560 The Nursing Care of Adults with Medical and Surgical Health Problems
115. The nurse ascertains that there is a discrep- 3. 80 mm Hg
ancy in the records of use of a controlled substance
for a client who is taking large doses of narcotic
pain medication. The nurse should do which of the
following next?
■ 1. Notify the Drug Enforcement Agency (DEA).
■ 2. Contact the Director of Quality and Risk Man-
agement/Legal Department.
■ 3. Notify the pharmacy technician who deliv-
ered the controlled substance.
■ 4. Notify the nursing supervisor of the clinical
unit.
Answers, Rationales, and Test
Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question.
Use these keys to further develop your test-taking
skills. For additional information about test-taking
skills and strategies for answering questions, refer to
pages 10–21, and pages 25–26 in Part 1 of this book.
The Client with a Head Injury
1. 2, 3, 4. The nurse should maintain ICP by
elevating the head of the bed and monitoring neuro-
logic status. An ICP greater than 20 mm Hg indi-
cates increased ICP, and the nurse should notify the
health care provider. Coughing and range-of-motion
exercises will increase ICP and should be avoided in
the early postoperative stage.
CN: Physiological adaptation;
CL: Synthesize
2. 1, 4. The nurse must monitor the systolic and
diastolic blood pressure to obtain the mean arte-
rial pressure (MAP), which represents the pressure
needed for each cardiac cycle to perfuse the brain.
The nurse must also monitor the cerebral perfu-
sion pressure (CPP), which is obtained from the ICP
and the MAP. The nurse should also monitor urine
output, respirations, and pain; however, crucial
measurements needed to maintain CPP are ICP and
MAP. When ICP equals MAP, there is no CPP.
CN: Management of care;
CL: Analyze
Billings_Part 2_Chap 3_Test 11.indd 560
To obtain the MAP, use this formula:
MAP = [systolic BP + (2 × diastolic BP)] ÷ 3
MAP = [120 + (2 × 60)] ÷ 3
MAP = 240 ÷ 3 = 80.
CN: Management of care; CL: Apply
4. 2, 3. The nurse should determine if the cli-
ent’s pupils are equal and react to light, and ask the
client if he has a headache. Confusion, agitation,
and restlessness are subtle clinical manifestations of
increased intracranial pressure (ICP). At this time, it
is not appropriate for the nurse to find a television
or arrange for the client to see his wife and baby.
Administering a sedative at this time will obscure
assessment of increased ICP.
CN: Management of care; CL: Synthesize
5. 1. The highest priority for a client with
multiple injuries is to establish an open airway for
effective ventilation and oxygenation. Unless the
client has a patent airway, other care measures will
be futile. Replacing blood loss, stopping bleeding
from open wounds, and checking for a neck fracture
are important nursing interventions to be completed
after the airway and ventilation are established.
CN: Safety and infection control;
CL: Synthesize
6. 1. Increasing ICP causes unequal pupils as a
result of pressure on the third cranial nerve. Increas-
ing ICP causes an increase in the systolic pressure,
which reflects the additional pressure needed to per-
fuse the brain. It increases the pressure on the vagus
nerve, which produces bradycardia, and it causes
an increase in body temperature from hypothalamic
damage.
CN: Reduction of risk potential;
CL: Analyze
7. 3. The clear drainage must be analyzed to
determine whether it is nasal drainage or cerebro-
spinal fluid (CSF). The nurse should not give the
client tissues because it is important to know how
much leakage of CSF is occurring. Compressing the
nares will obstruct the drainage flow. It is inappro-
priate to tilt the head back, which would allow the
fluid to drain down the throat and not be collected
for a sample. It is inappropriate to administer an
antihistamine because the drainage may not be from
postnasal drip.
CN: Reduction of risk potential;
CL: Synthesize
8/7/2010 10:22:05 AM

8. 1. Neural control of respiration takes place in
the brain stem. Deterioration and pressure produce
irregular respiratory patterns. Rapid, shallow res-
pirations, asymmetric chest movements, and nasal
flaring are more characteristic of respiratory distress
or hypoxia.
CN: Physiological adaptation;
CL: Apply
9. 3. Normal ICP is 15 mm Hg or less for 15 to
30 seconds or longer. Hyperventilation causes vaso-
constriction, which reduces cerebrospinal fluid and
blood volume, two important factors for reducing
a sustained ICP of 20 mm Hg. A cooling blanket is
used to control the elevation of temperature because
a fever increases the metabolic rate, which in turn
increases ICP. High doses of barbiturates may be
used to reduce the increased cellular metabolic
demands. Fluid volume and inotropic drugs are
used to maintain cerebral perfusion by supporting
the cardiac output and keeping the cerebral perfu-
sion pressure greater than 80 mm Hg.
CN: Physiological adaptation;
CL: Synthesize
10. 4. A decrease in the client’s LOC is an early
indicator of deterioration of the client’s neurologic
status. Changes in level of consciousness, such as
restlessness and irritability, may be subtle. Widen-
ing of the pulse pressure, decrease in the pulse rate,
and dilated, fixed pupils occur later if the increased
ICP is not treated.
CN: Physiological adaptation;
CL: Analyze
11. 1. The client’s ICP is elevated, and the client
should be positioned to avoid extreme neck flexion
or extension. The head of the bed is usually elevated
30 to 45 degrees to drain the venous sinuses and
thus decrease the ICP. Trendelenburg’s position
places the client’s head lower than the body, which
would increase ICP. The Sims position (side lying)
and elevating the head on two pillows may extend
or flex the neck, which increases ICP.
CN: Reduction of risk potential;
CL: Synthesize
12. 2. After administering mannitol, the nurse
closely monitors intake and output because manni-
tol promotes diuresis and is given primarily to pull
water from the extracellular fluid of the edematous
brain. Mannitol can cause hypokalemia and may
lead to muscle contractions, not muscle relaxation.
Signs and symptoms, such as widening pulse pres-
sure and pupil dilation, should not occur because
mannitol serves to decrease ICP.
CN: Pharmacological and parenteral
therapies; CL: Analyze
Billings_Part 2_Chap 3_Test 11.indd 561
The Client with Neurologic Health Problems 561
13. 3, 4, 5. The nurse should assess the client for
spinal shock, which is the immediate response to
spinal cord transection. Hypotension occurs and the
body loses core temperature to environmental tem-
perature. The nurse must treat the client immedi-
ately to manage hypotension and hypothermia. The
nurse should also ensure that there is an adequate
airway and respirations; there may be respiratory
compromise due to intercostal muscle involvement.
Once the client is stable, the nurse should conduct
a complete neurologic check. The nurse should take
all precautions to keep the client’s head, neck, and
spine position in straight alignment. If the client
is conscious, the nurse should briefly assess major
reflexes, such as the Achilles, patellar, biceps, and
triceps tendons, and sensation of the perineum for
bladder function.
CN: Management of care; CL: Analyze
14. 4. The correct motor function test for C8 is
a hand-grasp check. The motor function check for
C4 to C5 is shoulders shrugging against downward
pressure of the examiner’s hands. The motor func-
tion check for C5 to C6 is an arm pulling up from a
resting position against resistance. The motor func-
tion check for C7 is an arm straightening out from a
flexed position against resistance.
CN: Management of care; CL: Analyze
15. 2, 3, 5. The client with a C3 to C4 fracture has
neck control but may tire easily using sore muscles
around the incision area to hold up his head. There-
fore, the head and neck of his wheelchair should be
high. The seat of the wheelchair should be lower
than normal to facilitate transfer from the bed to the
wheelchair. When a client can use his hands and
arms to move the wheelchair, the placement of the
back to the client’s scapula is necessary. This client
cannot use his arms and will need an electric chair
with breath, chin, or voice control to manipulate
movement of the chair. A firm or hard cushion adds
pressure to bony prominences; the cushion should
instead be padded to reduce the risk of pressure
ulcers.
CN: Basic care and comfort;
CL: Synthesize
16. 4. It is important to first explain where a cli-
ent is to orient him to time, person, and place. Offer-
ing to get his family and asking him questions to
determine whether he is oriented are important, but
the first comments should let the client know where
he is and what happened to him. It is useful to be
empathetic to the client, but making a comment such
as “I’ll bet you’re a little confused” when he first
awakens is not helpful and may cause him anxiety.
CN: Psychosocial adaptation;
CL: Synthesize
8/7/2010 10:22:05 AM
 562 The Nursing Care of Adults with Medical and Surgical Health Problems
17. 2. It is best for the client to wear mitts, which
help prevent the client from pulling on the I.V.
without causing additional agitation. Using a jacket
or wrist restraint or tucking the client’s arms and
hands under the drawsheet restrict movement and
add to feelings of being confined, all of which would
increase her agitation and increase ICP.
CN: Physiological adaptation;
CL: Synthesize
18. 3. Coughing is contraindicated for a client at
risk for increased ICP because coughing increases
ICP. Deep breathing can be continued. Turning and
passive ROM exercises can be continued with care
not to extend or flex the neck.
CN: Reduction of risk potential;
CL: Synthesize
19. 2. Diabetes insipidus results from deficiency
of antidiuretic hormone (ADH). The condition may
occur in conjunction with head injuries as well as
with other disorders. In ADH deficiency, the client
is extremely thirsty and excretes large amounts of
highly diluted urine. Measuring the urine output
to detect excess amount and checking the specific
gravity of urine samples to determine urine concen-
tration are appropriate measures to determine the
onset of diabetes insipidus. The client may be tachy-
cardic and hypotensive from fluid deficit; however,
altered vital signs in a client with a head injury may
occur for other reasons as well. Blood gas analysis
and blood glucose levels will not reveal diabetes
insipidus.
CN: Physiological adaptation;
CL: Analyze
20. 3. Recovery from a serious head injury is a
long-term process that may continue for months or
years. Depending on the extent of the injury, clients
who are transferred to rehabilitation facilities most
likely will continue to exhibit cognitive and mobil-
ity impairments as well as behavior and personality
changes. The client would be expected to partici-
pate in the rehabilitation efforts to the extent he is
capable. Family members and significant others will
need long-term support to help them cope with the
changes that have occurred in the client.
CN: Physiological adaptation;
CL: Evaluate
21. 4. Decerebrate posturing occurs in clients
with damage to the upper brain stem, midbrain, or
pons and is demonstrated clinically by arching of
the back, rigid extension of the extremities, prona-
tion of the arms, and plantar flexion of the feet.
Internal rotation and adduction of arms with flexion
of elbows, wrists, and fingers describes decorticate
Billings_Part 2_Chap 3_Test 11.indd 562
posturing, which indicates damage to corticospinal
tracts and cerebral hemispheres.
CN: Physiological adaptation;
CL: Apply
22. 2. Cluster breathing consists of clusters of
irregular breaths followed by periods of apnea on
an irregular basis. A lesion in the upper medulla or
lower pons is usually the cause of cluster breathing.
Because the client had a bleed in the occipital lobe,
which is just superior and posterior to the pons and
medulla, clinical manifestations that indicate a new
lesion are monitored very closely in case another
bleed ensues. The nurse should notify the physician
immediately so that treatment can begin before res-
pirations cease. The client is not obtaining sufficient
oxygen and the depth of breathing is assisted by the
ventilator. The health care provider will determine
changes in the ventilator settings.
CN: Physiological adaptation;
CL: Synthesize
23. 2. Elevating the head of the bed to 30 degrees
is contraindicated for infratentorial craniotomies
because it could cause herniation of the brain down
onto the brain stem and spinal cord, resulting in
sudden death. Elevation of the head of the bed to
30 degrees with the head turned to the side opposite
the incision, if not contraindicated by the increased
intracranial pressure, is used for supratentorial
craniotomies.
CN: Physiological adaptation;
CL: Synthesize
The Client with Seizures
24.
3. Ease the client to the floor.
1. Maintain a patent airway.
4. Obtain vital signs.
2. Record the seizure activity observed.
To protect the client from falling, the nurse first
should ease the client to the floor. It is important
to protect the head and maintain a patent airway
since altered breathing and excessive salivation can
occur. The assessment of the postictal period should
include level of consciousness and vital signs. The
nurse should record details of the seizure once the
client is stable. The events preceding the seizure,
timing with descriptions of each phase, body parts
8/7/2010 10:22:06 AM

affected and sequence of involvement, and autonomic
signs should be recorded.
CN: Safety and infection control;
CL: Synthesize
25. 3. Temperatures are not assessed orally with
a glass thermometer because the thermometer could
break and cause injury if a seizure occurred. The
client can perform personal hygiene. There is no
clinical reason to discourage the client from wear-
ing his own clothes. As long as there are no other
limitations, the client should be encouraged to be
out of bed.
CN: Physiological adaptation;
CL: Synthesize
26. 4. A generalized tonic-clonic seizure involves
both a tonic phase and a clonic phase. The tonic
phase consists of loss of consciousness, dilated
pupils, and muscular stiffening or contraction,
which lasts about 20 to 30 seconds. The clonic
phase involves repetitive movements. The seizure
ends with confusion, drowsiness, and resumption of
respiration. A partial seizure starts in one region of
the cortex and may stay focused or spread (e.g., jerk-
ing in the extremity spreading to other areas of the
body). An absence seizure usually occurs in chil-
dren and involves a vacant stare with a brief loss of
consciousness that often goes unnoticed. A complex
partial seizure involves facial grimacing with patting
and smacking.
CN: Physiological adaptation;
CL: Analyze
27. 4. The client will be asked to hold the head
very still during the examination, which lasts about
30 to 60 minutes. In some instances, food and fluids
may be withheld for 4 to 6 hours before the pro-
cedure if a contrast medium is used because the
radiopaque substance sometimes causes nausea.
There is no special preparation for a CT scan, so a
shampoo the night before is not required. The client
may drink fluids until 4 hours before the scan is
scheduled. Electrodes are not used for a CT scan,
nor is the head shaved.
CN: Physiological adaptation;
CL: Synthesize
28. 2. Beverages containing caffeine, such as cof-
fee, tea, and cola drinks, are withheld before an EEG
because of the stimulating effects of the caffeine
on the brain waves. A meal should not be omitted
before an EEG because low blood sugar could alter
brain wave patterns; the client can have the entire
meal except for the coffee.
CN: Physiological adaptation;
CL: Synthesize
Billings_Part 2_Chap 3_Test 11.indd 563
The Client with Neurologic Health Problems 563
29. 1. Trauma is one of the primary causes of
brain damage and seizure activity in adults. Other
common causes of seizure activity in adults include
neoplasms, withdrawal from drugs and alcohol, and
vascular disease. Given the history of head injury,
electrolyte imbalance is not the cause of the seizure.
There is no information to indicate that the seizure
is related to a congenital defect. Epilepsy is usually
diagnosed in younger clients.
CN: Physiological adaptation;
CL: Apply
30. 2. Gabapentin (Neurontin) may impair
vision. Changes in vision, concentration, or coordi-
nation should be reported to the physician. Gabap-
entin should not be stopped abruptly because of the
potential for status epilepticus; this is a medication
that must be tapered off. Gabapentin is to be stored
at room temperature and out of direct light.
It should not be taken with antacids.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
31. 3. A priority for the client in the postictal
phase (after a seizure) is to assess the client’s breath-
ing pattern for effective rate, rhythm, and depth.
The nurse should apply oxygen and ventilation to
the client as appropriate. Other interventions, to be
completed after the airway has been established,
include reorientation of the client to time, person,
and place. Determining the client’s level of sleepi-
ness is useful, but it is not a priority. Positioning
the client comfortably promotes rest but is of less
importance than ascertaining that the airway is
patent.
CN: Reduction of risk potential;
CL: Synthesize
32. 4. Carbamazepine (Tegretol) is an anticon-
vulsant that helps prevent further seizures. Bed rest,
sedation (phenobarbital), and providing privacy do
not minimize the risk of seizures.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
33. 4. During a seizure, the nurse should note
movement of the client’s head and eyes and muscle
rigidity, especially when the seizure first begins, to
obtain clues about the location of the trigger focus
in the brain. Other important assessments would
include noting the progression and duration of the
seizure, respiratory status, loss of consciousness,
pupil size, and incontinence of urine and stool. It is
typically not possible to assess the client’s pulse and
blood pressure during a tonic-clonic seizure because
the muscle contractions make assessment diffi-
cult to impossible. The last dose of anticonvulsant
8/7/2010 10:22:07 AM
 564 The Nursing Care of Adults with Medical and Surgical Health Problems
medication can be evaluated later. The nurse should
focus on maintaining an open airway, preventing
injury to the client, and assessing the onset and
progression of the seizure to determine the type of
brain activity involved. The type of aura should be
assessed in the preictal phase of the seizure.
CN: Physiological adaptation;
CL: Analyze
34. 1. The nurse should expect a client in the
postictal phase to experience drowsiness to somno-
lence because exhaustion results from the abnormal
spontaneous neuron firing and tonic-clonic motor
response. An inability to move a muscle part is
not expected after a tonic-clonic seizure because a
lack of motor function would be related to a com-
plication, such as a lesion, tumor, or stroke, in
the correlating brain tissue. A change in sensation
would not be expected because this would indicate
a complication such as an injury to the peripheral
nerve pathway to the corresponding part from the
central nervous system. Hypotension is not typically
a problem after a seizure.
CN: Physiological adaptation;
CL: Analyze
35. 2. Anticonvulsant drug therapy should never
be stopped suddenly; doing so can lead to life-
threatening status epilepticus. Phenytoin sodium
does not carry a risk of physical dependency or lead
to hypoglycemia. Phenytoin has antiarrhythmic
properties, and discontinuation does not cause heart
block.
CN: Pharmacological and parenteral
therapies; CL: Apply
36. 2. Specific motor vehicle regulations and
restrictions for people who experience seizures vary
locally. Most commonly, evidence that the seizures
are under medical control is required before the
person is given permission to drive. Time of day
is not a consideration when determining driving
restrictions related to seizures. The amount of time
a person has been seizure-free is a consideration for
lifting driving restrictions; however, the time frame
is usually 2 years. It is recommended, not required,
that a person who is subject to seizures carry a card
or wear an identification bracelet describing the ill-
ness to facilitate quick identification in the event of
an emergency.
CN: Reduction of risk potential;
CL: Synthesize
37. 3. An aura is a premonition of an impending
seizure. Auras usually are of a sensory nature (e.g.,
an olfactory, visual, gustatory, or auditory sensa-
tion); some may be of a psychic nature. Evaluating
an aura may help identify the area of the brain from
which the seizure originates. Auras occur before a
Billings_Part 2_Chap 3_Test 11.indd 564
seizure, not during or after (postictal). They are not
similar to hallucinations or amnesia or related to
relaxation.
CN: Physiological adaptation;
CL: Synthesize
38. 2. Toxic effects of topiramate (Topamax)
include nephrolithiasis, and clients are encour-
aged to drink 6 to 8 glasses of water a day to dilute
the urine and flush the renal tubules to avoid stone
formation. Topiramate is taken in divided doses
because it produces drowsiness. Although eating
fresh fruits is desirable from a nutritional stand-
point, this is not related to the topiramate. The drug
does not have to be taken with meals.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
39. 3. A common adverse effect of long-term
phenytoin therapy is an overgrowth of gingival tis-
sues. Problems may be minimized with good oral
hygiene, but in some cases, overgrown tissues must
be removed surgically. Phenytoin does not cause
weight gain, insomnia, or deteriorating eyesight.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
40. 1, 2, 3. The nurse should assess the number
and type of seizures the client has experienced since
starting clonazepam monotherapy for seizure con-
trol. The nurse should also determine if the client
might be pregnant because clonazepam crosses the
placental barrier. The nurse should also ask about
the client’s use of alcohol because alcohol potenti-
ates the action of clonazepam. Although the nurse
may want to check on the client’s diet or use of ciga-
rettes for health maintenance and promotion, such
information is not specifically related to clonazepam
therapy.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
The Client with a Stroke
41. 15 points
The Glasgow Coma Scale provides three objective
neurologic assessments: spontaneity of eye opening,
best motor response, and best verbal response on a
scale of 3 to 15. The client who scores the best on all
three assessments scores 15 points.
CN: Management of care; CL: Apply
42. 2, 3, 5. The maximum dosage of warfarin
sodium (Coumadin) is not achieved until 3 to 4 days
after starting the medication, and the effects of the
drug continue for 4 to 5 days after discontinuing the
medication. The client should have his blood levels
8/7/2010 10:22:08 AM

tested periodically to make sure that the desired
level is maintained. Warfarin has a peak action
of 9 hours. Vitamin K is the antidote for warfarin;
protamine sulfate is the antidote for heparin.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
43. 1. A helpless client should be positioned on
the side, not on the back, with the head on a small
pillow. A lateral position helps secretions escape
from the throat and mouth, minimizing the risk of
aspiration. It may be necessary to suction the client
if he aspirates. Suction equipment should be nearby.
It is safe to use a padded tongue blade, and the
client should receive oral care, including brushing
with a toothbrush.
CN: Reduction of risk potential;
CL: Synthesize
44. 3. Studies show that clients who receive
recombinant t-PA treatment within 3 hours after the
onset of a stroke have better outcomes. The time
from the onset of a stroke to t-PA treatment is criti-
cal. A complete health assessment and history is
not possible when a client is receiving emergency
care. Upcoming surgical procedures may need to
be delayed because of the administration of t-PA,
which is a priority in the immediate treatment of
the current stroke. While the nurse should identify
which medications the client is taking, it is more
important to know the time of the onset of the
stroke to determine the course of action for admin-
istering t-PA.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
45. 3. Control of blood pressure is critical during
the first 24 hours after treatment because an intrac-
erebral hemorrhage is the major adverse effect of
thrombolytic therapy. Vital signs are monitored, and
blood pressure is maintained as identified by the
physician and specific to the client’s ischemic tissue
needs and risk of bleeding from treatment. The other
vital signs are important, but the priority is to moni-
tor blood pressure.
CN: Reduction of risk potential;
CL: Synthesize
46. 2. It is crucial to monitor the pupil size and
pupillary response to indicate changes around the
cranial nerves. The cholesterol level is not a priority
assessment, although it may be an assessment to be
addressed for long-term healthy lifestyle rehabilita-
tion. Bowel sounds need to be assessed because an
ileus or constipation can develop, but this is not a
priority in the first 24 hours, when the primary con-
cerns are cerebral hemorrhage and increased intrac-
ranial pressure. An echocardiogram is not needed
Billings_Part 2_Chap 3_Test 11.indd 565
The Client with Neurologic Health Problems 565
for the client with a thrombotic stroke without heart
problems.
CN: Physiological adaptation;
CL: Analyze
47.
4. Provide sedation.
2. Hyperoxygenate.
1. Suction the airway.
3. Suction the mouth.
Increased agitation with suctioning will increase
intracranial pressure (ICP), therefore sedation
should be provided first. The client should be
hyperoxygenated before and after suctioning to
prevent hypoxia since hypoxia causes vasodilation
of the cerebral vessels and increases ICP. The airway
should then be suctioned for no more than 10 sec-
onds. The mouth can be suctioned once the airway
is clear to remove oral secretions. Once the mouth is
suctioned the suction catheter should be discarded.
CN: Physiological adaptation;
CL: Synthesize
48. 1. The primary reason for the nursing assess-
ment of a client’s functional status before and after a
stroke is to guide the plan. The assessment does not
help to predict how far the rehabilitation team can
help the client to recover from the residual effects
of the stroke, only what plans can help a client who
has moved from one functional level to another. The
nursing assessment of the client’s functional status
is not a motivating factor.
CN: Physiological adaptation; CL: Apply
49. 2. Sliding a client on a sheet causes fric-
tion and is to be avoided. Friction injures skin and
predisposes to pressure ulcer formation. Rolling the
client is an acceptable method to use when chang-
ing positions as long as the client is maintained in
anatomically neutral positions and her limbs are
properly supported. The client may be lifted as long
as the nurse has assistance and uses proper body
mechanics to avoid injury to himself or herself or
the client. Having the client help lift herself off the
bed with a trapeze is an acceptable means to move a
client without causing friction burns or skin break-
down.
CN: Reduction of risk potential;
CL: Synthesize
50. 3. The use of ankle-high tennis shoes has
been found to be most effective in preventing
8/7/2010 10:22:08 AM
 566 The Nursing Care of Adults with Medical and Surgical Health Problems
plantar flexion (footdrop) because they add support
to the foot and keep it in the correct anatomic
position. Footboards stimulate spasms and are not
routinely recommended. Regular repositioning and
range-of-motion exercises are important interven-
tions, but the client’s foot needs to be in the cor-
rect anatomic position to prevent overextension of
the muscle and tendon. Massaging does not pre-
vent plantar flexion and, if rigorous, could release
emboli.
CN: Reduction of risk potential;
CL: Synthesize
51. 1, 2, 4. Placing a pillow in the axilla so the
arm is away from the body keeps the arm abducted
and prevents skin from touching skin to avoid skin
breakdown. Placing a pillow under the slightly
flexed arm so the hand is higher than the elbow
prevents dependent edema. Positioning a hand
cone (not a rolled washcloth) in the hand prevents
hand contractures. Immobilization of the extrem-
ity may cause a painful shoulder-hand syndrome.
Flexion contractures of the hand, wrist, and elbow
can result from immobility of the weak or paralyzed
extremity. It is better to extend the arms to prevent
contractures.
CN: Reduction of risk potential;
CL: Synthesize
52. 2. Expressive aphasia is a condition in which
the client understands what is heard or written but
cannot say what he or she wants to say. A com-
munication or picture board helps the client com-
municate with others in that the client can point to
objects or activities that he or she desires.
CN: Physiological adaptation;
CL: Synthesize
53. 2. A client with dysphagia (difficulty swal-
lowing) commonly has the most difficulty ingesting
thin liquids, which are easily aspirated. Liquids
should be thickened to avoid aspiration. Maintain-
ing an upright position while eating is appropriate
because it minimizes the risk of aspiration. Intro-
ducing foods on the unaffected side allows the
client to have better control over the food bolus. The
client should concentrate on chewing and swallow-
ing; therefore, distractions should be avoided.
CN: Safety and infection control;
CL: Synthesize
54. 2. Homonymous hemianopia is blindness in
half of the visual field; therefore, the client would
see only half of his plate. Eating only the food on
half of the plate results from an inability to coordi-
nate visual images and spatial relationships. There
may be an increased preference for foods high in
salt after a stroke, but this would not be related to
homonymous hemianopia. Forgetting the names of
Billings_Part 2_Chap 3_Test 11.indd 566
foods would be aphasia, which involves a cerebral
cortex lesion. Being unable to swallow liquids
is dysphagia, which involves motor pathways of
cranial nerves IX and X, including the lower brain
stem.
CN: Physiological adaptation;
CL: Analyze
55. 4. To expand the visual field, the partially
sighted client should be taught to turn the head from
side to side when walking. Neglecting to do so may
result in accidents. This technique helps maximize
the use of remaining sight. Covering an eye with a
patch will limit the field of vision. Personal items
can be placed within sight and reach, but most
accidents occur from tripping over items that cannot
be seen. It may help the client to see the door, but
walking presents the primary safety hazard.
CN: Reduction of risk potential;
CL: Synthesize
56. 3. A client who has brain damage may be
emotionally labile and may cry or laugh for no
explainable reason. Crying is best dealt with by
attempting to divert the client’s attention. Ignoring
the behavior will not affect the mood swing or the
crying and may increase the client’s sense of isola-
tion. Telling the client to stop is inappropriate.
CN: Psychosocial adaptation;
CL: Synthesize
57. 4, 5. When offering emotional support to a
client who is discouraged and has a negative self-
concept because of physical handicaps, the nurse
should approach the client with encouragement
and patience. The client should be praised when
he or she shows progress in efforts to overcome
handicaps. An attitude of helpfulness and sympathy
allows the client to assume a role of someone not
ordinary, someone who is not like others. Regardless
of the handicap, the client still feels the same on the
inside and has the same innate needs for his or her
growth and developmental age-group. An attitude of
charity tends to make the client feel like a “charity
case” or like someone who is given something free
because of his “condition.” The client feels unequal
to his peers or unable to fulfill the role relationships
that were obtained before the stroke. An approach
using firmness is inappropriate because it implies
that the client can do better if he just tries harder
and leaves no room for softness in the approach to
overcoming a negative self-concept.
CN: Psychosocial adaptation;
CL: Synthesize
58. 2. The nurse should encourage the client
to write messages or use alternative forms of com-
munication to avoid frustration. Presenting one
thought at a time decreases stimuli that may distract
8/7/2010 10:22:09 AM

the client, as does speaking in a normal volume and
tone. The nurse should ask the client to “show me”
and should encourage the use of gestures to assist in
getting the message across with minimal frustration
and exhaustion for the client.
CN: Psychosocial adaptation;
CL: Synthesize
59. 3. Thrombolytic enzyme agents are used for
clients with a thrombotic stroke to dissolve emboli,
thus reestablishing cerebral perfusion. They do not
increase vascular permeability, cause vasoconstric-
tion, or prevent further hemorrhage.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
The Client with Parkinson’s Disease
60. 3, 4, 5. The nurse should contact the health
care provider before administering Sinemet because
this medication can cause further symptoms of
depression. Suicide threats in clients with chronic
illness should be taken seriously. The nurse should
also determine if the client is on an MAO inhibitor
because concurrent use with Sinemet can cause a
hypertensive crisis. Sinemet is not a treatment for
depression. Having the client discuss his feelings is
appropriate when the prescription is finalized.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
61. 2. The first sign of Parkinson’s disease is
usually tremors. The client commonly is the first to
notice this sign because the tremors may be mini-
mal at first. Rigidity is the second sign, and brady-
kinesia is the third sign. Akinesia is a later stage of
bradykinesia.
CN: Physiological adaptation;
CL: Analyze
62. 3. The primary focus is on maintaining a safe
environment because the client with Parkinson’s
disease usually has a propulsive gait, characterized
by a tendency to take increasingly quicker steps
while walking. This type of gait commonly causes
the client to fall or to have trouble stopping. The
client should maintain a balanced diet, enhance the
immune system, and enjoy diversional activities;
however, safety is the primary concern.
CN: Reduction of risk potential;
CL: Synthesize
63. 2. Voluntary and purposeful movements
often temporarily decrease or stop the tremors
associated with Parkinson’s disease. In some cli-
ents, however, tremors may increase with voluntary
effort. Tremors associated with Parkinson’s disease
Billings_Part 2_Chap 3_Test 11.indd 567
The Client with Neurologic Health Problems 567
are not psychogenic but are related to an imbalance
between dopamine and acetylcholine. Tremors can-
not be reduced by distracting the client.
CN: Physiological adaptation;
CL: Analyze
64. 2. Demanding physical activity should be
performed during the peak action of drug therapy.
Clients should be encouraged to maintain indepen-
dence in self-care activities to the greatest extent
possible. Although some clients may have more
energy in the morning or after rest, tremors are man-
aged with drug therapy.
CN: Physiological adaptation;
CL: Synthesize
65. 4. Helping the client function at his or her
best is most appropriate and realistic. There is no
known cure for Parkinson’s disease. Parkinson’s dis-
ease progresses in severity, and there is no known
way to stop its progression. Many clients live for
years with the disease, however, and it would not
be appropriate to start planning terminal care at this
time.
CN: Physiological adaptation;
CL: Synthesize
66. 1. The primary goal of physical therapy and
nursing interventions is to maintain joint flex-
ibility and muscle strength. Parkinson’s disease
involves a degeneration of dopamine-producing
neurons; therefore, it would be an unrealistic goal
to attempt to build muscles or increase endurance.
The decrease in dopamine neurotransmitters results
in ataxia secondary to extrapyramidal motor system
effects. Attempts to reduce ataxia through physical
therapy would not be effective.
CN: Physiological adaptation;
CL: Synthesize
67. 2. Levodopa is prescribed to decrease severe
muscle rigidity. Levodopa does not improve mood,
appetite, or alertness in a client with Parkinson’s
disease.
CN: Pharmacological and parenteral
therapies; CL: Evalulate
68. 3. Vital signs should be monitored, especially
during periods of adjustment. Changes, such as
orthostatic hypotension, cardiac irregularities, pal-
pitations, and light-headedness, should be reported
immediately. The client may actually experience
suicidal or paranoid ideation instead of euphoria.
The nurse should monitor the client for elevated
liver enzyme levels, such as lactate dehydrogenase,
aspartate aminotransferase, alanine aminotrans-
ferase, blood urea nitrogen, and alkaline phos-
phatase, but the client should not be jaundiced. The
client should not experience signs and symptoms of
8/7/2010 10:22:10 AM
 568 The Nursing Care of Adults with Medical and Surgical Health Problems
diabetes or a low serum glucose level, but the nurse
should check the hemoglobin and hematocrit levels.
CN: Pharmacological and parenteral
therapies; CL: Analyze
69. 4. While the client is hospitalized for adjust-
ment of medication, it is essential that the medi-
cations be administered exactly at the scheduled
time, for accurate evaluation of effectiveness. For
example, levodopa-carbidopa (Sinemet) is taken in
divided doses over the day, not all at one time, for
optimum effectiveness.
CN: Pharmacological and parenteral
therapies; CL: Apply
70. 2. Ongoing self-care is a major focus for
clients with Parkinson’s disease. The client should
be given additional time as needed and praised for
her efforts to remain independent. Firmly telling the
client that she needs assistance will undermine her
self-esteem and defeat her efforts to be independent.
Telling the client that her perception is unrealistic
does not foster hope in her ability to care for herself.
Suggesting that the client modify her routine seems
to put the hospital or the nurse’s time schedule
before the client’s needs. This will only decrease the
client’s self-esteem and her desire to try to continue
self-care, which is obviously important to her.
CN: Psychosocial adaptation;
CL: Synthesize
71. 1. The goal of a pallidotomy is to improve
functional ability for the client with Parkinson’s
disease. This is a priority. The pallidotomy creates
lesions in the globus pallidus to control extrapy-
ramidal disorders that affect control of movement
and gait. If functional ability is improved by the
pallidotomy, the client may experience a secondary
response of an improved emotional response, but
this is not the primary goal of the surgical proce-
dure. The procedure will not improve alertness or
appetite.
CN: Basic care and comfort; CL: Apply
The Client with Multiple Sclerosis
72. 3. Symptoms that can occur with multiple
sclerosis are muscle spasticity and weakness,
fatigue, visual disturbances, hearing loss, and bowel
and bladder incontinence. Seizures are not associ-
ated with myelin destruction.
CN: Management of care; CL: Evaluate
73. 2, 3, 4, 5. Maintaining urinary function in a
client with neurogenic bladder dysfunction from
MS is an important goal. The client should ide-
ally drink 400 to 500 mL with each meal; 200 mL
Billings_Part 2_Chap 3_Test 11.indd 568
midmorning, midafternoon, and late afternoon; and
attempt to void at least every 2 hours to prevent
infection and stone formation. The client may need
to catheterize herself to drain residual urine in the
bladder. Restricting fluids during the day will not
produce sufficient urine. However, in bladder train-
ing for nighttime continence, the client may restrict
fluids for 1 to 2 hours before going to bed. The client
should drink at least 2,000 mL every 24 hours.
CN: Physiological adaptation; CL: Create
74. 2. With MS, hyperexcitability and euphoria
may occur, but because of muscle weakness, sudden
bursts of energy are unlikely. Visual disturbances,
weakness in the extremities, and loss of muscle tone
and tremors are common symptoms of MS.
CN: Physiological adaptation;
CL: Analyze
75. 3. Baclofen is a centrally acting skeletal mus-
cle relaxant that helps relieve the muscle spasms
common in MS. Drowsiness is an adverse effect, and
driving should be avoided if the medication pro-
duces a sedative effect. Baclofen does not stimulate
the appetite or reduce bacteria in the urine.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
76. 2. Evaluating drug effectiveness is difficult
because a high percentage of clients with MS exhibit
unpredictable episodes of remission, exacerbation,
and steady progress without apparent cause. Clients
with MS do not necessarily have increased intoler-
ance to drugs, nor do they endure long periods of
exacerbation before the illness responds to a par-
ticular drug. Multiple drug use is not what makes
evaluation of drug effectiveness difficult.
CN: Physiological adaptation;
CL: Analyze
77. 4. Asking a client to speak louder even when
tired may aggravate the problem. Asking the client
to speak slowly and distinctly and to repeat hard-to-
understand words helps the client to communicate
effectively.
CN: Psychosocial adaptation;
CL: Synthesize
78. 4. The nurses’ notes should be concise,
objective, clearly stated, and relevant. This client
trembles when she attempts voluntary actions, such
as drinking a beverage or fastening clothing. This
activity should be described exactly as it occurs
so that others reading the note will have no doubt
about the nurse’s observation of the client’s behav-
ior. Identifying the “intentional” activity of daily liv-
ing will help the interdisciplinary team individual-
ize the client’s plan of care. Clarifying what is meant
by “worsening” with a purposeful act will facilitate
8/7/2010 10:22:10 AM

the inter-rater reliability of the team. It is better to
state what the client did than to give vague nursing
orders in the nurses’ notes.
CN: Management of care; CL: Apply
79. 4. Limiting fluid intake is likely to aggravate
rather than relieve symptoms when a bowel retrain-
ing program is being implemented. Furthermore,
water imbalance, as well as electrolyte imbalance,
tends to aggravate the signs and symptoms of MS. A
diet high in fiber helps keep bowel movements regu-
lar. Setting a regular time each day for elimination
helps train the body to maintain a schedule. Using
an elevated toilet seat facilitates transfer of the client
from the wheelchair to the toilet or from a standing
to a sitting position.
CN: Physiological adaptation;
CL: Synthesize
80. 3. MS is a progressive, chronic neurologic
disease characterized by patchy demyelination
throughout the central nervous system. This inter-
feres with the transmission of electrical impulses
from one nerve cell to the next. MS affects speech,
coordination, and vision, but not cognition. Care for
the client with MS is directed toward maintaining
joint mobility, preventing deformities, maintaining
muscle strength, rehabilitation, preventing and treat-
ing depression, and providing client motivation.
CN: Reduction of risk potential;
CL: Synthesize
81. 2. The nurse’s most positive approach is to
encourage a client with MS to keep active, use stress
reduction strategies, and avoid fatigue because it
is important to support the immune system while
remaining active. A quiet, inactive lifestyle is not
necessarily indicated. Good health habits are not
likely to alter the course of the disease, although
they may help minimize complications. Practicing
using aids that will be needed for future disabilities
may be helpful but also can be discouraging.
CN: Physiological adaptation;
CL: Synthesize
82. 1, 3, 4, 5. A client with impaired peripheral
sensation does not feel pain as readily as someone
whose sensation is unimpaired; therefore, water
temperatures should be tested carefully. The client
should be advised to avoid using hot water bottles
or heating pads and to protect against cold tem-
peratures. Because the client cannot rely on minor
pain as an indicator of damaged skin or sore spots,
the client should carefully inspect the skin daily to
visualize any injuries that he cannot feel. The client
should not be instructed to avoid kitchen activi-
ties out of fear of injury; independence and self-
care are also important. However, the client should
meet with an occupational therapist to learn about
Billings_Part 2_Chap 3_Test 11.indd 569
The Client with Neurologic Health Problems 569
assistive devices and techniques that can reduce
injuries, such as burns and cuts that are common in
kitchen activities.
CN: Reduction of risk potential;
CL: Create
83. 3. Maintaining a regular voiding pattern
is the most appropriate measure to help the cli-
ent avoid urinary incontinence. Fluid intake is not
related to incontinence. Incontinence is related to
the strength of the detrusor and urethral sphincter
muscles. Inserting an indwelling catheter would be
a treatment of last resort because of the increased
risk of infection. If catheterization is required, inter-
mittent self-catheterization is preferred because of
its lower risk of infection. Antibiotics do not influ-
ence urinary incontinence.
CN: Physiological adaptation;
CL: Synthesize
84. 2. An individualized regular exercise pro-
gram helps the client to relieve muscle spasms. The
client can be trained to use unaffected muscles to
promote coordination because MS is a progressive,
debilitating condition. The data do not indicate that
the client needs psychotherapy, day care for the
granddaughter, or visits from other clients.
CN: Physiological adaptation;
CL: Synthesize
The Unconscious Client
85. 3. Activated charcoal powder is administered
to absorb remaining particles of salicylate. Vita-
min K is an antidote for warfarin sodium (Couma-
din). Dextrose 50% is used to treat hypoglycemia.
Sodium thiosulfate is an antidote for cyanide.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
86. 2, 3, 4. An excess of cholinergic agents
produce urinary and fecal incontinence, increased
salivation, diarrhea, and diaphoresis. In a severe
overdose, CNS depression, seizures and muscle
fasciculations, bradycardia or tachycardia, weak-
ness, and respiratory arrest due to respiratory
muscle paralysis occur. Anticholinergics produce
dry mucous membranes. Skin rash is not a sign of
overdose with a cholinergic agent.
CN: Pharmacological and parenteral
therapies; CL: Analyze
87. 3. The initial response to crisis is high
anxiety. Anxiety must dissipate before a person
can deal with the actual situation. Allowing family
members to ventilate their feelings can help diffuse
their anxiety. The reasons for the client’s actions are
8/7/2010 10:22:11 AM
 570 The Nursing Care of Adults with Medical and Surgical Health Problems
unknown; assumptions must be validated before
they become facts. Touch can be appropriate but not
when it is used as false reassurance. Helping with
the client’s care is appropriate at a later time.
CN: Psychosocial adaptation;
CL: Synthesize
88. 3. Maintaining intact skin is a priority for
the unconscious client. Unconscious clients need
to be turned every hour to prevent complications
of immobility, which include pressure ulcers and
stasis pneumonia. The unconscious client cannot be
educated at this time. Pain is not a concern. During
the first 24 hours, the unconscious client will mostly
likely be on nothing-by-mouth status.
CN: Reduction of risk potential;
CL: Synthesize
89. 2. The nurse must clean the unconscious
client’s mouth carefully, apply a thin coat of petro-
leum jelly, and move the endotracheal tube to the
opposite side daily to prevent dryness, crusting,
inflammation, and parotiditis. The unconscious
client’s temperature should be monitored by a route
other than the oral route (e.g., rectal, tympanic)
because oral temperatures will be inaccurate. The
client should be positioned in a lateral or semiprone
position, not a supine position, to allow for drain-
age of secretions and for the jaw and tongue to fall
forward. The client should not be dragged when
turned, as may happen when a drawsheet is used.
Care should be taken to lift the client’s heels, but-
tocks, arms, and head off of the sheets when turning.
Trochanter rolls, splints, foam boot aids, specialty
beds, and so on—not just two pillows—should be
used to keep the client in correct body position and
to decrease pressure on bony prominences.
CN: Reduction of risk potential;
CL: Synthesize
90. 3. The client is not in proper body alignment
if, when in the right side-lying position, the client’s
left arm rests on the mattress with the elbow flexed.
This positioning of the arm pulls the left shoulder
out of good alignment, restricting respiratory move-
ments. The arm should be supported on a pillow.
The client’s head also should be placed on a small
pillow to keep it in alignment with the body. The
right leg should be extended on the mattress with-
out a pillow to avoid hyperrotation of the hip. A
pillow should be placed between the left and right
legs with the left knee flexed so that on no parts of
the legs is skin touching skin.
CN: Physiological adaptation;
CL: Synthesize
91. 4. The goal of performing passive ROM exer-
cises is to maintain joint mobility. Active exercise is
needed to preserve bone and muscle mass. Passive
Billings_Part 2_Chap 3_Test 11.indd 570
ROM movements do not prevent bone demineraliza-
tion or have a positive effect on the client’s muscle
tone.
CN: Physiological adaptation;
CL: Evaluate
92. 1. Maintaining a patent airway is the prior-
ity. Therefore, the nurse should keep suction equip-
ment available to remove secretions. The client
should be placed in a side-lying, not prone, posi-
tion. Performing oral hygiene is a clean procedure;
therefore, the nurse wears clean gloves, not sterile
gloves. The nurse should never place any fingers in
an unconscious client’s mouth; the client may bite
down. Padded tongue blades, swabs, or a toothbrush
should be used instead; but maintaining the airway
is the priority.
CN: Physiological adaptation;
CL: Synthesize
93. 2. When the blink reflex is absent or the eyes
do not close completely, the cornea may become dry
and irritated. Corneal abrasion can occur. Taping
the eye closed will prevent injury. Having the client
wear eyeglasses or cleaning the eyelid will not pro-
tect the cornea from dryness or irritation. Artificial
tears instilled once per shift are not frequent enough
for preventing dryness.
CN: Reduction of risk potential;
CL: Synthesize
94. 3. Restlessness is an early indicator of
hypoxia. The nurse should suspect hypoxia in the
unconscious client who becomes restless. The most
accurate method for determining the presence of
hypoxia is to evaluate the pulse oximeter value or
arterial blood gas values. Cyanosis and decreased
respirations are late indicators of hypoxia. Hyper-
tension, not hypotension, is a sign of hypoxia.
CN: Physiological adaptation;
CL: Apply
95. 2. The client should be placed in a semi-
Fowler’s position to reduce the risk of aspiration.
The formula should be at room temperature, not
heated. Administering enteral tube feedings is a
clean procedure, not a sterile one; therefore, sterile
supplies are not required. Clients receiving enteral
feedings should be weighed regularly, but not neces-
sarily before each feeding.
CN: Reduction of risk potential;
CL: Synthesize
96. 4. Gastric residuals are checked before
administration of enteral feedings to determine
whether gastric emptying is delayed. A residual
of less than 50% of the previous feeding volume
is usually considered acceptable. In this case, the
amount is not excessive and the nurse should
8/7/2010 10:22:12 AM

reinstill the aspirate through the tube and then
administer the feeding. If the amount of gastric
residual is excessive, the nurse should notify the
physician and withhold the feeding. Disposing of
the residual can cause electrolyte and fluid losses.
CN: Reduction of risk potential;
CL: Synthesize
97. 1. Good catheter care, including meticulous
cleaning of the area around the urethral meatus, is
the highest priority for the client with an indwell-
ing catheter. Clamping an indwelling catheter is
not recommended. Irrigation of the catheter, which
requires breaking the closed system, is not recom-
mended. Manipulation of the catheter taped to the
client’s leg causes trauma to the urethral meatus,
which can predispose the client to an infection and
is also not recommended.
CN: Reduction of risk potential;
CL: Synthesize
98. 2, 3, 4. A client who is brain dead typically
demonstrates nonreactive dilated pupils and nonre-
active or absent corneal and gag reflexes. The client
may still have spinal reflexes, such as deep tendon
and Babinski reflexes, in brain death. Decerebrate
or decorticate posturing would not be seen. Clients
who are brain dead do not have a blink reflex.
CN: Physiological adaptation;
CL: Apply
The Client in Pain
99. 2. Morphine 2 mg was given 1 hour ago
and the client can have up to 4 mg every 2 hours.
Although the pain level is at 1, the nurse should
give medication prior to the dressing change with
packing that is likely to cause discomfort. A 4 mg
dose of morphine would exceed the 2 hour limit
and, if given after the dressing change, would not
manage pain during the procedure. The client has
been responding to the pain medication dosing and
a new order is not required at this time.
CN: Management of care;
CL: Synthesize
100. 1. Pain perception is an individual experi-
ence. Research indicates that pain tolerance and
perception vary widely among individuals, even
within cultures.
CN: Psychosocial adaptation;
CL: Synthesize
101. 1. Experience has demonstrated that clients
who feel confidence in the persons who are caring
for them do not require as much therapy for pain
relief as those who have less confidence. Without
Billings_Part 2_Chap 3_Test 11.indd 571
The Client with Neurologic Health Problems 571
the client’s confidence, developed in an effective
nurse-client relationship, other interventions may be
less effective. The client’s family can be an impor-
tant source of support, but it is the nurse who plans
strategies for pain relief. The client may require time
to adjust to the pain, but the nurse and client can
collaborate to try to evaluate a variety of pain relief
strategies. Arranging for the client to share a room
with another client who has little pain may have
negative effects on the client who has pain that is
difficult to relieve.
CN: Basic care and comfort;
CL: Synthesize
102. 4. Although meperidine hydrochloride can
be given orally, it is more effective when given intra-
muscularly. The equianalgesic dose of oral meperi-
dine is up to four times the I.M. dose (75 × 4 = 300).
CN: Pharmacological and parenteral
therapies; CL: Apply
103. 1. Opioid analgesics relieve pain by reduc-
ing or altering the perception of pain. Meperidine
hydrochloride does not decrease the sensitivity of
pain receptors, interfere with pain impulses travel-
ing along sensory nerve fibers, or block the conduc-
tion of pain impulses in the central nervous system.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
104. 3. The client’s innate responses to pain are
directed initially toward escaping from the source of
pain. Variations in tolerance and perception of pain
are apparent only in conscious clients, and only
conscious clients can employ distraction to help
relieve pain.
CN: Physiological adaptation; CL: Apply
105. 1. Ergotamine tartrate is used to help abort a
migraine attack. It should be taken as soon as pro-
dromal symptoms appear. Reduced migraine sever-
ity and relief from sleeplessness and vision prob-
lems address symptoms that occur after the migraine
has occurred and are not effects of ergotamine.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
106. 4. Biofeedback translates body processes
into observable signs so that the client can develop
some control over certain body processes. Biofeed-
back does not involve electrical stimulation. Use of
unpleasant stimuli such as electrical shock is a form
of aversion therapy. Biofeedback does not involve
monitoring body processes for the therapist to inter-
pret; rather, it is a self-directed, self-care activity
that reinforces learning because the client can see
the results of his actions.
CN: Psychosocial adaptation; CL: Apply
8/7/2010 10:22:13 AM
 572 The Nursing Care of Adults with Medical and Surgical Health Problems
107. 1. A back rub stimulates the large-diameter
cutaneous fibers, which block transmission of
pain impulses from the spinal cord to the brain. It
does not block the transmission of pain impulses
or stimulate the release of endorphins. A back rub
may distract the client, but the physiologic process
of fiber stimulation is the main reason a back rub is
used as therapy for pain relief.
CN: Basic care and comfort;
CL: Apply
108. 2. It is essential that the nurse document the
client’s response to pain medication on a routine,
systematic basis. Reassuring the client that pain will
be relieved is often not realistic. A client who con-
tinually presses the PCA button may not be getting
adequate pain relief, but through careful assessment
and documentation, the effectiveness of pain relief
interventions can be evaluated and modified. Pain
medication is not titrated until the client is free from
pain but rather until an acceptable level of pain
management is reached.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
109. 1. An epidural catheter is used for postopera-
tive pain management to block the pain sensation
below the point of insertion. If the client is rating
pain high, the PCA pump may be malfunctioning,
the catheter may have become misplaced, or the
amount of medication may not be sufficient. The
nurse should first check the PCA pump to determine
if it is functioning properly. Assessing vital signs
would be important to provide additional data about
the possible cause of pain. The catheter placement,
including removing the dressing or manipulating
the catheter, and drug dosage are the responsibility
of the physician, usually an anesthesiologist, who
inserted the catheter. This person should be con-
tacted if the PCA pump is functioning appropriately.
The epidural catheter lies just above the dura of the
spinal space. Infection, hypotension, and loss of
mental alertness are just a few of the complications
that can occur if the catheter is pushed through the
dura.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
110. 1. The nurse using healing touch affects a cli-
ent’s pain primarily through assessing and directing
the flow of energy fields. Healing touch can involve
touching, but it does not have to involve body con-
tact. Massage and hypnosis are not parts of healing
touch.
CN: Physiological adaptation;
CL: Apply
Billings_Part 2_Chap 3_Test 11.indd 572
Managing Care Quality and Safety
111. 3. Pulling the client up under the arm can
cause shoulder displacement. A belt around the
waist should be used to move the client. Passive
range of motion exercises prevents contractures and
atrophy. Raising the foot of the bed assists in venous
return to reduce edema. High top tennis shoes are
used to prevent foot drop.
CN: Management of care; CL: Synthesize
112. 3. Clients with Parkinson’s disease can expe-
rience dysphagia. Thickening liquids assists with
swallowing, preventing aspiration. Hyperextending
the neck opens the airway and can increase risk
of aspiration. Pressing the chin firmly on the chest
makes swallowing more difficult. The chin should
be slightly tucked to promote swallowing. The nurse
should suggest a speech therapy consult for evalua-
tion of the client’s ability to swallow.
CN: Safety and infection control;
CL: Synthesize
113. 2. Clients with Parkinson’s disease may expe-
rience a freezing gait when they are unable to move
forward. Instructing the client to march in place,
step over lines in the flooring, or visualize stepping
over a log allows them to move forward. It is impor-
tant to ambulate the client and not keep them on
bedrest. A muscle relaxant is not indicated.
CN: Management of care; CL: Synthesize
114. 1, 2, 3, 7. Pressure points in the side-lying
position include the ears, shoulders, ribs, greater
trochanter, medial or lateral condyles, and ankles.
The sacrum, occiput, and heels are pressure point
areas affected in the supine position.
CN: Safety and infection control;
CL: Analyze
115. 4. All health care facilities in which con-
trolled medications (Schedules II, III, and IV) are
stored for dispensing and/or administration to cli-
ents are required to follow procedures for the proper
maintenance of narcotic inventory. Narcotic inven-
tory maintenance includes, but is not limited to, all
discrepancies will have thorough and appropriate
documentation with accompanying reasons (.i.e.,
tablet/amp/vial breakage, additional medication
volume, etc.), timely resolution of inventory dis-
crepancies, and timely notification regarding con-
trolled substance inventory discrepancies of persons
in oversight areas (i.e., Pharmacy, Security, Nursing
House Supervisor). In the event of a significant inci-
dent, the proper external authorities will be notified
(i.e., DEA, local police department) by the Quality
and Risk Management/Legal Department.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
8/7/2010 10:22:13 AM