dosage of medication. Tensilon
will exacerbate symptoms in cholinergic crisis to the point where the client may need intubation
and mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these
anticholinesterase medications. Morphine sulfate and pyridostigmine bromide would worsen the
symptoms of cholinergic crisis. Isuprel is not indicated for cholinergic crisis.

170) A client admitted to the nursing unit from the emergency department has a C-4 spinal cord
injury. Which assessment should the nurse perform first when admitting the client to the nursing
unit?

Options:

A) Take the client’s temperature

B) Assess extremity muscle strength

C) Observe for dyskinesias

D) Listen to breath sounds


Correct Answer is: D

Explanation : Because compromise of respiration is a leading cause of death in cervical cord


injury, respiratory assessment is the highest priority. Assessment of temperature and strength
can be done after adequate oxygenation is assured. Dyskinesias occur in cerebellar disorders, so
they are not as important in cord-injured clients, unless head injury is suspected.

171) A client suddenly experiences a seizure, and the nurse notes that the client exhibits
uncontrollable jerking movements. The nurse documents that the client experienced which type
of seizure?

Options:

A) Absence seizure

B) Myoclonic seizure

C) Clonic seizure

D) Tonic seizure

Correct Answer is: B

Explanation : A myoclonic seizure is characterized by sudden uncontrollable jerking movements


of a single muscle group or multiple muscle groups. Absence seizures occur in childhood and
adolescence and are characterized by a vacant facial expression. A clonic seizure is characterized
by rhythmic muscular contraction and relaxation lasting several minutes. A tonic seizure is
characterized by an abrupt increase in muscle tone and contraction and the presence of
autonomic manifestations.

172) A magnetic resonance imaging (MRI) test is prescribed for a client with Bell’s palsy. Which
nursing action is included in the client’s plan of care to prepare for this test?

Options:

A) Keep the client NPO for 6 hours before the test

B) Remove all metal-containing objects from the client

C) Shave the groin for insertion of a femoral catheter


D) Instruct the client in inhalation techniques for the administration of gas.

Correct Answer is: B

Explanation : In an MRI, radio-frequency pulses in a magnetic field are converted into pictures.
All metal objects, such as rings bracelets, hairpins, watches etc., should be removed. In addition,
a history should be taken to ascertain whether the client has any internal metallic devices, such
as orthopedic hardware, pacemakers, shrapnel, etc. For an abdominal MRI, the client is usually
NPO. An NPO status is not necessary for an MRI of the head. The groin may be shaved for an
angiogram, and inhalation of gas may be prescribed with a positron emission tomography (PET)

173) A medication nurse is supervising a newly hired licensed practical nurse (LPN) during the
administration of oral pyridostigmine (Mestinon) to a client with myasthenia gravis. Which
observation by the medication nurse would indicate safe practice by the LPN?

Options:

A) Asking the client to lie down on his or her right side

B) Instructing the client to void before taking the mediation

C) Asking the client to take sips of water

D) Asking the client to look up at the ceiling for 30 seconds

Correct Answer is: C

Explanation : Myasthenia gravis can affect the client’s ability to swallow. The primary assessment
is to determine the client’s ability to handle oral medications or any oral substance. Options 1
and 4 are not appropriate. Option 1 could result in aspiration and option 4 has no useful
purpose. There is no specific reason for the client to void before taking this medication.

174) A clinic nurse is assessing a client for environmental risk factors related to neurological
disorders. The nurse understands that which of the following is least likely associated with
neurological disorders?

Options:

A) Exposure to fumes, such as paints or bonding agents (glue)


B) Exposure to pesticides

C) Ventilation in the work area

D) Number of windows in the work area

Correct Answer is: D

Explanation : The nurse would asses for the risk of exposure to neurotoxic fumes and chemicals.
These could include paint, bonding agents, pesticides, and many more. The nurse also inquires
about the adequacy of ventilation in the home and work area. Many work spaces (such as
factories, insurance companies, and operating rooms) are adequately ventilated without the use
of windows.

175) A client who has experienced a cerebrovascular accident has partial hemiplegia of the left
leg. The straight-leg cane formerly used by the client is not sufficient to provide support. The
nurse interprets that the client could benefit from the somewhat greater support and stability
provided by a:

Options:

A) Quad-cane

B) Wooden crutch

C) Lofstrand crutch

D) Wheelchair

Correct Answer is: A

Explanation : A quad-cane may be prescribed for the client who requires greater support and
stability than is provided by a straight-leg cane. The quad-cane provides a four-point base of
support and is indicated for use by clients with partial of complete hemiplegia. Neither crutches
nor a wheelchair are indicated for use with a client such as described in this question. A
Lofstrand crutch is useful for clients with bilateral weakness.

176) A client who has experienced a cerebrovascular accident has partial hemiplegia of the left
leg. The straight-leg cane formerly used by the client is not sufficient to provide support. The
nurse interprets that the client could benefit from the somewhat greater support and stability
provided by a

Options:

A) Quad-cane

B) Wooden crutch

C) Lofstrand crutch

D) Wheelchair

Correct Answer is: A

Explanation : A quad-cane may be prescribed for the client who requires greater support and
stability than is provided by a straight-leg cane. The quad-cane provides a four-point base of
support and is indicated for use by clients with partial of complete hemiplegia. Neither crutches
nor a wheelchair are indicated for use with a client such as described in this question. A
Lofstrand crutch is useful for clients with bilateral weakness.

177) A client is being transferred to the nursing unit from the postanesthesia care unit following
spinal fusion with rod insertion. The nurse prepares to transfer the client form the stretcher to
the bed by using:

Options:

A) A bath blanket and the assistance of three people

B) A bath blanket and the assistance of four people

C) A transfer board and the assistance of two people

D) A transfer board and the assistance of four people

Correct Answer is: D

Explanation : Following spinal fusion, with or without instrumentation, the client is transferred
from the stretcher to the bed using a transfer board and the assistance of four people. This
permits optimal stabilization and support of the spine, while allowing the client to be moved
smoothly and gently.
178) A nurse is developing a nursing care plan for a client with severe. Alzheimer’s disease. The
nurse identifies which nursing diagnosis as the priority?

Options:

A) Impaired verbal communication

B) Ineffective role performance

C) Risk for injury

D) Social isolation

Correct Answer is: C

Explanation : Clients who have Alzheimer’s disease have signification cognitive impairment and
are therefore at risk for injury. It is critical for the nurse to maintain a safe environment,
particularly as the client’s judgment becomes increasingly impaired. Options 1, 2, and 4 may be
appropriate, but the highest priority is directed toward safety.

179) A nurse is admitting a client to the hospital who has a diagnosis of guillain-barre syndrome.
After ensuring that the client’s vital signs are stable and that the client is comfortable in bed, the
nurse asks a family member if the client has recently had:

Options:

A) A respiratory or gastrointestinal (GI) infection

B) Meningitis

C) A back injury or spinal cord trauma

D) Seizures or head trauma

Correct Answer is: A

Explanation : Guillain-Barre syndrome is a clinical syndrome of unknown origin that involves


cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1
to 4 week before the onset of neurological deficits. Occassionally, it has been triggered by
vaccination or surgery. The other options are not associated with an incidence of this syndrome.
180) A client is admitted to the hospital in myasthenic crisis. The nurse questions the family
about the occurrence of which precipitating factor for this event?

Options:

A) Not taking prescribed medication

B) taking excess prescribed medication

C) Getting more sleep than usual

D) A decrease in food intake recently

Correct Answer is: A

Explanation : Myasthnic crisis is often caused by undermedication and responds to the


administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine
(Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and
responds to withholding of medications. Change in diet and increased sleep are not precipitation
factors. However, overexertion and overeating could possibly trigger myasthenic crisis.

181) A client with refractory myasthenia gravis is told by the physician that plasmapheresis
therapy is indicated. After the physician leaves the room, the client asks the nurse to repeat the
physician’s reason for ordering this treatment. The nurse tells the client that this therapy will
most likely improve which of the client’s symptoms?

Options:

A) Urinary incontinence

B) Pins and needles sensation in the legs

C) Double vision

D) Difficulty breathing

Correct Answer is: D

Explanation : Plasmapheresis is a process that separates the plasma from the blood elements, so
that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in
myasthenia gravis and may give temporary relief to the clients with actual or impending
respiratory failure. Usually three to five treatments are required. This therapy is not indicated for
the reasons listed in options 1, 2, and 3.

182) A nurse is admitting a client to the hospital who has a diagnosis of guillain-barre syndrome.
After ensuring that the client’s vital signs are stable and that the client is comfortable in bed, the
nurse asks a family member if the client has recently had:

Options:

A) A respiratory or gastrointestinal (GI) infection

B) Meningitis

C) A back injury or spinal cord trauma

D) Seizures or head trauma

Correct Answer is: A

Explanation : Guillain-Barre syndrome is a clinical syndrome of unknown origin that involves


cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1
to 4 week before the onset of neurological deficits. Occassionally, it has been triggered by
vaccination or surgery. The other options are not associated with an incidence of this syndrome.

183) A client is admitted to the hospital in myasthenic crisis. The nurse questions the family
about the occurrence of which precipitating factor for this event?

Options:

A) Not taking prescribed medication

B) taking excess prescribed medication

C) Getting more sleep than usual

D) A decrease in food intake recently

Correct Answer is: A

Explanation : Myasthnic crisis is often caused by undermedication and responds to the


administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine
(Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and
responds to withholding of medications. Change in diet and increased sleep are not precipitation
factors. However, overexertion and overeating could possibly trigger myasthenic crisis.

184) A nurse is caring for a client with a C-6 spinal cord injury during the spinal shock phase. The
nurse implements which of the following when preparing the client to sit in a chair?

Options:

A) Teaches the client to lock the knees during the pivoting stage of the transfer

B) Administers a vasodilator in order to improve circulation of the lower limbs

C) Raises the head of the bed slowly to decrease orthostatic hypotensive episodes

D) Applies knee splints to stabilize the joints during transfer

Correct Answer is: C

Explanation : Spinal shock is often accompanied by vasodilation in the lower limbs, which results
in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse
should provide for a gradual progression in head elevation while monitoring the blood pressure.
A vasodilator would exacerbate the problem. Clients with cervical cord injuries cannot lock their
knees, and the use of splints would impair the transfer.

185) A nurse is planning a discharge teaching plan for a client with a spinal cord injury. To
provide for a safe environment regarding home care, which of the following would be the
priority in the discharge teaching plan?

Options:

A) What the physician has indicated needs to be taught

B) Follow-up laboratory and diagnostic tests that need to be done

C) Assisting the client to deal with long-term care placement

D) Including the client’s significant others in the teaching session

Correct Answer is: D

Explanation : Involving the client’s significant others in discharge teaching is a priority in planning
for the client with a spinal cord injury. The client will need the support of the significant others.
Knowledge and understanding of what to expect will help both the client and significant others
deal with the client’s limitations. A physician’s order is not necessary for discharge planning and
teaching; this is an independent nursing action. Laboratory and diagnostic testing are not priority
discharge instructions for this client. Long-term placement is not the only option for a client with
spinal cord injury.

186) A nurse is preparing to transfer an average-sized client with right-sided hemiplegia from the
bed to the wheelchair. The client is able to support weight on the unaffected side. The nurse
plans to use the hemiplegic transfer technique. The client is dangling on the side of the bed. For
the safest transfer, the wheelchair should be positioned:

Options:

A) Near the client’s right leg

B) Next to either leg

C) As space in the room permits

D) Near the client’s left leg

Correct Answer is: D

Explanation : Although space in the room is an important consideration for placement of the
wheelchair for a transfer, when the client has an affected lower extremity, movement should
always occur toward the client’s unaffected (strong) side. For example if the client’s right leg is
involved, and the client is sitting on the edge of the bed, position the wheelchair next to the
client’s left side. This wheelchair position allows the client to use the unaffected leg effectively
and safely.

187) The client who suffered a severe head injury had vigorous treatment to control cerebral
edema. Brain death has now been determined. The nurse prepares to carry out which of the
following that will maintain viability of the kidneys before organ donation?

Options:

A) Monitoring temperature

B) Administering intravenous (IV) fluids


C) Assessing lung sounds

D) Performing range of motion exercises to extremities

Correct Answer is: B

Explanation : Perfusion to the kidney is affected by blood pressure, which is in turn affected by
blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated to
control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys.
Thus, the nurse prepares to infuse IV fluids as prescribed, and continues to monitor urine
output. Options 1, 3, and 4 will not maintain viability of the kidneys.

188) A nurse is assessing the corneal reflex on an unconscious client. The nurse would use which
of the following as the safest stimulus to touch the client’s cornea?

Options:

A) Wisp of cotton

B) Sterile tongue depressor

C) Sterile glove

D) Tip of a 1-mL syringe with the needle removed

Correct Answer is: A

Explanation : The corneal reflex is tested in selected situations, such as with the unconscious
client. The client who is unconscious is at great risk for corneal abrasion. For this reason, the
safest way to test the corneal reflex is by touching the cornea lightly with cotton. The lids of both
eyes blink when the cornea is touched. Use of the items in options 2, 3, and 4 can cause injury to
the cornea.

189) A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine


(Tegretol). The nurse provides instructions to the client about the medication and determines
that the client understands the instructions if the client states:

Options:

A) “I will report a fever or sore throat to my doctor.”


B) “My urine may turn red in color, but this is nothing to be concerned about.”

C) “I must brush my teeth frequently to avoid damage to my gums.”

D) “Some joint pain is expected and is nothing to worry about.”

Correct Answer is: A

Explanation : Agranulocytosis is an adverse effect of carbamazepine and places the client at risk
for infection. If the client develop a fever or a sore throat, the physician should be notified.
Unusual bruising or bleeding are also adverse effects of the medication and need to be reported
to the physician if they occur.

190) A nurse makes a home care visit to a client with Bell’s palsy. Which statement by the client
requires clarification by the nurse?

Options:

A) “I have been gently massaging my face.”

B) “I wear dark glasses when I go out.”

C) “I wear an eye patch at night.”

D) “I am staying on a liquid diet.”

Correct Answer is: D

Explanation : It is not necessary for a client with Bell’s palsy to stay on a liquid diet. The client
should be encouraged to chew on the unaffected side. Options 1, 2, and 3 identify accurate
statements related to managing Bell’s palsy.

191) A home care nurse is evaluating a client’s understanding of self-management of trigeminal


neuralgia. Which client statement indicates that teaching is necessary?

Options:

A) “An analgesic will help relieve my pain.”

B) “I should chew on my good side.”


C) “I should use warm mouthwash for oral hygiene.”

D) “Taking my carbamazepine (Tegretol) will help control my pain.”

Correct Answer is: A

Explanation : Chronic irritation of the fifth cranial nerve results in trigeminal neuralgia and is
characterized by intermittent episodes of intense pain of sudden onset on the affected side of
the face. The pain is rarely relieved by analgesics. It is recommended threat clients chew on the
unaffected side and use warm mouthwash for oral hygiene. Medications such as carbamazepine
(Tegretol) help control the pain of trigeminal neuralgia.

192) A nurse has implemented a plan of care for a client with a C-5 spinal cord injury to promote
health maintenance. Which client outcome would indicate effectiveness of the intervention?

Options:

A) Regains bladder and bowel control

B) Performs activities of daily living independently

C) Maintains intact skin

D) Independently transfers self to and from the wheelchair

Correct Answer is: C

Explanation : A client with a C-5 spinal cord injury results in quadriplegia with no sensation
below the clavicle, including most of the arms and hands. The client maintains partial movement
of the shoulders and elbows. Maintaining intact skin is an outcome for spinal cord injury clients.
The remaining options are inappropriate for this client.

193) A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up
visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the
reddened area. After counseling the client to relieve pressure on the area according to a turning
schedule, which action by the nurse is most appropriate?

Options:

A) Ask a family member to assess the skin daily


B) Schedule the client to return to the clinic daily for a skin check

C) Teach the client to feel for reddened areas

D) Teach the client to use a mirror for skin assessment

Correct Answer is: D

Explanation : The client should be encouraged to be as independent as possible. The most


effective way of skin self-assessment for this client is with the use of a mirror. Asking a family
member to assess the skin daily does not promote independence. It is unnecessary and
unrealistic for the client to return to the clinic daily for a skin check. Redness cannot be felt.

194) An older client is given a prescription for haloperidol (Haldol). The nurse instructs the client
and family to report any signs of pseudoparkinsonism and tells the family to monitor for:

Options:

A) Stooped posture and a shuffling gait

B) Muscle weakness and decreased salivation

C) Tremors and hyperpyrexia

D) Motor restlessness and aphasia

Correct Answer is: A

Explanation : Pseudoparkinsonism is a common extrapyramidal side effect of antipsychotic


medications. This condition is characterized by a stooped posture, shuffling gait, masklike facial
appearance, drooling, tremors, and pill-rolling motions of the fingers. Hyperpyrexia is
characteristic of another extrapyramidal side effect, neuroleptic malignant syndrome (NMS).
Aphasia is not characteristic of pseudoparkinsonism.

195) A client with a spinal cord injury experiences bladder spasms and reflex incontinence. In
preparing for discharge to home, the nurse instructs the client to:

Options:

A) Limit fluid intake to 1000 mL in 24 hours


B) Catheterize self every 2 hours prn to prevent spasm

C) Catheterize self every 2 hours prn to prevent spasm

D) Avoid caffeine in the diet

Correct Answer is: D

Explanation : Caffeine in the diet can contribute to bladder spasms and reflex incontinence. This
should be eliminated in the diet of the client with a spinal cord injury. Limiting fluid intake doe
not prevent spasm and could place the client at further risk of urinary tract infection. Self-
monitoring of temperature would be useful in detecting infection, but does nothing to alleviate
bladder spasm. Self-catheterization every 2 hours is too frequent and serves no useful purpose.

196) A nurse teachers a client with a spinal cord injury about measures to prevent autonomic
dysreflexia (hyperreflexia). Which statement by the client would indicate the need for additional
teaching?

Options:

A) “I need to pay close attention to how frequently my bowels move.”

B) “It is best if I avoid tight clothing and lumpy bed clothes.”

C) “I should watch for headache, congestion, and flushed skin.”

D) “Symptoms I should watch for include fever and chest pain.”

Correct Answer is: D

Explanation : Symptoms of autonomic dysreflexia include headache congestion, flushed skin


above the injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain
are not associated with this condition.

197) A nurse provides home care instructions to a client with multiple sclerosis. The nurse tells
the client u:

Options:

A) Avoid becoming pregnant


B) Restrict fluid intake to 1000 mL daily

C) Maintain a low-fiber diet

D) Avoid taking hot baths or showers

Correct Answer is: D

Explanation : Because fatigue can be precipitated by warm temperatures, the client is instructed
to take cool baths and maintain a cool environmental temperature. A high-fiber diet and an
adequate fluid intake of 2000 mL daily is encouraged to prevent alterations in elimination and
bowel patterns. The client should not be told to avoid pregnancy, but the nurse should assist the
client to make informed decisions regarding pregnancy.

198) A nurse has taught a client with silicosis about situations to avoid to prevent self-exposure
to silica dust. The nurse determines that the client understands the instructions if the client
verbalizers to give up or wear a mask for which of the following hobbies?

Options:

A) Pottery making

B) Woodworking

C) Painting

D) Gardening

Correct Answer is: A

Explanation : Exposure to silica dust occurs with activities such as pottery making and doing
stone masonry. Exposure to the finely ground silica, such as is used with soaps, polishes, and
filters, is also dangerous. Silica is not a pesticide and is not found in the average soil. Silica is not
inhaled in fumes, such as with wood-working or painting.

199) A client who has a history of gout is also diagnosed with urolithiasis. The stones are
determined to be of uric acid type. The nurse gives the client instructions in foods to limit, which
includes:

Options:
A) Liver

B) Apples

C) Carrots

D) Milk

Correct Answer is: A

Explanation : Foods containing high amounts of purines should be avoided in the client with uric
acid stones. This includes limiting or avoiding organ meats, such a s liver, brain heart, and kidney.
Other foods to avoid include sweetbreads, herring, sardines, anchovies, meat extracts,
consommés, and gravies. Food that are low in purines include all fruits, many vegetables, milk,
choose eggs, refined cereals, coffee tea, chocolate and carbonated beverages.

200) A home care nurse visits a client who had a cerebrovascular accident (CVA) with resultant
unilateral neglect who was recently discharged from the hospital. The nurse provides
instructions to the family regarding care and tells the family to:

Options:

A) Place personal items directly in front of the client

B) Assist the client from the affected side

C) Assist the client to groom the unaffected side first

D) Discourage the client from scanning the environment

Correct Answer is: B

Explanation : Unilateral neglect is a pattern of lack of awareness of body parts such as paralyzed
arms or legs. Initially, the environment is adapted to the deficit by focusing on the client’s
unaffected side, and the client’s personal items are placed on the unaffected side. Gradually, the
client’s attention is focused to the affected side. The client is assisted from the affected side, and
the client grooms the affected side first. The client needs to scan the entire environment.

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