MEDICAL SURGICAL 3 FINAL COACHING EXAM – Dr.
Leni Arreglo
1. A patient with a spinal cord injury (SCI)
complains about a severe throbbing headache
that suddenly started a short time ago.
Assessment of the patient reveals increased
blood pressure (168/94) and decreased heart
rate (48/minute), diaphoresis, and flushing of
the face and neck. What action should you take
first?
a. Administer the ordered acetaminophen
(Tylenol).
b. Check the Foley tubing for kinks or
obstruction.
c. Adjust the temperature in the patient’s room.
d. Notify the physician about the change in
status.
Autonomic dysreflexia
● patient is experiencing
autonomic dysreflexia
● hyper/exaggerated autonomic response
● most common stimulus: bladder / bowel
distention / any discomfort
○ this bladder distention will stimulate
the sympha → exaggerated
response = vasoconstriction →
increase BP
○ stimulate sweat glands →
diaphoresis
○ baroreceptors detects inc bp will
signal the brain, stimulate PNS
○ vasodilation → headache, flushing
of face, nasal congestion, dec HR
● Management: Empty the bladder
● once the urine is removed from the
bladder, usually narerelieve na yung high
BP
● but if hindi nawala, management: elevate
the head of the bed 90 degrees so there is
pooling of blood pababa
SCI
- usually happens at the level of T6 and
above → inflammation → swelling of the
entire cord → loss of all spinal cord
function (spinal shock)
2. You are helping the patient with an SCI to
establish a bladder-retraining program. All
of the strategies may stimulate the patient to
void except:
a. Stroke the patient’s inner thigh. ✓
b. Pull on the patient’s pubic hair. ✓
c. Initiate intermittent straight
catheterization.
d. Pour warm water over the perineum ✓
Initiate intermittent straight catheterization – it
will not stimulate the patient to void by himself/
herself
Pull on the patient’s pubic hair - slight lang
naman kasi daw hahaha wag kang masama ang
isip, this will stimulate
3. The patient with multiple sclerosis tells the
nursing assistant that after physical therapy she
is too tired to take a bath. What is your priority
nursing diagnosis at this time?
a. Fatigue related to disease state
b. Activity Intolerance due to generalized
weakness
c. Impaired Physical Mobility related to
neuromuscular impairment
d. Self-care Deficit related to fatigue and
neuromuscular weakness
Multiple Sclerosis
- autoimmune
- demyelination of CNS
- first affected nerve: optic
- usually symptoms is blurring of vision
4. You are providing nursing care for a
patient with GBS. What observation would you
report immediately?
a. Complaints of numbness and tingling b.
Facial weakness and difficulty speaking c.
Rapid heart rate of 102 beats per minute
d. Shallow respirations and decreased
breath sounds
GBS
- demyelination of pns
- motor and sensory

- ascending paralysis
- reversible
- airway number 1
5. The patient who had a stroke needs to be
fed. What instruction should you give to the
nursing assistant who will feed the patient?
a. Position the patient sitting up in bed
before you feed her.
b. Check the patient’s vital signs.
c. Feed the patient quickly because there are
three more waiting.
d. Suction the patient’s secretions between bites
of food.
7. A patient recently started on phenytoin
(Dilantin) to control simple complex seizures is
seen in the outpatient clinic. Which information
obtained during his chart review and
assessment will be of greatest concern?
a. The gums appear enlarged and inflamed. -
gingival hyperplasia (expected)
b. The white blood cell count is
2300/mm3.
c. Patient occasionally forgets to take the
phenytoin until after lunch. - not of greatest
concern
d. Patient wants to renew his driver’s license in
the next month. - not of greatest concern

Assure safety first

6. While working in the ICU, you are assigned

to care for a patient with a seizure disorder.
Which of these nursing actions is most important
if the patient is having a seizure?

a. Place the patient on a non-rebreather mask

with the oxygen at 15 L/minute.
b. Administer lorazepam (Ativan) 1 mg IV.
c. Turn the patient to the side and protect
Dilantin causes gingival hyperplasia and other
airway.
anti-seizure drugs / calcium channel blockers
d. Assess level of consciousness during and
immediately after the seizure.
Normal WBC: 4,500 - 11,000
- patient is experiencing neutropenia
Priority: Protection of airway
8. Which of the following clients on the rehab
unit is most likely to develop autonomic
Seizure
dysreflexia?
1. Generalized seizure
I. Generalized tonic clonic seizure /
a. A client with a brain injury
grand mal
b. A client with a herniated nucleus pulposus
II. Petit mal / absence
c. A client with a high cervical spine
III. Myoclonic seizure (jerky)
injury d. A client with a stroke
2. Partial seizure
I. simple partial - start from one side
II. complex partial - psychomotor → lip The higher the spinal cord injury, the more likely
smacking to cause autonomic dysreflexia
Phases - at the level of T6 and above
1. Preictal phase
- aura 9. An 18-year-old client is admitted with a
2. Ictal phase - during seizure closed head injury sustained in a MVA. His
3. Post ictal phase intracranial pressure (ICP) shows an upward
a. asleep trend. Which intervention should the nurse
b. confused perform first?
a. Reposition the client to avoid neck
flexion
b. Administer 1 g Mannitol IV as ordered
c. Increase the ventilator’s respiratory rate to 20
breaths/minute
d. Administer antihypertensives as ordered.
Increase ICP:
- head and the neck is aligned – low-
fowler’s position
● purpose: to promote venous
drainage / return to the heart
- head of the bed 30 degrees
10. A client has been pronounced brain dead.
All of the following will be seen except: (-)
a. Decerebrate posturing b.
Dilated nonreactive pupils ✓ c.
Deep tendon reflexes ✓ d.
Absent corneal reflex ✓
Decerebrate posturing - still not brain dead,
signals that the motor function is decreasing
11. A client with head trauma develops a urine
output of 300 ml/hr, dry skin, and dry mucous
membranes. Which of the following nursing
interventions is the most appropriate to perform
initially?
a. Evaluate urine specific gravity b.
Anticipate treatment for renal failure
c. Provide emollients to the skin to prevent
breakdown
d. Slow down the IV fluids and notify the
physician
Diabetes Insipidus – ↓ ADH
specific gravity (urine) - 1.010 - 1.030
specific gravity (water) – 1.000
12. Which of the following describes
decerebrate posturing?
a. Internal rotation and adduction of arms with
flexion of elbows, wrists, and fingers -
Decorticate
b. Back hunched over, rigid flexion of all four
extremities with supination of arms and plantar
flexion of the feet
c. Supination of arms, dorsiflexion of feet
d. Back arched; rigid extension of all four
extremities.
- Decerebrate mas malala - can be seen
in patients with increased cranial pressure
13. A client has a cervical spine injury at
the level of C5. Which of the following
conditions would the nurse anticipate during the
acute phase?
a. Absent corneal reflex
b. Decerebrate posturing
c. Movement of only the right or left half of the
body
d. The need for mechanical ventilation
Buong spinal cord nag swell → infects C3 - C4 -
origin of the phrenic nerve → supply of the
diaphragm
14. Which of the following interventions
describes an appropriate bladder program for
a client in rehabilitation for spinal cord injury?
a. Insert an indwelling urinary catheter to
straight drainage - not bladder program
b. Schedule intermittent catheterization
every 2 to 4 hours
c. Perform a straight catheterization every 8
hours while awake - tagal beh
d. Perform Crede’s maneuver to the lower
abdomen before the client voids.
Bladder training / program – best
management for urge incontinence
Important na may schedule / time
15. A 20-year-old client who fell approximately
30’ is unresponsive and breathless. A cervical
spine injury is suspected. How should the first-
responder open the client’s airway for rescue
breathing?
a. By inserting a nasopharyngeal airway
b. By inserting a oropharyngeal airway
c. By performing a jaw-thrust maneuver
d. By performing the head-tilt, chin-lift
maneuver - mas magkaroon pa ng cervical spine
injury pag tinilt
c. Paraplegia - paralysis of lower extremity /
portion / levels of T6 and below / L2 / S2
d. Tetraplegia
Tetraplegia
- paralysis of four quadrants

16. A 30-year-old was admitted to the

progressive care unit with a C5 fracture from a
motorcycle accident. Which of the following
assessments would take priority?
a. Bladder distension
b. Neurological deficit
c. Pulse ox readings
d. The client’s feelings about the injury
To determine the status of airway
17. A client receiving vent-assisted mode
ventilation begins to experience cluster
breathing after recent intracranial occipital
bleeding. Which action would be most
appropriate?
19. A client comes into the ER after hitting his
head in an MVA. He’s alert and oriented. Which
of the following nursing interventions should be
done first?
a. Assess full ROM to determine extent of
injuries
b. Call for an immediate chest x-ray
c. Immobilize the client’s head and neck -
cause it might cause further injury
d. Open the airway with the head-tilt chin-lift
maneuver

a. Count the rate to be sure the ventilations are

deep enough to be sufficient
b. Call the physician while another nurse
checks the vital signs and ascertains the
patient’s Glasgow Coma score.
c. Call the physician to adjust the ventilator
settings. - tama din, but walang ginawa si nurse
d. Check deep tendon reflexes to determine the
best motor response

vent-assisted mode ventilation

● C1
- tinutulungan lang ng vent for breathing si
● C8
patient but di naman naka depende
● T1
cluster breathing
● T12
- di na makasunod / makaassist yung
● L1
ventilation kasi di na normal breathing ng
● L5
patient
● S1
- abnormal breathing tas mawawala tas mag
● S5
breath na ulit
● CO1
C1 to upper C5 - cervical plexus → phrenic nerve
* Hindi na kaya ng nurse, need mag help sa
= high quadriplegia - paralysis of the neck below
physician
- patient will be hooked to ventilator
for lifetime
18. A client with a C6 spinal injury would most
likely have which of the following symptoms? lower C5 to T1 - brachial plexus → upper
extremities = low quadriplegia paralysis from
a. Aphasia - speech problem the chest blow
b. Hemiparesis - weakness of one side of the
body

L2 - S4 - lumbosacral plexus → supply low
extremities and pelvis
T6 injury - high paraplegia paralysis from
the waist
L2 - low paraplegia paralysis form the hips below
20. A client has signs of increased ICP. Which
of the following is an early indicator of
deterioration in the client’s condition?
a. Widening pulse pressure - late
b. Decrease in the pulse rate -
late c. Dilated, fixed pupil - late
d. Decrease in LOC
21. A client who had a transsphenoidal
hypophysectomy should be watched carefully
for hemorrhage, which may be shown by which
of the following signs?
a. Bloody drainage from the
ears b. Frequent swallowing
c. Guaiac-positive stools
d. Hematuria
hypophysectomy - removal of pituitary gland
- frequent swallowing is a sign of bleeding
22. A client with C7 quadriplegia is flushed and
anxious and complains of a pounding headache.
Which of the following symptoms would also be
anticipated?
a. Decreased urine output or oliguria
b. Hypertension and bradycardia
c. Respiratory depression d.
Symptoms of shock
- Autonomic dysreflexia
23. The nurse is caring for the client with
increased intracranial pressure. The nurse would
note which of the following trends in vital signs
if the intracranial pressure is rising?
a. Increasing temperature, increasing pulse,
increasing respiration, decreasing blood
pressure b. Increasing temperature,
decreasing pulse, decreasing respiration,
increasing blood pressure
c. Decreasing temperature, decreasing pulse,
increasing respiration, decreasing blood pressure
d. Decreasing temperature, increasing pulse,
decreasing respiration, increasing blood pressure
Cushing’s triad - late sign of ↑ICP
- Increase in systolic pressure
(Hypertension) - widening of pulse
pressure
- Bradycardia (altered respiration
- Bradypnea (dec HR)
- Hyperthermia - but not part cushing’s
triad but it’s part of increasing ICP
24. The nurse is positioning the client with
increased intracranial pressure. Which of the
following positions would the nurse avoid?
a. Head midline ✓
b. Head turned to the side
c. Neck in neutral position ✓
d. Head of bed elevated 30 to 40 degrees ✓
Management for ↑ICP
1. Position: Low-fowler’s position
- head and neck align, bawal naka
yuko bawal nakaside
- elevate head of the bed 30-45 degrees
2. O2 administration
3. Reduce brain metabolism
I. Manage fever – high temperature
increases brain metabolism
II. Low dose sedative drugs
4. Hyperventilation (transient) → di matagal
I. Lower pCO2 (30 - 40 mmHg)
II. vasoconstriction
5. Avoid activities that ↑ICP
- straining, coughing, anything that will
increase intrathoracic pressure,
increase intra-abdominal pressure
6. Give osmotic diuretic
- Ex. Mannitol
- Measure intake and output
7. Steroids
- Ex. Hydrocortisone -
decrease inflammation
8. Manage the cause
25. The client recovering from a head injury is
arousable and participating in care. The nurse
determines that the client understands measures
to prevent elevations in intracranial pressure
if the nurse observes the client doing which of
the following activities? (+)
a. Blowing the nose - X
b. Isometric exercise - X
c. Coughing vigorously - X
d. Exhaling during repositioning
26. The client has clear fluid leaking from the
nose following a basilar skull fracture. The nurse
assesses that this is cerebrospinal fluid if the
fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH
of 6
c. Clumps together on the dressing and has a pH
of 7
d. Separates into concentric rings and
tests positive for glucose
CSF LEAK
Rhinorrhea - coming out of the nose
Otorrhea - coming out the ear
● to confirm if CSF → Halo signs and positive
for glucose
27. The nurse is evaluating the neurological
signs of the male client in spinal shock
following spinal cord injury. Which of the
following observations by the nurse indicates
that spinal shock persists?
a. Hyperreflexia - meron pa b.
Positive reflexes - meron pa
c. Reflex emptying of the bladder - meron pa
d. Inability to elicit a Babinski’s reflex ✓
28. The nurse is planning to institute seizure
precautions for a client who is being admitted
from the emergency department. Which of the
following measures would the nurse avoid in
planning for the client’s safety?
a. Padding the side rails of the bed
b. Putting a padded tongue blade at the
head of the bed → not being practiced na
c. Placing an airway, oxygen, and suction
equipment at the bedside
d. Having intravenous equipment ready for
insertion of an intravenous catheter
29. The nurse is caring for the client who begins
to experience seizure activity while in bed.
Which of the following actions by the nurse
would be contradicted?
a. Loosening restrictive clothing
b. Restraining the client’s limbs
c. Removing the pillow and raising padded side
rails
d. Positioning the client to the side, if possible,
with the head flexed forward
30. The nurse is assigned to care for a client
with complete right-sided hemiparesis. The
nurse plans care knowing that in this condition:
a. The client has complete bilateral paralysis of
the arms and legs
b. The client has weakness on the right
side of the body, including the face and
tongue
c. The client has the ability to move the right
arm but is able to walk independently
d. The client has lost the ability to ambulate
independently but is able to feed and bathe self
without assistance
31. The client with brain attack (stroke) has
residual dysphagia. When a diet order is
initiated, the nurse avoids doing which of the
following? (-)
a. Giving the client thin liquids - risk for
aspiration, mabilis kasi malulon, pwede
din mapunta sa airway
b. Thickening liquids to the consistency of
oatmeal
c. Placing food on the unaffected side of the
mouth
d. Allowing plenty of time for chewing and
swallowing
32. The nurse has instructed the family of a
client with brain attack (stroke) who has
homonymous hemianopsia about measures
to help the client overcome the deficit. The
nurse determines that the family understands
the measures to use if they state that they will:
a. Place objects in the client’s impaired field of
vision
b. Discourage the client from wearing eyeglasses
c. Approach the client from the impaired field of
vision
d. Remind the client to turn the head to
scan the lost visual field
Homonymous hemianopsia
- Visual field defect, kapag yung tao naka
straight lang hindi nakikita yung one side
of the visual field
33. A nursing student is caring for a client
with a brain attack (stroke) who is experiencing
unilateral neglect. The nurse would intervene
if the student plans to use which of the
following strategies to help the client adapt to
this deficit? (-)
a. Tells the client to scan the environment
b. Approaches the client from the
unaffected side - AFFECTED SIDE
c. Places the bedside articles on the affected
side
d. Moves the commode and chair to the affected
side
Unilateral neglect - a nursing diagnosis
- not a visual impairment
- usually seen in patients with right parietal
lobe
- manifestations → contralateral
● Approaches the client from the AFFECTED
side → to help them adapt from the deficit
34. The nurse is trying to communicate with a
client with brain attack (stroke) and aphasia.
Which of the following actions by the nurse
would be least helpful to the client? (-)
a. Speaking to the client at a slower rate
b. Allowing plenty of time for the client to
respond
c. Completing the sentences that the client
cannot finish
d. Looking directly at the client during attempts
at speech
Aphasia
Expressive aphasia (Broca’s)
- frontal lobe
Receptive (Wernicke’s)
- temporal
35. The client has experienced an episode of
myasthenic crisis. The nurse would assess
whether the client has precipitating factors such
as:
a. Getting too little exercise
b. Taking excess medication - cholinergic
crisis c. Omitting doses of medication
d. Increasing intake of fatty foods
Myasthenic crisis
- underdose of medication
Cholinergic crisis
- overdose
both condition will have muscle weakness
because wala sa therapeutic level
tensilon test - to determine if myasthenic crisis
or cholinergic
if temporary improvement - myasthenic crisis
temporary worsening - cholinergic crisis
Antidote / management:
myasthenic crisis → Pyridostigmine
cholinergic crisis → atropine sulfite
36. The client with Parkinson’s disease
has a nursing diagnosis of Falls, Risk for related
to an abnormal gait documented in the nursing
care plan. The nurse assesses the client, c. “I’ll try to eat my food either very warm
expecting to observe which type of gait? or very cold.”
d. “I should rinse my mouth sometimes if tooth-
a. Unsteady and staggering b. brushing is painful”
Shuffling and propulsive c.
Broad-based and waddling Trigeminal Neuralgia / Tic douloureux
d. Accelerating with walking on the toes - cranial nerve #5
- sensory - face
- motor - ms of mastification
- patient having severe pain on one side
of the face
- very warm / very col → painful
- massage → painful
- Pain reliever: antiseizure drug
● Carbamazepine (tegretol)
● Gabapentin
● NSAIDs
● Narcotics

- degenerative disease
- substantia nigra → dopamine producing
neuron in the midbrain
- neurologic disease (tanong sa
boards last time)
- dopamine is needed in the basal ganglia,
sa basal ganglia dapat balance ang
excitatory (ach) and inhibitory
(dopamine) kaya tumataas ang ach and
dopamine bumababa
- parkinson’s : movement disorders
37. The nurse has given instructions to the
client with Parkinson’s disease about maintaining
mobility. The nurse determines that the client
understands the directions if the client states
that he or she will: (+)
Complications
1. Oral infection
2. Nutritional imbalance
3. Anxiety
39. The nurse has given a client with Bell’s
palsy instructions on preserving muscle tone in
the face and preventing denervation. The nurse
determines that the client need additional
information if the client states that he or she
will:
a. Expose the face to cold and drafts
b. Massage the face with a gentle upward
motion ✓
c. Perform facial exercise ✓
d. Wrinkle the forehead, blow out the cheeks,
and whistle ✓

a. Sit in soft, deep chair Bell’s Palsy

b. Exercise in the evening to combat fatigue - inflammation of CN7
c. Rock back and forth to start movement - motor - face
with bradykinesia - be-bwelo - sensory -
d. Buy clothes with many buttons to maintain tongue manifestations
finger dexterity - unilateral facial
paralysis goal of management
38. The nurse has given suggestions to the - prevent muscle
client with trigeminal neuralgia about atrophy management
strategies to minimize episodes of pain. The - facial exercise
nurse determines that the client needs - massage
reinforcement of information if the client - wrinkle
makes which of the following statements? (-)

a. “I will wash my face with cotton pads.”

b. “I’ll have to start chewing on the unaffected
side.”

40. The client is admitted in the hospital with
a diagnosis of Guillain-Barré syndrome. The
nurse inquires during the nursing admission
interview if the client has a history of :
a. Seizures or trauma to the brain
b. Meningitis during the last 5 years
c. Back injury or trauma to the spinal chord
d. Respiratory or gastrointestinal infection
during the previous month - viral infection
41. The client with Guillain-Barré syndrome
has ascending paralysis and is intubated and
receiving mechanical ventilation. Which of the
following strategies would the nurse incorporate
in the plan of care to help the client cope with
this illness? (+)
a. Giving client full control over care decisions
and restricting visitors (-) – intubated
b. Providing positive feedback and encouraging
active range of motion - active range of motion
siya mismo gagalaw
c. Providing information, giving positive
feedback, and encouraging relaxation
d. Providing intravenously administered
sedatives, reducing distractions, and limiting
visitors
42. The client has impairment of cranial nerve
II. Specific to this impairment, the nurse would
plan to do which of the following to ensure
client’s safety?
a. Speaking loudly to the client
b. Test the temperature of the shower water
c. Check the temperature of the food on the
dietary tray
d. Provide a clear path for ambulation
without obstacle
Optic – CNII
- walang sagabal sa dadaan niya
43. The client has a neurological deficit involving
the limbic system. Specific to this type of deficit,
the nurse would document which of the
following information related to the client’s
behavior?
a. Is disoriented to person, place, and time
b. Affect is flat, with periods of emotional
lability
c. Cannot recall what was eaten for breakfast
today – memory
d. Demonstrates inability to add and subtract;
does not know who is the president – cognition
Limbic system: hypothalamus, frontal, temporal,
= emotion and behavior
44. The nurse is planning to test the
function of the trigeminal nerve (cranial nerve
V). the nurse would gather which of the
following items to perform the test?
a. Tuning fork and audiometer – CN8
b. Snellen chart, opthalmoscope – CN2
c. Flashlight, pupil size chart or millimeter ruler –
CN3
d. Safety pin, hot and cold water in test
tubes, cotton wisp
CN V – test sensation to the face
45. The nurse is testing the coordinated
functioning of cranial nerves III, IV, and VI. To
do this correctly, the nurse would test the:
a. Corneal reflex
b. Pupil response to light
c. Six cardinal fields of gaze
d. Pupil response to light and accommodation
III, IV, VI - One’s supplying extraocular muscles
46.The nurse is admitting a client with Guillain-
Barré syndrome to the nursing unit. The client
has an ascending paralysis to the level of
the waist. Knowing the complications of the
disorder, the nurse brings which of the following
items into the client’s room?
a. Nebulizer and pulse oximeter
b. Blood pressure cuff and flashlight c.
Flashlight and incentive spirometer
d. Electrocardiographic monitoring a. A negative Kernig’s sign b.
electrodes and intubation tray Absence of nuchal rigidity
c. A positive Brudzinski’s sign
47. The nurse is evaluating the respiratory d. A Glasgow Coma Scale score of 15
outcomes for the client with Guillain-Barré
syndrome. The nurse determines that which of
the following is the least optimal outcome for
the client? (-)

a. Spontaneous breathing
b. Oxygen saturation of 98%
c. Adventitious breath sounds - abnormal
breath sounds
d. Vital capacity within normal range

48. The nurse is caring for the client in the

emergency department following a head injury.
The client momentarily lost consciousness at
the time of the injury and then regained it. The
client now has lost consciousness again. The
nurse takes quick action, knowing that this is
compatible with:

a. Concussion
b. Skull fracture 50. The nurse has completed discharge
c. Subdural hematoma instruction for the client with application of a
d. Epidural hematoma halo device. The nurse determines that the
client needs further clarification of the
Epidural hematoma instructions if the client stated that he or she
will: (-)

a. Use a straw for drinking ✓

b. Drive only during the day time
c. Use caution because the device alters balance
✓
d. Wash the skin daily under the lamb’s wool
liner of the vest ✓

● Halo device – to stabilize cervical injury

Concussion
- walang makikita sa MRI
Contussion
- hematoma in the brain tissue (may pasa
sa brain

Subdural Hematoma
- most common cause: trauma on the brain
- bleeding in the subdural space

49. The nurse is evaluating the status of the
client who had a craniotomy 3 days ago. The
nurse would suspect that the client is developing
meningitis as a complication of surgery if the
client exhibits:
● The halo device alters balance and can
cause fatigue because of its weight.
● The client should cleanse the skin daily
under the vest to protect the skin from

ulceration and should avoid the use of
powders or lotions.
● The liner should be changed if odor
becomes a problem. The client should
have food cut into small pieces to facilitate
chewing and use a straw for drinking. Pin
care is done as instructed.
● The client cannot drive at all because the
device impairs range of vision.
51. An unconscious client with multiple injuries
arrives in an emergency department. Which
nursing intervention receives the highest
priority?
a. Establishing an airway
b. Replacing blood loss
c. Stopping bleeding from open wounds
d. Checking for neck fracture
52. A client is at risk for increased intracranial
pressure. Which of the following would be the
priority for the nurse to monitor?
a. Unequal pupil size
b. Decreasing systolic pressure
c. Tachycardia
d. Decreasing body temperature
53. Which of the following respiratory patterns
indicates increasing intracranial pressure in the
brain stem?
a. Slow, irregular respirations
b. Rapid, shallow respirations
c. Asymmetric chest
excursion d. Nasal flaring
54. Which of the following nursing interventions
is appropriate for a client wit increased
intracranial pressure of 21 mmHg?
a. Give the client warm blanket
b. Administer low-dose barbiturates
c. Encourage client to hyperventilate
d. Restrict fluids → will not dec ICP
55. A client has signs of increased intracranial
pressure. Which of the following is an early
indicator of deterioration in the client’s
condition?
a. Widening pulse pressure b.
Decreased in the pulse rate c.
Dilated, fixed pupils
d. Decrease in level of consciousness
56. A nurse obtains a specimen of clear nasal
drainage from a client with a head injury.
Which of the following tests differentiates
mucus from cerebrospinal fluid?
a. pH
b. Specific gravity
c. Glucose
d. Microorganisms
57. The client has sustained an increase in
intracranial pressure of 20 mmHg. Which client
position would be most appropriate?
a. Elevate head of bed 30-45 degrees
b. Trendelenburg’s position
c. Left Sims position
d. Head elevated on 2 pillows
58. The nurse administers mannitol (Osmitrol) to
the client with increase intracranial pressure.
Which parameter requires close monitoring?
a. Muscle relaxation
b. Intake and output
c. Widening pulse pressure
d. Pupil dilation
59. A client who is regaining consciousness after
a craniotomy becomes restless and attempts to
pull out her I.V. line. Which nursing intervention
protects the client without further increasing her
intracranial pressure?
a. Place her in a jacket restraint - inc ICP
b. Wrap her hands in soft “mitten”
restraints
c. Tuck her arms and hands under the draw
sheet - inc ICP
d. Apply a wrist restraint to each arm - inc ICP
60. Which activity should the nurse encourage
the client to avoid when there is a risk for
increased intracranial pressure?
a. Deep breathing
b. Turning
c. Coughing
d. Passive range-of-motion
61. Which of the following will the nurse
observe in the client in the ictal phase of a
generalized tonic-clonic seizure?
a. Jerking in 1 extremity that spreads gradually
to adjacent areas - Partial seizure
b. Vacant staring and abruptly ceasing all activity
- Petit mal / absence
c. Facial grimaces, patting motions, and lip
smacking - psychomotor
d. Loss of consciousness, body (tonic)
stiffening, and violent (clonic) muscle
contractions
62. It is the night before a client is to have a
computed tomography (CT) scan of the head
without contrast. Which statement by the nurse
would be most appropriate?
a. “You must shampoo your hair tonight and
remove all oil and dirt” - patients who will
undergo EEG
b. “You may drink fluids until midnight, but after
that drink nothing until the scan is completed” c.
“You will have some hair shaved to attach the
small electrode to your scalp”
d. “You will need to hold your head very
still during the examination”
63. Which clinical manifestation does the nurse
expect in the client in the postictal phase of
generalized tonic-clonic seizure?
a. Drowsiness
b. Inability to move
c. Paresthesia
d. Hypotension
64. For breakfast in the morning a client is to
have an electroencephalogram (EEG), the client
is served soft boiled egg, toast with butter and
marmalade, orange juice, and coffee. Which of
the following should the nurse do?
a. Remove all the food
b. Remove the coffee
c. Remove the toast
d. Substitute vegetable juice for the orange juice
65. Which of the following is an initial sign of
Parkinson’s disease?
a. Rigidity
b. Tremor - earliest
c. Bradikinesia
d. Akinesia
66. The nurse develops a teaching plan for a
client newly diagnosed with Parkinson’s disease.
Which of the following topics that the nurse
plans to discuss is the most important?
a. Maintaining a balanced nutrition
b. Enhancing the immune system
c. Maintaining a safe environment
d. Engaging in diversional activities
67. The nurse observes the client’s upper arm
tremors disappear as he unbuttons his shirt.
Which statement best guides the nurse’s
analysis of this observation about the client’s
tremors?
a. The tremors are probably psychological and
can be controlled at will
b. The tremors sometimes disappear with
purposeful and voluntary movements ✓
c. The tremors disappear when the client’s
attention is diverted by some activity - dapat
may gagawin siya sa kamay niya
d. There is no explanation for this observation, it
is probably a chance occurrence
Velcro - ang concern dito is loss of
finger dexterity
68. At what time should the nurse encourage
a client with Parkinson’s disease to schedule the
most demanding physical activities to minimize
the effects of hypokinesia?
a. Early in the morning when the client’s energy
level is high - kahit full energy niya, may
movement problem naman siya
b. To coincide with the peak action of drug
therapy - minimize the movement para
magawa yung activity
c. Immediately after a rest period
d. When family members will be available
Goal of management: to relieve the signs
and symptoms
- palliative
69. Which goal is the most realistic and
appropriate for a client diagnosed with
Parkinson’s disease?
a. To cure the disease - cannot be cured
b. To stop progression of the disease -
degenerative
c. To begin preparations for terminal care
d. To maintain optimal body function

70. What is the primary goal collaboratively
established by the client with Parkinson’s
disease, nurse, and physical therapist?
a. To maintain joint flexibility
b. To build muscle
c. To improve muscle
endurance d. To reduce ataxia
Pag hindi namentain lalong titigas which can
cause pa lalo ng bradykinesia and rigidity
71. Which of the following is not a typical
manifestation of Multiple sclerosis?
a. Double vision
b. Sudden bursts of energy
c. Weakness in the extremities
d. Muscle tremors
72. A client has had multiple sclerosis for 15
years and has received various drug therapies.
What is the primary reason why the nurse has
found it difficult to evaluate the effectiveness of
the drugs that the client used?
a. The client exhibits intolerance to many drugs
b. The client experiences spontaneous
remissions from time to time
c. The client requires multiple drugs
simultaneously
d. The client endures long periods of
exacerbation before the illness responds to a
particular drug
Multiple sclerosis
- pa-iba iba ng pattern, nawawala, tas
bumabalik, kaya mahirap icheck kung
effective
73. When a nurse talks to a client with multiple
sclerosis who has slurred speech, which nursing
intervention is contraindicated?
a. Encouraging the client to speak slowly b.
Encouraging the client to speak distinctly
c. Asking the client to repeat indistinguishable
words
d. Asking the client to speak louder when
tired
74. A client with multiple sclerosis is
experiencing bowel incontinence and is starting
a bowel retraining program. Which strategy is
inappropriate?
a. Eating a diet high in fiber
b. Setting a regular time for elimination
c. Using an elevated toilet seat
d. Limiting fluid intake to 1000mL/day
75. Which of the following is an inappropriate
outcome to establish with a client who has
multiple sclerosis?
a. The client will develop joint mobility b.
The client will develop muscle strength c.
The client will develop cognition d.
The client will develop mood elevation
76. The nurse is developing a plan of care for a
client scheduled for cataract surgery. The
nurse documents which most appropriate
nursing diagnosis in the plan of care?
a. Anxiety - scheduled
palang b. Self-care deficit
c. Nutrition, imbalanced
d. Sensory perception, disturbed
Physiologic before psychologic
Cataract
- increase opacity of the
lens Etiology:
1. Congenital
2. Trauma
3. DM
4. Age
Characteristic vision
- blurred vision
- cloudy vision
- ghost vision
- hazy vision
77. The Nurse is performing an assessment on
a client with a suspected diagnosis of cataract.
 The chief clinical manifestation that the nurse - Loss of peripheral vision – tunnel vision
would expect to note in the early stages of
(both)
cataract formation is:
Management: (both open and close)
a. Diplopia 1. Pilocarpine – miotic → pupillary
b. Eye pain constriction → to open the angle
c. Floating spots 2. Acetazolamide (Diamox) → to decrease
d. Blurred vision production of aqueous humor
3. Timolol (eye drops) → decrease production
Glaucoma and cause pupillary constriction
- group of intraocular disease characterized 4. Surgery →
by increase IOP (normal 10 - 21 mmHg) ● Iridotomy - open up the iris
- Tonometer - instruments used ● Iridectomy - remove the iris
Types : ● Trabeculectomy - remove the trabecular
Open angle glaucoma - chronic, most meshwork
common Close angle glaucoma - acute
Nursing mgt:
Causes: 1. provide safety measures bec patient has
1. Congenital disturbed sensory perception
2. Trauma to the eyes
3. Severe pupillary dilation
4. idiopathic
5. Risk factors: Family history

OPEN angle
1. Inc production of aqueous humor → babaha Retinal Detachment
→ increasing ocular pressure Etiology
2. obstruction in the trabecular meshwork 1. Trauma
2. Aging
Characteristics: 3. Retinopathy = DM, HPN
● Chronic – gradual and progressive, most
common Curtain-like vision
● due to aging bleeding → floaters
● 26 - 32 mmHg IOP
Management:
CLOSE angle Surgery
1. severe mydriasis → nagdidilate ● Scleral bucking
2. or nagkaroon ng displacement of the iris

Characteristics:
● Acute, sudden
● due to trauma
● 50 - 70 mmHg IOP
● headache and red eyes! – emergency
● bec of severe pressure → nausea and ● Pneumatic retinopexy
vomiting - inject air to bring back the retina from the
detached parts
Early sign:
78. In preparation for cataract surgery, the
nurse is to administer eye drops. The nurse
reviews the physician’s orders, expecting which
type of eye drops to be prescribed?
a. Miotic agent
b. Thiazide diuretic
c. Osmotic diuretic
d. Midriatic
Mydriatic → atropine eye drops every
hour prior to surgery
79. During the early post operative period, the
client who has had a cataract extraction
complains of nausea and severe eye pain
over the operative site. The initial nursing action
is to:
a. Call the physician
b. Reassure the client that this is normal
c. Turn the client in his or her operative site d.
Administer the ordered pain medication and
anti-emetic
Can be a sign of increased intraocular pressure
80. The client is being discharged from the
ambulatory care unit following cataract removal.
The nurse provides instructions regarding home
care. Which of the following, if stated by the
client, indicates an understanding of the
instructions? (+)
a. “I will take aspirin if I have any discomfort.”
b. “I will sleep on the affected side that I was
operated on.” - patient should be place on
unaffected or supine
c. “I will not lift anything if it weighs more than
15 pounds.” - not lifting anything at all
d. “I will wear my eye shield at night and
my glasses during the day”
81. The client with glaucoma asks the nurse if
complete vision will return. The most
appropriate response is:
a. “Your vision will never return to normal”
b. “Your vision will return as soon as the
medication begins to work”
c. “Your vision loss is temporary and will return
in about 3-4 weeks”
d. “Although some vision has been lost and
cannot be restored, further loss may be
prevented by adhering to the treatment
plan”
Glaucoma is irreversibile – what is loss cannot be
regained
- but further loss of vision can be prevented
if the patient adhered to the medication /
treatment regiment
82. The nurse is developing a teaching plan for
the client with glaucoma. Which of the following
instructions would the nurse include in the plan
of care?
a. Avoid overuse of the eyes
b. Decrease the amount of salt in the diet
c. Eye medications will need to be
administered for the client’s entire life
d. Decrease fluid intake to control the
intraocular pressure
83. The nurse is performing an admission
assessment on a client with a diagnosis of
detached retina. Which of the following is
associated with this eye disorder?
a. Total loss of vision
b. Pain in the affected eye
c. A yellow discoloration of the sclera
d. A sense of a curtain falling across the
field of vision
84. The nurse is caring for a client with a
diagnosis of detached retina. Which assessment
sign would indicate that bleeding has occurred
as a result of the retinal detachment?
a. Total loss of vision
b. A reddened conjunctiva
c. A sudden sharp pain in the eye
d. Complaints of a burst of black spots or
floaters
ARMD – macular degeneration
– Center of vision – loss of central vision
– caused by: Aging
→ Drusen - yellowish substance you see in the
eye of patient with macular degeneration
85. The client sustains a contusion of the
eyeball following a traumatic injury with a blunt
object. Which intervention is initiated
immediately?
a. Notify the physician c. 20/60
b. Apply ice to the affected eye d. 20/200
c. Irrigate the eye with cool water
d. Accompany the client to the emergency room 89. Tonometry is performed on the client with a
suspected diagnosis of glaucoma. The nurse
86. The client arrives in the emergency room analyzes the test results as documented in the
after sustaining a chemical eye injury from a client’s chart and understands the normal
splash of battery acid. The initial nursing intraocular pressure is:
action is to:
a. 2 – 7 mmHg
a. Begin visual acuity test b. 10 – 21 mmHg
b. Cover the eye with a pressure patch c. c. 22 – 30 mmHg
Swab the eye with antibiotic ointment d. 31 – 35 mmHg
d. Irrigate the eye with sterile normal
saline - to prevent damage to the eye
Hearing Problems
Hearing loss
87. The client’s vision is tested with a Snellen
● problem with external and middle ear →
chart. The results of the tests are documented
CONDUCTIVE HEARING LOSS
as 20/60. The nurse interprets this as:
● problem with inner ear → SENSORINEURAL
HEARING LOSS
a. The client is legally blind b.
● problem with the brain → CENTRAL
The client’s vision is normal
HEARING LOSS
c. The client can read only at a distance of 60
feet what a client with normal vision can read at
Most definitive diagnostic test:
20 feet
● Audiometry (audiogram)
d. The client can only read at a distance of
20 feet what a client with normal vision
Suggestive
can read at 60 feet
● Whisper test
- examiner will stand 1-2 ft on the
numerator – patient right side, command something like
denominator – normal person raise right hand, pag ginawa yung
sinabe, then do the same on the
Errors of refraction other side
nearsighted – myopia ● Weber test
● lens: biconcave lens - normal ears: vibrate tuning fork
farsighted: hyperopia lagay sa vertex, you hear the sound
● lens: biconvex lens on both ears
- conductive hearing loss: sound is
astigmatism - pinakamalala heard on the affected ear
- can cause too much restrain on the eye - sensorineural hearing loss: sound is
● lens: cylindrical lens heard on unaffected ear
● Rinne test
Presbyopia - normal due to aging - normal: air conducted sound is hear
- age of 40 and above longer than bone conducted sound
- loss of accommodation (AC > BC)
- conductive hearing loss - bone
88. The clinic nurse notes that following conducted is heard long than air
several eye examinations, the physician has conducted sound (BC > AC)
documented a diagnosis of legal blindness in the - sensorineural hearing loss - air
client’s chart. The nurse reviews the results of conducted sound is heard louder
Snellen Chart test expecting to note which than conducted sound
finding?

a. 20/20
b. 20/40
 Meniere's Disease
- endolymphatic hydrops
- malabsorption of endolymph
Etiology: idiopathic
RF: family history, aging

Severity of hearing loss:

● Mild hearing loss S/Sx
● moderate hearing loss TRIAD OF MENIERE’S DISEASE
● severe hearing loss 1. Tinnitus
● profound hearing loss 2. Vertigo
3. Sensorineural hearing loss
Presbycusis
- 60 and above ● nausea and vomiting
- high pitch sound ● unilateral
- moderate pitch ● nysttagmus
- low pitch ● characterized by acute attacks

Otosclerosis Most definitive diagnostic test → WALA XD

- hardening or fixation of the footplate of
stapes
- initially – conductive hearing loss then later
on → sensorineural hearing loss
Etio:
Risk factor: women, unilateral
Management:
1. Supplement – flouride
2. Surgery → Stapedectomy (replace
prosthesis)
- Post op: patient cannot ride the
airplane, dive under the ocean
but MRI must be done to rule out acoustic
neuroma (tumor in the CN8) → If wala →
meniere’s disease
Management:
1. low sodium – bec it attracts more water
kasi nga malabsorption
2. manage tinnitus → mask it with music
3. manage vertigo → safety (protection)
- lagyan ng pillow sa gilid ng mukha then fix
yung mata nag straight lang to counteract
the vertigo
4. Anti-vertigo: Meclizine, Bethistine,
Cinarazine
5. Anti-emtic: Metoclopramide, Ondansetron
6. Phenothiazine, Diazepam – CNS depression

90. The sterile nurse or sterile personnel

touch only sterile supplies and instruments.
When there is a need for sterile supply which is
not in the sterile field, who hands out these
items by opening its outer cover?

a. Circulating nurse
b. Anesthesiologist
c. Surgeon
d. Nursing aide
91. The OR team performs distinct roles for one
surgical procedure to be accomplished within a
prescribed time frame and deliver a standard
patient outcome. While the surgeon performs the
surgical procedure, who monitors the status of the
client like urine output, blood loss?
a. Scrub nurse
b. Surgeon
c. Anesthesiologist
d. Circulating nurse
92. Surgery schedules are communicated to the
OR usually a day prior to the procedure by the
nurse of the floor or ward where the patient is
confined. For orthopedic cases, what
department is usually informed to be present in
the OR?
a. Rehabilitation department
b. Laboratory department c.
Maintenance department d.
Radiology department
93. Troy is a one day post open reduction and
internal fixation (ORIF) of the left hip and is in
pain. Which of the following observation would
prompt you to call the doctor?
a. Dressing is intact but partially soiled
b. Left foot is cold to touch and pedal pulse
is absent - compromised blood flow c. Left
leg in limited functional anatomic position d. BP
114/78, pulse of 82 beats/minute
Neurovascular status : 6 P's
● Pain
● Pallor
● Paresthesia
● Paralysis
● Pulselessness
● Poikilothermia
94. There is an order of Demerol 50 mg I.M.
now and every 6 hours p r n. You injected
Demerol at 5 pm. The next dose of Demerol 50
mg I.M. is given:
a. When the client asks for the next dose
b. When the patient is in severe pain
c. At 11pm
d. At 12pm
95. Which of the following should be given
highest priority when receiving patient in the
OR?
a. Assess level of consciousness
b. Verify patient identification and
informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure and
dentures
96. Surgeries like I and D (incision and
drainage) and debridement are relatively short
procedures but considered ‘dirty cases’. When
are these; procedures best scheduled?
a. Last case
b. In between cases
c. According to availability of anesthesiologist
d. According to the surgeon’s preference
97. Another nursing check that should not be
missed before the induction of general
anesthesia is:
a. check for presence underwear
b. check for presence dentures c.
check patient’s blood studies
d. check baseline vital signs -
anesthesiologist would check
Circulating nurse – will check anesthesia
98. Some different habits and hobbies affect
postoperative respiratory function. If your
client smokes 3 packs of cigarettes a day for the
past 10 years, you will anticipate increased risk
for:
a. perioperative anxiety and
stress b. delayed coagulation time
c. delayed wound healing
d. postoperative respiratory dysfunction
99. Which of the following role would be the
responsibility of the scrub nurse?
a. Assess the readiness of the client prior to
surgery
b. Ensure that the airway is adequate
c. Account for the number of sponges,
needles, supplies, Used during the surgical
procedure
d. Evaluate the type of anesthesia appropriate
for the surgical client

100. As a perioperative nurse, how can you best
meet the safety need of the client after
administering preoperative narcotic?
a. Put side rails up and ask client not to
get out of bed
b. Send the client to ORD with the family
c. Allow client to get up to go to the comfort
room
d. Obtain consent form
101. It is the responsibility of the pre-op, nurse
to do skin prep for patients undergoing surgery.
If hair at the operative site is not shaved, what
should be done to make suturing easy and
lessen chance of incision infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed
102. It is also the nurse’s function to
determine when infection is developing in the
surgical incision. The perioperative nurse should
observe for what signs of impending infection?
a. Localized heat and redness
b. Serosanguinous exudates and skin
blanching c. Separation of the incision
d. Blood clots and scar tissue are visible
103. Which of the following nursing intervention
is done when examining the incision wound and
changing the dressing?
a. Observe the dressing and type and odor
of drainage if any
b. Get patient’s consent
c. Wash hands
d. Request the client to expose the incision
wound
104. Over dosage of medication or anesthetic
can happen even with the aid of technology like
infusion pump, sphygmomanometer, and similar
devices/machines. As a staff, how can you
improve the safety of using infusion pumps?
a. Check the functionality of the pump
before use
b. Select your brand of infusion pump like you
do with your cellphone
c. Allow the technician to set the; infusion pump
before use
d. Verify the flow rate against your computation
105. Universal protocol for surgical and invasive
procedures to prevent wrong site, wrong
person, and wrong procedures/surgery includes
the following EXCEPT:
a. Mark the operative site if possible
b. Conduct pre-procedure verification process
c. Take a video of the entire
intra-operative procedure - Privacy beh
d. Conduct time out immediately before starting
the procedure
106. You identified a potential risk of pre
and postoperative clients. To reduce the risk
of patient harm resulting from fall, you can
implement the following EXCEPT: (-)
a. Assess potential risk of fail associated with
the patient’s the following EXCEPT: medication
regimen
b. Take action to address any identified risks
through Incident Report (IR)
c. Allow client to walk with relative to the
OR
d. Assess and periodically reassess individual
client’s risk for falling
107. In the OR, the nursing tandem for every
surgery is:
a. Instrument technician and circulating nurse b.
Nurse anesthetist, nurse assistant, and
instrument technician
c. Scrub nurse and nurse anesthetist
d. Scrub and circulating nurses
108. While team effort is needed in the OR for
efficient and quality patient care delivery, we
should limit the number of people in the room
for infection control. Who comprise this team?
a. Surgeon, anesthesiologist, scrub nurse,
radiologist, orderly
b. Surgeon, assistants, scrub nurse,
circulating nurse, anesthesiologist
c. Surgeon, assistant surgeon, anesthesiologist,
scrub nurse, pathologist
d. Surgeon, assistant surgeon, anesthesiologist,
intern, scrub nurse
109. When surgery is on-going, who coordinates
the activities outside, including the family?
a. Orderly/clerk
b. Nurse supervisor
c. Circulating nurse
d. Anaesthesiologist
110. The breakdown in teamwork is often times
a failure in:
a. Electricity
b. Inadequate supply
c. Leg work
d. Communication
111. After an abdominal surgery, the circulating
and scrub nurses have critical responsibility
about sponge and Instrument count.
When is the first sponge/instrument count
reported?
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before closing the skin
d. Before the fascia is sutured
112. A one-day postoperative abdominal surgery
client has been complaining of severe throbbing
abdominal pain described as 9 in a 1-10 pain
rating. Your assessment reveals bowel sounds
on all quadrants and the dressing is dry and
intact. What nursing intervention would you
take?
a. Medicate client as prescribed
b. Encourage client to do imagery
c. Encourage deep breathing and
turning d. Call surgeon stat
113. One very common cause of postoperative
pain is:
a. Forceful traction during
surgery b. Prolonged surgery
c. Break in aseptic technique
d. Inadequate anesthetic
114. Which of the following is true about
wound evisceration?
a. Occurs 6-8 hours post op
b. Occurs as a consequence of anesthesia
c. Has increased risk of infection
d. Can be prevented by abdominal exercises
115. While playing football, 8-year-old Jonathon
Ramsey fractured his humerus. Supracondylar
fractures of the humerus are often treated with:
a. Russell’s traction - leg
b. Bryant’s traction - leg
c. Buck’s‘ traction - leg
d. Dunlop’s traction
All of these are skin traction
Bryant’s Buck’s
116. Which of these interventions would
demonstrate that the nurse understands the
underlying principles of traction?
a. Supplying countertraction
b. Maintaining the client in a prone position. -
supine
c. Maintaining the spreader in contact with the
bed - nope
d. Maintaining the weights in a dependent
position
117. What measure in regard to mobility should
a nurse take for a patient in continuous skeletal
traction/balanced suspension?
a. Instruct the patient in the use of the
trapeze bar - para makagalaw siya using
trapeze bar
b. Remove the weights when pulling the patient
up in bed
c. Adjust the level of the bed to provide sensory
stimulation
d. Turn the patient from side to side every 2
hours
118. You can tell when a plaster cast is dry
because it:
a. has a dull sound to percussion
b. is white and shiny
c. is warm to the touch
d. has a musky smell
 - Plaster of paris
- Fiberglass - mas mabilis matuyo
119. Immediately after the application of a long
leg plaster cast, the nursing intervention aimed
at reducing edema and stimulating circulation
would be:
a. covering the cast with a blanket
b. handling the wet cast only with the fingers -
mali to beh, it should be palm kasi lulubog
fingers
c. assessing the toes for color and temperature
once each 8 hours
d. placing the cast on a pillow
120. To prevent prosthesis dislocation after hip
surgery, the leg should be kept in:
a. Adduction
b. Abduction
c. Internal rotation
d. Flexion
Total hip surgery
- no adduction
- no internal rotation
121. X-rays show that the lower end of a
patient`s femur has been splintered into
fragments. This type of fracture is called
a. Greenstick / incomplete / partial
b. Compound - combination (open + complete)
c. Oblique
d. Comminuted
122. The school nurse conducting the scoliosis
screening clinic observed each child in which of
the following positions?
a. Bending forward at the waist, feet
together, knees unbent, and arms hanging
freely → Adam’s test
b. Lying on the side, with arms extended above
the head and legs unbent
c. Seated in a chair with arms extended above
the head
d. Standing with legs apart and hands placed on
hips
123. Six months after a scoliosis diagnosis was
made, the 11 year old client is admitted to the
hospital for a spinal fusion. The nurse
positioning the client the day after her surgery
a. places her in a prone position with the head
of the bed elevated 45 degree
b. utilizes a log-rolling technique to move
the client from one side to the other
c. raises the head of the bed slightly and
elevates the client’s knees 30°
d. encourages the client to move as much
as possible by herself
124. After a spinal fusion surgery to correct
a scoliosis, the 11 year old client requests the
bedpan frequently. She voids approximately 50
ml every half-hour. Nursing diagnosis is
"Alteration in urinary elimination" secondary to
a. difficulty in emptying the bladder in a
supine position
b. an excessive fluid intake
c. embarrassment at using the bedpan
d. a urinary tract infection due to poor hygiene
125. Meredith is placed in a body cast, which
she will wear for several months. During a
discharge planning conference with Meredith
and her mother the nurse emphasizes the need
for
a. weekly visits to the physician to have the
integrity of the cast assessed
b. coughing and deep breathing exercises to
prevent respiratory infections.
c. increasing fluids and roughage in the diet to
promote elimination
d. keeping the skin surrounding the cast
clean and dry and preventing sore areas at
pressure points
126. A client on crutches is not to bear weight
on her left injured leg. Therefore the gait that
will be used while crutch walking is:
a. swing through
To prevent stress on the joints
b. two points
c. three points
d. four points 129. Two-week-old Maria Sanchez has a
congenital dislocated hip. Which of the
following clinical manifestations is found in
infants with this abnormality?

a. Limited flexion of the knee on the affected

side
b. Limited adduction of the leg on the
unaffected side
c. Limited abduction of the leg on the
affected side
d. Limited extension of the ankle on the
unaffected side

127. A post amputation (AKA) client can prevent

hip contracture deformities by doing which of
the following?

a. Placing a pillow between his stump and his

other leg
b. Ambulating several times a day
c. Lying on his abdomen several times
during the day
d. Putting the stump through range of motion
exercises

- Need to straighten the hip

- to prevent the hip from flexing
- if hindi na prevent, hindi na pwede 130. Susan De Bono. 6 months old, has been
malagyan ng prosthesis placed in a spica cast for treatment of congenital
dislocated hip. The nurse teaches Mrs. De Bono
how to care for Susan while she is in the spica
cast. The HIGHEST priority in caring for Susan
128. Nine-year-old Edward Burke has juvenile
at this time is to
rheumatoid arthritis. He is to be discharged from
the hospital. Edward was very active in sports
a. provide appropriate toys to promote normal
before his hospitalization. Which of the following
growth and development
would now be appropriate for Edward to
b. keep the skin around the spica cast clean and
participate in?
dry
c. assess for signs of circulatory
a. Baseball
impairment
b. Skiing
d. maintain the integrity of the cast
c. Swimming
d. Hockey
Spica cast → body cast Legg-Calve-Perthes Disease
- death of the femoral head / necrosis

131. A six-year-old child has a short arm

cast placed on the right extremity. While
assessing the fingers during the immediate
period after casting, a nurse would report which
of the following findings?

a. Mild edema - expected

b. Pain on movement - expected
c. Slight coolness of the cast when touched
d. Capillary refill greater than three
seconds - indicates poor circulation
132. A patient who has had a right hip
replacement should be instructed to carry out
which of the following techniques when turning
in bed?
a. Bring both knees to the chest before turning
b. Keep an abductor wedge between the
legs
c. Maintain flexion of the affected hip
d. Move the affected leg with the unaffected
foot
134. When assessing a female adolescent for
scoliosis, the nurse would ask the client to do
which of the following?
a. Bend forward at the waist with arms
hanging freely
b. Lie flat on the floor and extend her legs
straight from the trunk
c. Sit in a chair while lifting her feet and legs to
right angle with the trunk
d. Stand against a wall while pressing the length
of her back against the wall

135. After teaching the family of a child

133. A child who limps and complains of pain
has been found to have Legg-Calve-Perthes
Disease. Which of the following would the
nurse expect to be included in the plan of care?
a. Initiation of pain control measures especially
at night when acute
b. Promotion of ambulation despite of child’s
discomfort in the affected hip
c. Prevention of flexion in the affected hip and
knee
d. Avoidance of weight bearing on the
head of the affected femur
with scoliosis who needs to wear a Boston
Brace, which of the following statements reflect
understanding? The brace can be removed:
a. When bathing for about an hour per
day b. While eating for about 3 hours a day c.
During school for about 8 hours a day
d. When sleeping for a total of 10 hours a day
You can remove → 1 hour per day
136. When teaching the child with scoliosis
being treated with a Boston Brace about
exercises, the nurse explains the purpose of the
exercise as:
a. To decrease back muscle spasm
b. To improve the brace’s traction
effect c. To prevent spinal contractures
d. To strengthen the back and abdominal
muscles
137. The parents of the child with congenital
clubfoot were told that their child will need a
cast. They were taught how to care for the cast.
Which of the following statements by the
parents indicate understanding the instructions?
a. “If the cast becomes soiled, we’ll clean it with
soap and water.”
b. “We’ll elevate the leg with the cast on pillows,
so the leg is above heart level.”
c. “We’ll check the color and temperature
of the toes of the casted leg frequently.”
checking neurovascular status
d. “The petals on the edge of the cast can be
removed after the first 24 hours.”
138. A preschooler with a fractured femur of
the left leg in traction is complaining that his leg
hurts. It is too early for pain medication. It is
best to do which of the following?
a. Place a pillow under the child’s buttocks to
provide support
b. Remove the weight from the left leg
c. Assess the leg for signs of
neuromuscular impairment
d. Reposition the pulley so the traction is looser
139. After a plaster cast has been applied to
the arm of a child with fractured right humerus,
the nurse completes discharge teaching. The
teaching is effective if the mother agrees to seek
medical help if which of the following is
experienced?
a. Inability to extend the fingers of the
right hand
b. Vomiting after the cast is applied
c. Coolness and dampness of the cast after 5
hours
d. Fussiness with complaints that the cast is
heavy
Compromise circulation or merong paralysis
140. The nurse would teach the mother of a
child who has a new cast for a fractured radius
to do which of the following for the first few
days at home?
a. Use a hair dryer to dry the cast more quickly
b. Have the child refrain from strenuous
activities → rest
c. Check movement and sensation of the child’s
fingers once a day
d. Administer acetaminophen every 8 to 12
hours for discomfort
141. While assessing a three year old child who
has had an injury to the leg, complains of pain,
and refuses to walk, the nurse notes that the
child’s left thigh is swollen. Which of the
following would the nurse do next?
a. Assess the neurologic status of the toes
b. Determine the circulatory status of the upper
thigh
c. Obtain the child’s vital signs
d. Notify the physician immediately
142. During the initial assessment of the child
with osteomyelitis of the left tibia, the nurse
would expect the area to exhibit:
a. Diffused tenderness
b. Decreased pain
c. Increased warmth
d. Localized edema
Osteomyelitis → inflammation
- caused by infection
- direct entry → open fracture
- most common bacteria: Staphylococcus
- Blood borne: Pott’s disease (TB of the
bone) – spine deformity
Osteoporosis → reduced bone mass
- brittle bone disease
Osteomalacia → reduced calcium in the bones
- soft bone disease
 - sa adult tawag: osteomalacia ● commonly: hands and fingers
- child: rickets ● characteristic lesions: PANNUS
Osteoarthritis - degenerative disease
Osteitis deformans (Paget’s disease) ● affectation: assymetrical and
- localized rapid bone turnover non-migratory
● affected: ● first joints to be affected: weight bearing
○ skull joints: knees / hips
○ vertebra ● characteristic lesions: osteophytes (bone
○ pelvis supra)
○ femur ● heberden’s (distal portion) and bouchard's
○ tibia (proximal)
- inc osteoclast activity with compensatory Gouty Arthritis - metabolic joint disease
increased in osteoblast activity ● uric acid crystal precipitation in the joints
● characteristic lesions: tophi
Paget’s disease management: ● affectation: asymmetrical, migratory
● palliative
● symptomatic deformity and pain
145. A patient in crutch would like to go
● pain reliever
upstairs. Which leg would he move first to the
● physical therapy
step?

Complications
a. unaffected leg
1. deformities
b. affected leg
2. pain
c. both legs with the crutch as his support
3. hearing loss = skull = compression of CN 8
d. the crutch first

143. After receiving orders for laboratory tests

and antibiotics for a child with osteomyelitis, the
nurse would expect to start the antibiotic after
the blood is withdrawn for which of the
following?
a. Creatinine
b. Culture
c. Hemoglobin
d. White blood cell count
144. A client diagnosed with rheumatoid
arthritis complains of joint stiffness and difficulty
beginning the day's activities. The client is
concerned about functioning at home. The
nursing diagnosis is “impaired physical mobility
related to joint stiffness.” An expected outcome
to evaluate nursing care is:
a. Client is able to sleep
b. Client's vital signs are stable
c. Client performs self-care activities
d. Client is pain free
Rheumatoid arthritis - systemic autoimmune,
inflammatory disease of the synovial joints
● common among women
● affectation: bilateral, symmetrical and
migratory
good leg up bad leg down
146. Alda Bagnoy is a 75-year-old widow who
fell while cleaning the yard. The nurse noticed
that she is unable to move her left leg. The first
priority is to:
a. Extend her leg into a normal position
b. Try to reduce the fracture c. Elevate
the extremity
d. Treat her as if a fracture has occurred
147. When changing the stump dressing after
an above knee amputation, the nurse is aware
that:
a. Improper bandaging will cause shrinkage of
stump
b. Purpose of bandaging is to shape the
stump for the prosthesis.
c. No pressure should be exerted on the stump
or constriction will occur.
d. Apply the bandage when the patient is
standing up on crutches
148. A nurse is conducting health screening for
osteoporosis. Which of the following clients is at
greatest risk of developing this disorder?
a. A 25-year-old woman who jogs
b. A 36-year-old man who has asthma
c. A 70-year-old man who consumes excess
alcohol
d. A sedentary 65-year-old woman who
smokes cigarettes
b. Massage the skin of the right leg with lotion
every 8 hours.
c. Inspect the skin on the right leg at least
once every 8 hours.
d. Release the weights on the right leg for daily
range-of-motion exercises.

149. A nurse has given instructions to a client
returning home after knee arthroscopy. The
nurse determines that the client understands the
instructions if the client states that he or she
will:
a. Resume regular exercise the following day.
b. Stay off the leg entirely for the rest of the
day.
c. Report fever or site inflammation to the
physician.
d. Refrain from eating food for the remainder of
the day.
153. A nurse is assessing the casted extremity
of a client. The nurse would assess for which of
the following signs and symptoms indicative of
infection?
a. Dependent edema
b. Diminished distal pulse
c. Presence of a “hot spot” on the cast
d. Coolness and pallor of the extremity

150. A client has a fiberglass (nonplaster) cast

applied to the leg. The client asks the nurse
when the client will be able to walk using the
casted leg. The nurse replies that the client will
be able to bear weight on the casted leg:

a. In 48 hours
154. A client has sustained a closed fracture
b. In 24 hours
and has just had a cast applied to the affected
c. In about 8 hours
arm. The client is complaining of intense pain.
d. Within 20 to 30 minutes of application –
The nurse elevates the limb, applies an ice bag,
mabilis drying ng fiberglass
and administers an analgesic, with little relief.
The nurse interprets that this pain may be
151. A client with a hip fracture asks the nurse
caused by:
why Buck’s extension traction is being applied
before surgery. The nurse’s response is based
a. Infection under the cast
on the understanding the Buck’s extension
b. The anxiety of the client
traction primarily;
c. Impaired tissue perfusion - there may
be necrosis or impaired tissue perfusion d.
a. Allows bony healing to begin before surgery
The recent occurrence of the fracture
b. Provides rigid immobilization of the fracture
site
155. A client is complaining of skin irritation
c. Lengthens the fractured leg to prevent
form the edges of a cast applied the previous
severing of blood vessels
day. The nurse should take which of the
d. Provides comfort by reducing muscle
following actions?
spasms and provides fracture
immobilization
a. Petal the cast edges with adhesive tape.
b. Massage the skin at the rim of the cast.
152. A client has Buck’s extension traction
c. Use a rough file to smooth the cast edges.
applied to the right leg. The nurse would plan
d. Apply lotion to the skin at the rim of the cast.
which of the following interventions to prevent
complications of the device?

a. Give pin care once a shift.


156. A client is being discharged to home after
application of a plaster leg cast. The nurse
determines that the client understands proper
care of the cast if the client states that he or she
should:
a. Avoid getting the cast wet.
b. Cover the casted leg with warm blankets.
c. Use the fingertips to lift and move the leg.
d. Use a padded coat hanger end to scratch
under the cast.
157. A nurse has given a client instructions
about crutch safety. The nurse determines that
the client needs reinforcement of information if
the client states:
a. That he or she will not use someone else’s
crutches
b. That crutch tips will not slip even when
wet
c. The need to have spare crutches and tips
available
d. That crutch tips should be inspected
periodically for wear
158. A nurse is caring for a client being treated
for fat embolus after multiple fractures. Which of
the following data would the nurse evaluate as
the most favorable indication of resolution of the
fat embolus?
a. Minimal dyspnea
b. Clear chest radiograph
c. Oxygen saturation of 85%
d. Arterial oxygen level of 78 mm Hg
FAT EMBOLISM SYNDROME
Major Criteria (one necessary for diagnosis)
● Petechial rash
● Respiratory insufficiency
● Cerebral involvement
Minor criteria (four necessary for diagnosis)
● Tachycardia >120 beats / min
● Fever
● Retinal changes : fat or petechiae
● Jaundice
● Renal signs : anuria or oliguria
● Thrombocytopenia
● Anemia
● High Erythrocyte sedimentation rate
(ESR)
● Fat Macroglobinemia
Fat embolism → bumabara din sa lungs
159. A nurse has conducted teaching with a
client in an arm cast about signs and symptoms
of compartment syndrome. The nurse
determines that the client understands the
information if the client states that her or she
should report which of the following early
symptoms of compartment syndrome?
a. Cold, bluish-colored fingers
b. Numbness and tingling in the fingers
c. Pain that increases when the arm is
dependent
d. Pain relieved only by oxycodone and aspirin
(Percodan)
160. A nurse is caring for a client who had an
above knee amputation 2 days ago. The residual
limb was wrapped with an elastic compression
bandage which has come off. The nurse
immediately:
a. Calls the physician
b. Applies ice to the site
c. Rewraps the stump with an elastic
compression bandage
d. Applies a dry sterile dressing and elevates it
on 1 pillow