A1 PASSERS TRAINING, RESEARCH,  
     B. place a hot-water bottle at his
REVIEW and DEVELOPMENT
COMPANY
MATERNAL AND CHILD NURSING
SET 8
Situation: John Lee is an 18-year old
high school student who suffered an
injury to his cervical spine in a
football game.
1. In directing emergency care until
the ambulance arrives, it is most
important that the school nurse
      A. place a small makeshift pillow
under his head
      B. check to see if he can move all
of his extremities
      C. keep him flat and immobilized
in a natural position
      D. cover him with a blanket
2. A primary goal of nursing care
when John is brought into the
emergency room will be
      A. prevention of spinal shock
      B. maintenance of respiration
      C. maintenance of orientation        C. apply suction and gently rotate
      D provision for pain relief
Situation: Crutchfield tongs are used
to apply traction to realign the spinal
cord.
3. A nursing measure for john while
he is in cervical traction should be to
      A. massage the back of his head
      B. position him from side to side
      C. remove the weights at least
once a shift
      D. encourage involvement in his
own care
Situation: John is found to have a
temperature of 36ºC (96.8ºF).
4. The most appropriate initial
nursing measure for John in response
to his hypothermia would be to
      A. cover him with additional
blankets
the  following choices would be the
feet
      C. check for signs of shock
      D. notify his physician
Situation: John has a tracheostomy
performed and is on assisted
ventilation.
5. The alarm on the ventilator
sounds. The initial response by the
nurse should be to quickly
      A. notify the respiratory therapist
      B. check all connections from the
respirator
      C. notify the respiratory therapist
to come immediately
      D. use a self-inflating bag to
ventilate John
6. When suctioning John, the nurse
should
      A. ensure that he is able to take a
breath between insertions of the
catheter
      B. suction him for at least 30
seconds with each catheter insertion
the catheter while inserting it into
the bronchial bifurcation
      D. use clean technique during the
suction procedure
7. John suddenly becomes
diaphoretic, his blood pressure rises
to 190/110, and he complains of a
headache. The nurse should assess
the patient for signs of
      A. increased intracranial pressure
      B. spinal meningitis
      C. pulmonary congestion
      D. fecal impaction
8. Upon admission John had a
complete loss of motor
ability. Within 48 hours he is noted to
be having  muscle spasms. His family
becomes very excited when they
notice these movements. Which of
      C. elevated temperature and
most appropriate response by the
nurse?
 A. at this stage, muscle spasms are
expected, but it is too soon to
evaluate the extent of the injury    or
its permanent effects    Mr. Richards should include
      B. I can understand your
excitement. These movements are a
good sign that he is making progress        B. awakening the patient every 2
      C. these movements are an
indication that he is trying to move
and that his will is very strong
      D. these movements are reflex
activities that indicate that his spinal
cord is intact
Situation: Mark Richards has a
compound fracture of the temporal
bone.
9. The nurse notices bleeding from
the orifice of the ear. Which of the
following actions by the nurse can
be safely used to determine if the
drainage contains cerebrospinal fluid
(CSF)? The nurse should
      A. swab the orifice of the ear
with sterile applicator and send the
specimen to the laboratory
      B. blot the drainage with a sterile
gauze pad and look for a clear halo
or ring around the spot of     blood
      C. gently suction the ear an send
the specimen to the laboratory
      D. test the CSF with a Tes-Tape
and get a negative reading for sugar
10. The nursing care plans states
“Observe for early signs of increased
intracranial pressure (IIP).” Early
symptoms of IIP include
      A. widening pulse pressure and
dilated pupils
      B. rising blood pressure and
bradycardia
decerebrate posturing
      D. nausea, vomiting, and
restlessness
11. During the initial period after a
head injury, nursing intervention for
      A. packing the ear with cotton
balls to stop bleeding
hours to determine his level of
consciousness
      C. placing the patient in
Trendelenburg’s position
      D. forcing fluids to restore
hydration
12. Before discharge, a computerized
axial tomogram will be performed to
rule out any intracranial or
extracranial bleeding. Mr. Richards
should be told that
      A. the procedure is noninvasive
and he will not feel any pain
      B. he will experience a burning
sensation as the dye is being injected
      C. the procedure is done in the
operating room under anesthesia
      D. local anesthetic is used before
injecting air into the ventricles of the
brain via the spinal canal
Situation: Tonnie Miccio is a 43-year
old divorced man who has been
rushed to the emergency room with
an acute gouty arthritis.
13. While admitting Mr. Miccio to the
hospital, the nurse should recognize
those factors that can precipitate  an
acute attack. They include
 A. excessive smoking
      B. large alcohol intake
      C. emotional stress
      D. improper rest
14. A serum uric acid level is
performed by the hospital
laboratory. In acute gout, the uric
acid level is  approximately
      A. 1.0 mg/100 ml
      B. 2.1 mg/100 ml
      C. 6.5 mg/100 ml
      D. 10 mg/100 ml
15. Colchicine is the standard drug
used to treat acute gout: The
physician orders colchicines, 1.0 mg
every  2 hours. After receiving the
third dose, the patient complains of
nausea, vomiting, and diarrhea. The
nurse should recognize that this is
      A. a transient side effect and give
the next dose
      B. a sign of toxicity and withhold
the medication
      C. an allergic response to the drug
and notify the physician
      D. a psychogenic response to the
severe pain
16. The expected outcome for
colchicine is to
      A. reduce uric acid levels
      B. relieve joint pain and
inflammation
      C. increase blood flow to the
kidney
      D. detoxify purines in the liver
17. During the night, Mr. Miccio
complains of severe pain in his toe
and asks the nurse for 2 aspirin
tablets.   The nurse should
      A. give the patient the 2 aspirin
tablets
      B. elevate the foot on a pillow
      C. notify the physician
      D. offer the patient a cup of tea
18. Some physicians prescribe an
alkali-ash diet to enhance the effect
of the medications. Which of the
following foods are allowed?
      A. liver, shellfish, and fats
      B. cranberries, cheese, and whole
grain cereals
      C. milk, vegetables, and most
fruits
      D. eggs, milk, prunes, and plums
19. After the acute attack subsides,
the physician orders allopurinol
(Zyloprim), 300 mg/day. The
expected  outcome for this drug is to
 A. lower the plasma and urinary
uric acid level
      B. reduce inflammation of the
affected joints
      C. produce diuresis
      D. relieve pain
20. A teaching program for Mr.
Miccio should include
      A. emphasizing that aspirin is
contraindicated in patient’s taking
allopurinol
      B. restricting fluid intake to 1,000
ml/day
      C. explaining that acute gouty
attacks often occur during initiation
of allopurinol therapy
 D. stating that a low-purine diet
should be followed while taking
allopurinol
21. About 2 months after taking the
allopurinol, Mr. Miccio develops a
skin rash. The nurse should
      A. recognize this as a minor side
effect that will subside
      B. ask the patient if he has been
taking any aspirin while taking the
allopurinol
      C. recognize this is an indication
to discontinue the drug
      D. be aware that concomitant use
of colchicines with allopurinol causes
this reaction
22. One day, Jennifer asks her
roommate, Erin, how her scoliosis
was first recognized. Erin replies,
“The  school health nurse told me
that there may be a problem after all
the girls in my class were asked to
stand erect while she examined our
backs.” The nurse suspected scoliosis
when she observed that Erin’s
shoulder on one side was elevated
and her
      A. head appeared aligned to the
opposite side
      B. leg on the same side appeared
shorter
      C. hip on the opposite side
appeared prominent
      D. arm on the same side appeared
longer
23. When Erin’s scoliosis was
diagnosed after x-ray examination of
her spine, she was fitted with a
Milwaukee brace. Erin asks the nurse
when it could be removed each
day. Which of the following  would
be the best response?
 A. only when you are lying flat,
either resting or sleeping
      B. for 1 hour a day when you
bathe, shower, or go swimming
      C. only for special occasions, such
as a party
      D. for 3 hours a day: one in the
morning, one in the afternoon, and
one in the evening
Situation: Erin’s admission to the
hospital for spinal fusion was
necessary because hr scoliosis did
not respond to the Milwaukee brace.
24. Preoperative preparation for Erin
includes explaining that for 2 weeks
after surgery she will be  positioned
      A. on either side or prone
      B. sitting upright
      C. flat and will be logrolled
      D. on her back
25. When Erin is told that after
surgery she will wear a body cast for
about 1 year, she begins to sob. She
tells the nurse she will look like a
football player, not a girl. Which of
the following is the best response
the nurse can make?
      A. the people who really care
about you won’t even notice your
cast
      B. it only will be for a year. You’re
mature enough to wait
      C. just ignore any comments that
people make
      D. a pretty hairstyle and some
loose peasant blouses will keep you
looking feminine
26. After surgery, the nurse applies
slight pressure to Erin’s toes and asks
Erin is he can feel her foot being
touched. Erin replies, “No, I don’t
feel anything.” The nurse should then
      A. wait 1 hour and supply
pressure again
      B. record Erin’s expected
response
      C. ask Erin if her toes feel cold
      D. report Erin’s response to the
surgeon
Situation: Virginia K is a 25- year old
woman who works as a lifeguard at
the local beach. On her way to work
she is in an automobile accident and
is rushed to the hospital by
ambulance. A diagnosis of complete
transaction of the spinal cord at the
third lumbar (L3) level is made.
27. While assess Ms. K for neurologic
function, the nurse can expect she
will be unable to
      A. shrug her shoulders
      B. tighten her abdominal muscles
      C. bend her elbow
      D. straighten her legs
28. Long-term goals for Ms. K include
developing skills in
      A. performing wheelchair
ambulation
      B. activating an electric
wheelchair
      C. walking with leg braces and
crutches
      D. walking without aids
29. observing for symptoms of which
of the following is the priority of care
for Ms. K in the acute stages of
complete transaction of the lumbar
cord?
 A. spinal shock
      B. respiratory insufficiency
      C. autonomic hyperreflexia
      D. hypertensive crisis
30. To prevent the complication of
urinary tract infections, which of the
following measures should be
included in the nursing care plan?
      A. encouraging extra fluid intake
      B. offering at least two servings of
citrus fruit juice per day
      C. telling the patient to avoid fruit
juices such as plum, prune, and
cranberry
      D. notifying the dietician to
include a container of milk at all
meals
Situation: Jim, a 17-year old senior in
high school, has sustained a simple
fracture of the mandible after falling
from his motorbike.
31. Upon admission to the
emergency room, which of the
following choices should the nurse
expect to  observe?
      A. bleeding in the external
auditory canal
      B. dropped prominence of the
cheek on the affected side
      C. edema of the eyes and cheeks
      D. teeth unevenly lined up
Situation: An open reduction with
wiring of the lower jaw to the upper
jaw has been done by the surgeon.
32. In anticipating the postoperative
needs o the patient, which of the
following actions has the priority for
Jim?
A. placing paper and pencil at the
bedside
      B. providing a tracheostomy set
for tracheostomy care
      C. taping a wire cutter to the
head of the bed
      D. inserting a gauze wick in the
inside of the cheek
33. While teaching Jim mouth care
the nurse should
      A. show him how to use
moistened gauze sponges to clean
his mouth and tongue
      B. demonstrate how an oral
irrigation can be performed by
inserting the catheter along the
inside of the mouth between the
teeth and the cheek   over chest, and crossed the right leg
      C. explain to him that mouth care
should not be done until the wires
are removed
      D. tell him to use an astringent
mouthwash to remove all the debris
      
Mrs. Marian H is a 50-year old
woman who has a spinal cord lesion
at the fourth thoracic (T4) vertebra.
34. When there are lesions above T4
and T6, the patient may experience
autonomic hyperreflexia. This
condition can be prevented by
 A. avoiding bladder distention
      B. changing the patient’s position
hourly
      C. wearing supportive elastic hose
      D. doing a neurologic check
35. Mrs. H complains of severe
headache and is extremely
anxious. The nurse checks her blood
pressure  and finds it is 210/110. The
nurse should then
 A. check the patency of the urinary
catheter
      B. apply ice packs to her head
      C. place the patient in a flat
position
      D. sit with the patient until the
symptoms subside
Situation: Dorothy C, RN, age 35, is at
work. After moving a particularly
heavy patient, she suddenly develops
severe pain in the lumbosacral area
that radiates down her right leg. The
preliminary diagnosis is rupture of an
intervertebral disk.
36. Proper body mechanics may have
prevented this injury to Ms. C. If she
had adhered to the correct  method
of turning a patient from the supine
position to the left side, she would
have crossed the patient’s  right arm
over the left leg. Then, while standing
with her feet
 A. together at the patient’s right
side, she would gently turn the
patient by pushing at the shoulder
and    sacral areas
      B. apart at the right side of the
bed, she would turn the patient by
gently pushing at the shoulder and
center of the back
      C. apart at the left side of the bed,
she would gently roll the patient
toward her while keeping her legs
straight
      D. apart at the left side of the
bed, she would gently roll the
patient toward her while flexing her
knees
37. Instructions for Ms. C’s
recuperation at home should include
the use of a bed board, firm
mattress, and  rest in which of the
following positions?
      A. completely flat in bed
      B. head elevated on a pillow, and
knees and feet elevated with pillows
      C. head elevated with several
pillows, and her legs flat
      D. Head elevated with several
pillows, and several pillows under her
knees
38. Ms. C should be reminded that if
she is turning on her side, it is best if
she
      A. grasps a chair leg by the side of
the bed, and slowly pulls herself
over, flexing the uppermost knee
      B. keeps her legs extended while
crossing them to the side to which
she is turning, and then uses her  
      arms to help turn the upper
portion of her body
 C. crosses her arms, flexes the
uppermost knee toward the side to
which she is turning, and then    rolls
over  
      D. crosses her arms, crosses her
legs while they are extended to the
side toward which she is turning,  
and then rolls over
39. The physician gives Ms. C a
prescription for methocarbamol
(Robaxin). Because of her nursing
background, Ms. C will know that the
mediation is having the desired
effects if which of the following
occurs?
      A. She feels drowsy, and is
sleeping more
      B. she has a feeling of euphoria
      C. there is a decrease in muscle
spasms
      D. there is an increase in the
knee-jerk reflex
Situation: After a week of bed rest at
home, Ms. C’s condition remains
about the same. She is admitted to
the hospital for further treatment
and diagnostic tests.
40. Phenylbutazone (Butazolidin) is
ordered for Ms. C. Planning for the
administration of this medication
should include directions to
 A. administer it immediately before
or after eating
      B. avoid administering it with
dairy products
      C. administer it at least 2 hours
after eating
      D. administer it at specific time
intervals, without regard to meals
41. In addition to the order for
phenylbutazone, Ms. C is placed on
bed rest and in pelvic traction. To
diminish adverse responses to this
treatment, the nurse should request
an order for
      A. acetylsalicylic acid (aspirin)
      B. diphenoxylate hydrochloride
(Lomotil)
      C. prochlorpeazine (Compazine)
      D. dioctyl sodium sulosuccinate
(Colace)
42. A myelogram is performed on
Mrs. C with a water-soluble contrast
medium. Care after this procedure
should include
      A. limiting fluid intake and
elevating the head of the bed to 15
to 30 degrees
      B. not allowing anything by mouth
and keeping the bed flat
      C. encouraging fluid intake and
keeping the bed flat
      D. encouraging fluid intake and
raising the head of the bed to 15 to
30 degrees
43. Ms. C has a
laminectomy. Postoperatively, she
complains that the pain is no
different now than it was  before
surgery. The nurse should
      A. administer analgesics as
ordered, and explain that the pain is
to be expected because of the
edema that results from the
surgery         A. an elevated erythrocyte
      B. administer the analgesics as
ordered, but request that the
physician check the patient
immediately
      C. withhold the analgesic and
notify the physician
      D. administer the analgesics as
ordered, and tell Ms. C it will give her
relief shortly
44. Rehabilitation will be facilitated if
Ms. C is encouraged to do which of
the following?
      A. sleep in prone position  for Mrs. S during this initial acute
      B. sit up for at least part of he day
      C. perform abdominal-
strengthening exercise
      D. perform full trunk range-of-
motion exercises
Situation: Martha S is a 27-year old
patient who has experienced
increasing generalized stiffness,
especially in the morning, fatigue,
general malaise, and swelling and
pain in the finger joints. She has a
tentative diagnosis of rheumatoid
arthritis.
45. Upon admission, Mrs. S is noted
to have a rectal temperature of
37.7ºC (100ºF). A white blood count
is  ordered, and the report comes
back at 8,500/mm³. The nurse should
recognize this as being consistent
with rheumatoid arthritis because it
is
 A. within normal limits
      B. evidence of leukopenia
      C. only slightly elevated
      D. indicative of a generalized
infectious process
46. Which of the following blood-
analysis tests would be consistent
with diagnosis of rheumatoid
arthritis?
sedimentation rate and negative C-
reactive protein
      B. an elevated erythrocyte
sedimentation rate and positive C-
reactive protein
      C. a low erythrocyte
sedimentation rate and negative C-
reactive protein
      D. a low erythrocyte
sedimentation rate and positive C-
reactive protein
47. The primary goal of nursing care
phase of rheumatoid arthritis should
be to
 A. prevent deformity and reduce
inflammation
      B. prevent the spread of the
inflammation to other joints
      C. provide for comfort and relief
of pain
      D. assist her to accept the fact
that rheumatoid arthritis is a log-
term illness
48. During hospitalization, the nurse
should explain to Mrs. Samuel that
analgesics of choice would be
      A. codeine
      B. acetylsalicylic acid (aspirin)
      C. acetaminophen (Tylenol)
      D. proppoxyphene hydrochloride
(Darvon)
49. During the acute phase of Mrs.
S’s illness, which of the following
measures would be the most
appropriate?
 A. frequent periods of active
exercises
      B. frequent periods of bed rest
      C. rest for he affected joints only
      D. encouragement to perform
activities of daily living independently
50. The nurse understands that the
main nursing goal in helping Mrs. S
adapt to her chronic illness and plan
is to
      A. provide the care she is unable
to give herself
      B. provide guidance so that she
will not repress her illness
      C. plan for social contacts so that
she will not feel alone
      D. arrange for her after-care with
the home health aide
51. Mrs. S is given instructions for
using paraffin for her hands. The
nurse should include the fact that the
dips will be most effective if they are
performed
      A. before exercising her hands
      B. after exercising her hands
      C. instead of exercising her fingers
      D. while exercising her fingers
52. Whenever Mrs. S feels pain from
her arthritis, she tells the nurse she
feels not only the pain but that her
“whole body feels
threatened.” Which response by the
nurse is the most therapeutic?
      A. I will have someone stay with
you so you won’t harm yourself
      B. I will teach you some relaxing
exercises so you won’t be so tense
 C. you must have some medication
to help you gain control
      D. arthritic pain will lessen if you
try to grin and bear it
53. When Mrs. S is discharged, she is
instructed to take aspirin at home. It
is important that she be told to
take the drug
      A. on a regular basis throughout
the day
      B. only when other measures are
not effective
      C. upon arising and again at
bedtime
      D. between meals to promote its
absorption
54. When Mrs. S is discharged, the
nursing staff refers her to a nurse
therapist who will assist her in
dealing  with the anxiety over her
arthritis and the changes it has made
in her life. The nursing team
recognizes  that the role of the nurse
therapist is to
      A. work in conjunction with a
psychiatrist
      B. provide individual nursing
psychotherapy
      C. lead groups in therapy for
those with similar problems
      D. give family nursing
psychotherapy
Situation: Twenty years after Mrs. S
was first diagnosed with rheumatoid
arthritis, she is admitted for a right
total hip replacement. She has
experienced severe right hip pain
that has not responded to treatment
for several years, and has had
increasing difficulty moving about
because of damage to the right hip
joint.
55. Preoperative teaching for Mrs. S
should include
      A. isometric exercises of the
quadriceps and gluteal muscles
      B. instructions on the necessity
for keeping the right leg perfectly
straight after surgery
      C. the need to flex the involved
hip postoperatively to maintain
mobility
      D. the avoidance of aspirin for 4
days prior to surgery
56. Which of the following should the
nurse consider to be most significant
if noted when checking Mrs. S 3  days
postoperatively?
      A. pain in the operative site
      B. swelling of the operative sites
      C. pain and tenderness in the calf
      D. orthostatic hypotension
57. The physical therapist orders
exercises of Mrs. S’s right hip, knee,
and foot to gradually increase range
of motion to the right hip. The nurse
can best assist Mrs. S by
      A. administering an analgesic
before the exercises
      B. stopping the exercises if Mrs. S
experiences pain
      C. performing the exercises for
Mrs. S
      D. observing Mrs. S’s ability to
perform the exercises
58. Mrs. S should be instructed to
avoid
      A. adduction of her right leg
      B. abduction of hr right leg
      C. bearing any weight on her right
leg
      D. the prone position in bed
59. The nurse and Mrs. S plan for her
rehabilitation. Mrs. S asks the nurse,
“What do I have to do in
therapy?” Which reply by the nurse
most accurately describes the task of
the patient in rehabilitation?  To
      A. follow the instructions of the
rehabilitation team
      B. regain some function that was
lost
      C. prevent further loss of your
ability to function
      D. learn to deal realistically with
your disability
60. When the rehabilitation therapist
tells Mrs. S that the outcome of her
therapy depends on “the ability of
the nursing staff” as well as on her
motivation, Mrs. S questions the
nurse on the meaning of this phrase.        C. extend from the fracture site
The nurse should reply that “the
nurse’s role in rehabilitation is to
      A. make the patient as
comfortable as possible
      B. follow the directions of the
rehabilitation therapist
      C. supervise the patient’s therapy
appointments and exercise program
      D. assist the patient in
establishing therapy priorities and
goals
61. Mrs. S asks the nurse if her new
joint will function normally. The
nurse can best answer this by saying
that
      A. the new joint will be stronger
than the old one
      B. the new joint won’t function as
well as a normal joint, but it will be
better than the arthritic joint  program
      C. the new joint will function
almost as well as a normal joint,
particularly if you perform your
exercise faithfully        C. an additional booster injection
 D. the doctor will be able to assess
your limitations in 6 weeks and then
explain them to you   Situation: Mr. Lee is taken to the
Situation: Mr. Lee is a 20-year-old
patient who sustains a compound
fracture of the right shaft of the
femur and a simple fracture of the
ulna in a motorcycle accident.
62. While serving as a member of a
first aid squad, Mary V, RN, reaches
the scene of the motorcycle  accident
and administers emergency
treatment, which includes the
application of a splint. It is important
that the splint
 A. be applied while the limb is in
good alignment
      B. be applied to the limb in the
position in which it is found
downward
      D. extend from the fracture site
upward
63. While Mr. Lee is being
transported in the ambulance to the
hospital, he should be positioned
with the  affected limbs
      A. elevated
      B. in a flat position
      C. lower than his heart
      D. slightly abducted
64. While taking a history from the
patient, the nurse determines that
his last booster injection for tetanus  
immunization was 5 years ago. The
nurse should recognize that this
information is important because it 
      means that he should receive
 A. a full tetanus immunization
      B. nothing, because he is
sufficiently immunized against
tetanus
      D. human tetanus immune
globulin
operating room and the wound
caused by the fracture of the femur
is cleansed and debrided. The
fracture is then reduced, and a
Steinmann pin for skeletal traction is
inserted. A closed reduction of the
ulna is performed, and a cast is
applied.
65. The most important nursing
measure in the immediate
postoperative period will be
      A. encouragement of isometric
exercises
      B. cleansing of the area around
the Steinmann pin
      C. careful observation of vital
signs
      D. massage of pressure areas
66. After Mr. Lee returns to his room,
he complains of pain in his right
arm. The initial action of the nurse
should be to
      A. administer analgesics as
ordered
      B. check his fingers
      C. notify his physician
immediately
      D. pad the edges of the cast
67. To maintain proper alignment
and immobilization of the femur, the
physician has ordered skeletal
traction with a Thomas splint. While
caring for Mr. Lee, the nurse should
explain to him that he
      A. cannot turn or sit up
      B. cannot turn but can sit up
      C. can turn but cannot sit up
      D. can turn and can sit up
68. In dealing with the weights that
are applying the traction, the nurse
should
      A. allow them to hang freely in
place
      B. hold them up if the patient is
shifting position in bed
      C. remove them if the patient is
being moved up in bed
      D. lighten them for short periods
if the patient complains of pain
69. Mr. Lee has a Thomas knee splint
in place. In addition to the usual
measures for a patient in traction, it
will be important that the nurse
observe
      A. the groin area for pressure
      B. for constipation
      C. his skin for sings of decubiti
      D. for signs of hypostatic
pneumonia
70. If Mr. Lee should show an
increase in blood pressure and signs
of confusion and increased
restlessness,  the nurse should
suspect
      A. a concussion
      B. impending shock
      C. fat emboli
      D. anxiety
71. Because of the nature of Mr.
Lee’s wound and the insertion of a
Steinmann pin, it is especially
important  that the nurse observe for
      A. a foul odor
      B. foot drop
      C. pulmonary congestion
      D. fecal impaction
72. Mr. Lee develops an acute
localized osteomyelitis. He is placed
on intravenous antibiotic
therapy. The  wound is incised and
drained, and neomycin irrigations are
ordered four times a day. It is
important that  these irrigations be
performed
      A. with strict aseptic techniques
      B. with a warm solution
      C. for at least 5 minutes
      D. at equal time intervals
Situation: Maria Alfredo is a 30-year
old married woman who has
systemic lupus erythematosus (SLE).
73. While doing as nursing history on
Mrs. Alfredo, the nurse should
recognize that the most common
initial  symptoms of SLE are
 A. petechiae in the skin, nosebleeds,
and pallor
      B. hematuria, increased blood
pressure, and edema
      C. tachycardia, tremors, and loss
of weight
      D. painful muscles and joints,
stiffness, and inflammation of joints
74. Mrs. Afredo is instituted on long-
term prednisone therapy. Her daily
maintenance dose is 5 mg/day. In
the instructions to Mrs. Alfredo, the
nurse should emphasize that
      A. once the symptoms of SLE
subside, the medication will be
discontinued gradually
      B. a weight gain 2 pounds per
week should be reported to the
physician
      C. the maintenance dose will be
the lowest dose that controls
symptoms
      D. if adrenal atrophy occurs,
adrenocorticotropic hormone (ACTH)
will have to be prescribed
75. Mrs. Alfredo questions the nurse
about family planning and birth
control. Which of the following
choices should the nurse include in
her answer?
      A. oral contraceptives can
precipitate an acute exacerbation of
your condition
      B. Intrauterine devices are the
recommended brithcontrol measures
      C. there are no contraindications
for pregnancy, as long as the disease
is being treated
      D. studies indicate that the
corticosteroids produce fetal damage
76. The nursing care plan states,
“Observe for signs of Raynaud’s
phenomenon.” The nurse should
recognize that this phenomenon
      A. occurs as a side effect of
prednisone
      B. is aggravated by smoking
      C. is relieved by application of
cold compresses to the hands
      D. is the priority care
77. Although many abnormal
laboratory findings are found in SLE,
there is no one specific diagnostic
test.   The test that is positive in over
95 percent of all patients with SLE is
the blood test for
      A. the lupus erythematosus (LE)
factor
      B. the rheumatoid factor
      C. antinuclear antibodies (ANA)
      D. C-reactive protein (CRP)
78. The teaching program for Mrs.
Alfredo planned by the nurse should
include emphasis on which of the
following?
      A. once the symptoms are
controlled, the corticosteroids will be
discontinued
      B. if hair loss occurs, it is
irreversible
      C. overexposure to the sun can
produce an exacerbation of
symptoms
      D. a low-potassium, low-protein
diet is recommended
79. Mrs. Alfredo tells the nurse that
she has had black, tarry stools. The
nurse should
      A. reassure the patient that this is
a minor side effect of prednisone
      B. tell the patient that if she takes
the prednisone with milk, black, tarry
stools will be avoided
      C. tell the patient that she will ask
the physician to prescribe aluminum
hydroxide
      D. notify the physician because
black, tarry stools can be an
indication of bleeding peptic ulcer
80. Mrs. Alfredo calls the physician’s
office and complains that she has
chills, a fever, and a cough. The
nurse should
      A. advise that she remain in bed,
drink extra fluids, and take aspirin
every 4 hours
      B. recommended that she
increase her dose of prednisone until
her temperature is normal
      C. recommended that she come
to the office to be examined by the
physician
      D. tell Mrs. Alfredo to call for an
appointment when she is feeling
better
Situation:  Irene P is being treated in
the emergency room for an acute
attack of Meniere’s syndrome
81. The nurse should recognize that
the triad of symptoms associated
with Meniere’s syndrome is
      A. nystagmus, arthralgia, and
vertigo
      B. nausea, vomiting, and
arthralgia
      C. syncope, headache, and
hearing loss
      D. hearing loss, vertigo, and
tinnitus
82. Patient teaching for Mrs. P
includes helping her to recognize that
      A. Meniere’s syndrome is
psychogenic and is brought on by
stress
      B. most patients can be
successfully treated with a low-salt
diet and diuretics
      C. acute infection can precipitate
an attack
      D. a labyrinthectomy is the
preferred treatment for relieving
symptoms and restoring hearing
83. Nursing intervention during an
acute attack includes
      A. encouraging the patient to
walk
      B. placing the patient in a semi-
Fowler’s position
      C. Having the patient lie flat
      D. placing the patient in
Trendelenburg’s position
Situation: Mrs. C, 30 years old, has
symptoms of diplopia, fatigue, slight
vertigo, and a lack of
coordination. After a neurological
work-up she is diagnosed as having
multiple sclerosis.
84. The main goal of nursing care for
Mrs. C during the acute phase of the
disease should be to
      A. promotes rest
      B. prevent constipation
      C. maintain normal functioning
      D. encourage activities of daily
living
85. Mrs. C is note d to be having
mood swings. In deciding what
approach to use with her, the nursing
staff should recognize that this
      A. is probably the result of an
underlying mental disorder  electroencephalogram (EEG) and
      B. indicates that Mrs. C is having
difficulty accepting her diagnosis
      C. may be a result of pathology
and involvement of the limbic
system in the disease
      D. indicates that Mrs. C’s
intellectual capacity has been
compromised
86. Mrs. C questions the nurse
concerning the usual course of
multiple sclerosis. Which would be
the best  reply by the nurse?
      A. each individual is very
different; we cannot tell what will
happen
      B. I know you are worried, but it is
too soon to predict what will happen
      C. usually, acute episodes like
this are followed by remissions,
which may last a long time
      D. the future will take care of
itself; let’s concentrate on the
present
87. As Mrs. C’s condition improves, it
is most important that she be given
guidance in
      A. developing a program of
exercise
      B. learning to handle stressful
situations
      C. seeking vocational
rehabilitation
      D. limiting her activities to those
that are absolutely necessary
Situation: Barbara is a 23-year-old
woman who lives with her mother,
sister, and brother in a private
residence. She is attending the
neurological out-patient clinic for the
first time. Her health history includes
two grand mal seizures./ A diagnosis
of idiopathic epilepsy has been
made. The physician has ordered an
phenytoin sodium (Dilantin), 300
mg/day
88. While doing a nursing history on
Barbara, the nurse should recognize
that
      A. persons with idiopathic
epilepsy have a lower intelligence
level
      B. grand mal seizures do not
cause mental deterioration
      C. a common characteristic of
idiopathic epilepsy is committing acts
of violence
      D. idiopathic epilepsy is a form of
mental illness
89. To prepare Barbara for EEG, the
nurse should explain that
      A. during the test she will
experience small electric shocks that
feels like pin pricks
      B. the test measures mental
status as well as electrical brain
waves
      C. during the hyperventilation
portion of the test, she may
experience dizziness
      D. she will be unconscious during
the test
90. Health teaching for Barbara
includes ensuring that she
understands that
      A. proper prophylactic
medication can control the
incidence of seizures
      B. moderate use of alcohol is
permitted
      C. forcing fluids helps to reduce
the incidence of seizures
      D. the incidence of seizures is
related to hyperglycemia
91. During a follow-up clinic visit,
Barbara tells the nurse that her urine
has had a reddish-brown color. The
nurse should
      A. reassure Barabara  that this is
a harmless side effect of phenytoin
sodium (Dilantin)
      B. tell Barbara that this is a sign of
hepatic toxicity
      C. recommend that Barbara go to
the laboratory for a serum Dilantin
concentration test
      D. notify the physician that
Barbara has hematuria
92. A long-term goal for Barbara is to
minimize the gingival hyperplasia
associated with Dilantin therapy.  and mood changes
The nurse should recognize that        B. Muscle twitching, lapse of
      A. another anticonvulsant will be
prescribed if it occurs
      B. the physician will reduce the
dosage at the first sign of hyperplasia
      C. a regular plan of good oral
hygiene is essential
      D. vitamin C should be taken daily
with the Dilantin
93. Barbara’s serum concentration
level Dilantin is 15 µg/ml. The nurse
should recognize this as
      A. a desired therapeutic serum
level
      B. below the desired therapeutic
level
      C. above the recommended
serum level
      D. a toxic serum level
94. Family members should be
instructed about caring Barbara
during a grand mal
seizure. Immediate care  during a
seizure should include
      A. restraining Barbara’s arms and
legs
      B. forcing the mouth open to
insert an airway
      C. giving orange juice before the
clonic stage begins
      D. turning Barbara’s head to the
side
95. The nurse explains to Barbara
that safety precautions can be taken
by those who have warning
symptoms before the seizure. (These
symptoms are not part of the seizure,
as the aura is.) What warning
symptoms should the nurse tell
Barbara to be aware of?
      A. Hot and cold sensations,
gastrointestinal problems, anxiety,
consciousness, anxiety, and
gastrointestinal problems
      C. tingling in a local region,
anxiety, and lapse of consciousness
      D. increased tonicity of muscles
and autonomic behavior
96. The nurse should tell Barbara’s
family that after a seizure she will be
in a confused state and will need
some supervision. It is most
important for the caring one to be
calm because the confused state of
the  epileptic is considered to be
      A. One mood swings and a feeling
of general inadequacy and fatigue
that result in a decrease of    interest
      B. an adaptive period, when one
slowly learns to cope with the
devastating insults to one’s
psychological and physical integrity
      C. a gross impairment in social
and intellectual functioning with
crude, tactless, and impulsive         B. physical activity should be
behavior
      D. a helpless state, with
intellectual deterioration, difficulty in
communication, and regression to
the   emergency use
infantile state
97. Barbara asks the nurse if it is true
that there is an “epileptic
personality.” Which of the following
choices would be the nurse’s best
response/
      A. the person must be aware that
anxiety over anticipation of a seizure
may cause personality problems
      B. No, deviation in personality is
caused by restrictions imposed by
society
      C. Yes, one may learn to induce       D. edrophonium chloride
seizures as a way of getting attention (Tensilon)
from others
      D. the person may take on a sick
role if mismanaged at home or in
the community
Situation: Ms. R, a 35-year old
woman, has myasthenia gravis. She
has been referred to the neurology
clinic by her physician.
98. While doing a nursing history on
Ms. R, the nurse should expect her to
complain of which of the  following
symptoms?
 A. passive tremors, cogwheel
rigidity, and drooling
      B. spastic weakness of the limbs,
intention tremors, and incontinence
      C. diplopia, ptosis, and fatigue
      D. nystagmus, ataxia, and tinnitus
99. In preparing a teaching plan for
Ms. R, the nurse should emphasize
that
      A. the anticholinesterase
medications cause fewer side effects
when taken on an empty stomach
planned for the late afternoon early
evening
      C. a member of the family should
be taught how to use suction for
      D. edrophonium chloride
(Tensilon) is the drug of choice in the
treatment of myasthenia gravis
100. Respiratory distress is common
in people with myasthenic
crisis? Marked improvement of
respirations  occurs after the
administration of intravenous
 A. diazepam (Valium)
      B. hydrocortisone
      C. atropine sulfate