1.

A patient admitted to the hospital with a subarachnoid hemorrhage has complaints of severe
headache, nuchal rigidity,

A. The client needs mechanical ventilation

B. intracranial pressure is increased

D. Blood is anticipated in the cerebrospinal fluid

C. Vomiting continues

2. A client with subdural hematoma was given mannitol to decrease intracranial pressure. Which of the
following results would best show the mannitol was effective?

B. Systolic blood pressure remains at 150 mmHg

A. Urine output increases

D. NUN and creatinine returns to normal

C. Pupils are 88mm and nonreactive

3. A lumbar puncture is performed on a child suspected of having bacterial meningitis. Cerebrospinal

fluid (CSF) is obtained for analysis. Nurse Ada reviews the results of the cerebrospinal fluid analysis and
determines that which of the following results would verify the diagnosis?

A. Clear CSF, elevated protein, and decreased glucose

B. Cloudy CSF, decreased protein, and decreased glucose

C. Cloudy CSF, elevated protein, and decreased glucose

D. Clear CSF, decreased pressure, and elevated protein

4. While in the dining room having lunch, Dondon, a nursing home client with Alzheimer's disease
suddenly begins shouting and banging on the table. Which action should be taken by the nurse first?

A. Peak in a firm voice asking the client to stop the behavior

B. Put the client in the corner of the dining room by himself

C. Take the client back to his room to finish lunch

D. Remove the lunch tray until the client can control himself

5. Norse Koleen is caring for a client diagnosed to have head injury. Which of the following situation
needs intervention by the nurse?
A. The padded side rails are up

B. The bed is adjusted to low level

C. The client's spouse turns on the television one hour in the afternoon and 2 hours in the evening

D. The head of bed is elevated at 30-degree angle

6. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate
to the nursing assistant?

B. Take the patient's vital signs

A. Document the seizure.

D. Restrain the patient for protection.

C. Perform neurologic checks.

14. The nurse determines that teaching regarding diet patient selects which of these meals as having the
highest amount of …

a. Sardine sandwich on whole wheat bread, one cup of fruit yogurt, and one cup of milk

b. Two egg omelet with American cheese, one slice of whole wheat toast, and a half grapefruit

Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple

d. Chicken stir fry with bok choy, onions, and snap peas and one cup of steamed brown rice

15. When administering alendronate (Fosamax) to a patient, the nurse will fest

a. Administer the ordered calcium carbonate

b. Be sure the patient has recently eaten.

c. Assist the patient to sit up at the bedside

d. Ask about any leg cramps or hot flashes

16. When evaluating the effectiveness of treatment for a patient who is being treated for Paget's
disease with calcitonin (Clbacalcin) and ibandronate (Boniva), the nurse will ask the patient about

a. weight loss.

b. skeletal pain.

c. decreased appetite.

d. frequent cough.
17. A patient is receiving gentamicin (Garamyein) 80 mg IV twice daily for acute osteomyelitis. Which
action should the nurse take before administering the gentamicin?

a. Obtain the patient's oral temperature.

b. Review the patient's BUN and creatinine levels.

c. Ask the patient about any nausea.

d. Change the wet-to-dry dressing.

18. When planning care for a patient who will be treated with 2 days of bed rest for low back pain,
which intervention will the nurse include?

a. Telling the patient about the importance of a high fiber and fluid intake

b. Instructing the patient to avoid positioning the knee in the flexed position

c. Educating the patient that continuous heat application will reduce pain

d. Teaching the patient that the prone position will help relieve back pain

19. Which of these nursing actions included in the care of a patient after laminectomy can the nurse
delegate to an experienced nursing assistant?

a. Evaluation of the effectiveness of the PCA

b. Monitoring plantar and dorsiflexion of the feet

c. Rolling the patient from side to side every 2 hours

d. Determining the patient’s readiness to ambulate

20. A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident.
The nurse knows preoperative teaching for this client should include:

1. Explaining that the client will be walking with a prosthesis soon after surgery

2. Encouraging the client to share his feelings and fears about the surgery

3. Taking the informed consent form to the client and asking him to sign It.

4. Evaluating how the client plans to maintain his schoolwork during hospitalization

21. An 8-year-old girl has a closed transverse fracture of her right ulna. Which of the following actions, if
performed by the nurse before the application of a cast, is MOST important?

1. Check the radial pulses bilaterally and compare.

2. Evaluate the skin temperature and tissue turgor in the area.

3. Assess sensation of each foot while the girl closes her eyes.

4. Apply baby powder to decrease skin irritation under the cast.

22. The nurse in the outpatient clinic assists with the application of a cast to the left arm of a five-year
old girl. After the cast is applied, the nurse should

1. Petal the edges of the cast to prevent irritation.

2. Elevate the client's left arm on two pillows.

3. Apply cool, humidified air to dry the cast.

4. Ask the client to move her fingers to maintain mobility.

2. Risk for impaired skin integrity related to immobilization and secretions.

3. Risk wound infection related to involuntary bowel secretions.

4. Risk for fluid volume excess related to secretions

27. A 25-year-old woman is admitted to the neurosurgery unit for the removal of a cerebellar tumor.
The nurse would expect the patient to make which of the following statements about her symptoms?

1. "I have been having difficulty with my hearing.”

2. "I lose my balance easily.”

3. “I can't tell the difference between a sweet and sour taste."

4. "It is not easy for me to remember names and faces."

28. A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The
client has a cervical level (C-4) spinal cord injury, is tearful, constantly complains of discomfort, and
requests to be suctioned. The nurse understands that the client's attention-seeking behaviors may be
due to

1. anger and frustration

2. awareness of vulnerability.

3. increased social isolation.

4. increased sensory stimulation.

Test II: Exam on Musculo-Skeletal Disorder

1. A patient with an open fracture of the left tibia and soft tissue damage underwent a surgical
reduction and fixation of the tibia with debridement of nonviable tissue and drain placement. When
assessing the patient during the postoperative period, the nurse will be most concerned about

a. fever with chills and night sweats.

b. light yellow drainage from the wound.

c. pain on movement of the affected limb.

d. muscle spasms around the affected bone

2. A patient is hospitalized for initiation of regional antibiotic perfusion for acute osteomyelitis of the
right femur. Which intervention will be included in the plan of care?

a. Frequent weight bearing exercise

b. Immobilization of the right leg

c. Avoid administration of NSAIDS

d. Support right leg in a flexed position

3. A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left
leg. Which information will be included in the discharge teaching?

a. The reason for taking oral antibiotics for 7 to 10 days after discharge

b. The need for daily aerobic exercise to help maintain muscle strength

c. How to monitor and care for the long-term IV catheter site

d. How to apply warm packs safely to the leg to reduce pain

4. A patient has chronic osteomyelitis of the left femur, which is being managed at home with self-
administration of IV antibiotics. On a home visit, the nurse identifies the nursing diagnosis of ineffective
therapeutic regimen management when the nurse finds that the patient

a. is unable to plantar flex the foot on the affected side.

b. buses crutches to avoid weight bearing on the affected leg.

c. takes and records the oral temperature twice a day.

d. is irritable and frustrated with the length of treatment required.

5. Which statement by a patient who is scheduled for an above the knee amputation for treatment of an
osteogenic sarcoma of the right tibia indicates that patient teaching is needed?

a. "I wish that I did not have chemotherapy after this surgery."

b. "I do not mind the surgery because it will finally cure the cancer.”

c. "I know that will need lots of physical therapy after surgery.”

d. "I will use the patient-controlled analgesia to help control my pain level after surgery."

6. A 20-year-old patient with a 6-year history of muscular dystrophy is hospitalized with a respiratory
tract infection. Which nursing action will be included in the plan of care?

a. Logroll the patient every 1 to 2 hours

b. Teach the patient about the muscle biopsy procedure

c. Provide the patient with a pureed diet.

d. Assist the patient with active range-of-motion (ROM) exercises.

7. The nurse identifies a nursing diagnosis of pain related to muscle spasms for a patient with acute low
back pain associated with acute lumbosacral strain. An appropriate nursing intervention for this problem
is to teach the patient to

a. twist gently from side to side to maintain range-of motion in the spine

b. place a small pillow under the upper back to flex the lumbar spine gently

c. keep the head elevated slightly and flex the knees when resting in bed

d. avoid the use of cold because it will exacerbate

8. A patient whose work involves loading and unloading boxes has a history of chronic back pain, Which
statement after the nurse has taught the patient about correct body mechanics indicates that the
teaching has been effective?

à. "I plan to start doing sit-ups and leg lifts to strengthen the muscles of my back.”

b. "I will try to sleep with my hips and knees extended to prevent back strain."

c. "I can tell my boss that I need to change to a job where I can work at a desk.”
d. “I will keep my back straight when I need to lift anything higher than my waist."

9. A patient with a herniated intravertebral disk undergoes a laminectomy and discectomy. Following
the surgery, the nurse should position the patient on the side by

a. elevating the head of the bed 30 degrees and having the patient extend the legs while turning to the
side

9. Which of these patients in the neurologic intension cares will be best to assign to an registered
floated from the medical unit?

A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose

B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured
berry aneurysm

C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic
dose due

D. A 65-year-old patient with a astrocytoma who has just returned to the unit after having a craniotomy

10. You are supervising a senior nursing student who is caring for a patient with a right hemisphere
stroke. Which action by the student nurse requires that you intervene?

A. The student instructs the patient to sit up straight, resulting in the patient's puzzled expression

B. The student moves the patient's tray to the right side of her over-bed tray

C. The student assists the patient with passive range-of-motion (ROM) exercises

D. The student combs the left side of the patient's hair when the patient combs only the right side

11. Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

B. Ineffective airway clearance

A. Imbalanced nutrition: Less than body requirements

C. Dusk for injury

D. Impaired urinary elimination

12. You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with
meningococcal meningitis. Which action by the student requires that you intervene immediately?
A. The student enters the room without putting on a mask and gown

B. The student instructs the family that visits are restricted to 10 minutes

C. The student gives the patient a warm blanket when he says he feels cold

D. The student checks the patient's pupil response to light every 30 minutes

13. Tanya, is a female client is admitted to the facility for investigation of balance and coordination
problems, Including possible Meniere's disease. When assessing this client, Nurse Wacky expects to note

B. vertigo, vomiting, and nystagmus

A. vertigo, tinnitus, and hearing loss

D. vertigo, blurred vision, and fever

C. Vertigo, pain, and hearing impairment

14. Arthur, a male client is admitted with a cervical spine injury sustained during a diving accident. When
planning this client's care, Nurse Allen should assign highest priority to which nursing diagnosis?

A. Impaired physical mobility

C. Disturbed sensory perception

B. Ineffective breathing pattern

D. Self-care deficient: Dressing/grooming

15. White reviewing a client’s chart, Nurse Christine notices that the female client has myasthenia
gravis. Which of the following statements about neuromuscular blocking agents is true for a client with
this condition?

A. a neuromuscular blocking agent

B. The client may be less sensitive to the effects of Succinylcholine shouldn't be used; pancuronium may
be used in a lower dosage.

C. Pancuronlum shouldn't be used; succinylcholine may be used in a lower dosage.

D. Pancuronium and succinylcholine both require cautious administration

16. Shortly after admission to an acute care facility, Sonny, a male client with a seizure disorder develops
status epilepticus. The physician orders diazepam 10 mg I.V. stat. How soon can Nurse Alvin administer a
second dose of diazepam, if needed and prescribed?
A. in 30 to 45 minutes

B. in 30 to 45 seconds

C. In 10 to 15 minutes

D. In 1 to 2 hours

17. Nurse Ivy is assessing a child diagnosed with brain tumor. Which of the following signs and
symptoms would the nurse expect the child to demonstrate? Select all that apply.

4. Lethargy

1. Head tilt

5. Increased appetite

2. Vomiting

6. Increased pulse

3. Polydipsia

B. 1,2,4

D. 2,3,6

C. 3,4,6

A. 1,3,4

18. Alfie, an 89 years old male client, who has a mild Alzheimer’s disease was admitted 2 days ago.
Which of the following signs and symptoms are expected in the client? Select all that apply

3. unable to remember misplaced objects

1. poor attention span

2. poor personal hygiene

6. shuffling gait

5. intention tremors

4. Irritable

A. 2,3,4

D. 3,4,5

B. 2,3,4,5
C. 1,2,3,4,5,6

19. An 18-year-old client is admitted with a closed head injury sustained in a motor-vehicular accident.
His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform
first?

B. Administer 1g Mannitol IV as ordered

A. Reposition the client to avoid neck flexion

C. Increase the ventilator's respiratory rate to 20 breaths/minute

D. Administer 100 mg of pentobarbital IV as ordered.

20. Antonio, a 15-year-old client was hit in the head with a baseball during practice. When discharging
him to the care of his mother, the nurse gives which of the following instructions?

1. "Watch him for keyhole pupil the next 24 hours."

2. "Expect profuse vomiting for 24 hours after the injury.

3. "Wake him every hour and assess his orientation to person, time, and place."

4. "Notify the physician immediately if he has a headache."

21. The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment
findings would suggest the complication of autonomic dysreflexia?

1. Urinary bladder spasm pain

2. Severe pounding headache.

3. Tachycardia.

4. Severe hypotension

22. A college student comes to the college health services with complaints of a severe headache,
nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumber puncture
(LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis were
made?

1. cerebrospinal fluid (CSF) cloudy, Heb 13 g/dL, Het 38 % , WBC 18,000/nm3

2. CSF with RBCS present, Hgb 10 g/dt, Hct 37 % , WBC 8,000/mm3.

3. CSF cloudy, Hgb 12 g/dL, Hct 37 % , WBC 7,000/mm3 .

4. CSF clear, Hgb 15 g/dl, Hct 40% , WBC 11,000/mm3.

23. The nurse is caring for a patient admitted two days ago with a diagnosis of closed head injury. If the
patient develops diabetes insipidus, the nurse would observe which of the following symptoms?

1. Decerebrate posturing, BP 160/100, pulse 56

2. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.

3. Glycosuria, osmotic diuresis, loss of water and electrolytes.

4. Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L

24. In planning discharge teaching for a client after a lumbar laminectomy, the nurse would instruct the
client to exercise regularly to strengthen which muscles?

1. Anal sphincter.

2. Abdominal

3. Trapezius

4. Rectus femoris

25. For a client with a neurological disorder, which of the following nursing assessments will be MOST
helpful in determining subtle changes in the client's level of consciousness?

1.Client posturing

2. Glasgow coma scale.

3. Client thinking pattern.

4.Occurrence of hallucinations

26. A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining
abdominal wound, and diarrhea. Based on the nursing assessment, an appropriate priority nursing
diagnosis is

1. risk for constipation related to immobilization.