Medsurg Success PDF

Med-Surg Success
A Q&A Review Applying Critical

Thinking to Test Taking
Third Edition
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Med-Surg
Success A Q&A Review
Applying Critical Thinking to Test Taking
Third Edition
Kathryn Cadenhead Colgrove, RN, MSN, CNS

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2017 by F.A. Davis Company
Copyright © 2017 by F.A. Davis Company. All rights reserved. This book is protected by
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Content Project Manager: Julia L. Curcio
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Library of Congress Cataloging-in-Publication Data
Names: Colgrove, Kathryn Cadenhead, author.

Title: Med-surg success : a Q&A review applying critical thinking to test
taking / Kathryn Cadenhead Colgrove.
Description: Third edition. | Philadelphia, PA : F.A. Davis Company, [2017]
| Includes bibliographical references and index.
Identifiers: LCCN 2016019304 | ISBN 9780803644021
Subjects: | MESH: Nursing | Nursing Care | Test Taking Skills | Problem
Solving | Examination Questions
Classification: LCC RD99.25 | NLM WY 18.2 | DDC 617/.0231076--dc23 LC record available at
https://lccn.loc.gov/2016019304
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$.25.
The authors dedicate this book to all nursing students who provide safe,
competent, and “caring” nursing care which makes a difference in their
clients’ lives. We hope this book helps these students to be successful
in their nursing program, successful on their NCLEX-RN, and successful
in the nursing profession. Our continued thanks to Bob Martone, who
took a chance on us, and to Julia Curcio, who continues to support our
endeavors in the publishing world. We would also like to thank Kara
Evans for her editorial support during the production of the third edition.
We hope the nursing students who use this book have as long,
wonderful, and exciting a career as we have had in the nursing
profession.
I would like to dedicate this book to the memory of my mother, Mary

Cadenhead, and grandmother, Elsie Rogers. They always said that I
could accomplish anything I wanted to accomplish. I would also like to
dedicate this book to my husband, Larry, children Laurie and Todd and
Larry Jr. and Mai, and grandchildren Chris, Ashley, Justin C., Justin A.,
Connor, Sawyer, and Carson. Without their support and patience the
book would not have been possible.
Kathryn Colgrove
This book is dedicated to the memory of my husband, Bill, and my

parents, T/Sgt. Leo and Nancy Hargrove, who are the rocks on which
my life is built. I would like to thank my sisters, Gail and Debbie, my
nephew Benjamin, and Paula for their support and encouragement
through the good times and the bad. My children, Teresa and Aaron,
are the most important people in my life and I want to thank them for
always believing in me.
Ray Hargrove-Huttel
(This was Ray’s dedication. Ray lost her battle with cancer on
December 23, 2012. She is much loved and greatly missed. Kathy
Colgrove)
Reviewers
Pamela K. DeMoss, MSN, RN
Assistant Professor
Beth Batturs Martin, RN, MSN University of Dubuque
Director of Nursing and Healthcare Dubuque, Iowa
Initiatives
Anne Arundel Community MaryAnn Edelman, RN, MS
College Arnold, Maryland Professor, Department of Nursing
Kingsborough Community
Glenda Bondurant, MSN, RN College Brooklyn, New York
Dean of Allied Health/Sciences
Wilson Community College Karen Elsea, MSN, RN
Wilson, North Carolina Assistant Professor
University of Indianapolis
Johnnie A. Bratton, MSN, BSN, RN Indianapolis, Indiana
ADN Instructor
Durham Technical Community Marie Everhart, MSN, RN, CNE
College Durham, North Carolina Associate Professor
Northampton Community College
Marsha Cannon, EdD, MSN, RN Bethlehem, Pennsylvania
Associate Professor Christina Flint, RN, MSN, MBA
University of West Alabama Assistant Professor
Livingston, Alabama University of Indianapolis
Indianapolis, Indiana
Barbara A. Caton, MSN, RN, CNE
Assistant Professor Rebecca Fountain, RN, PhD
Missouri State University – West Assistant Professor
Plains West Plains, Missouri University of Texas at Tyler
Tyler, Texas
Lorraine Smirle Collins, RN,
MSN, CNOR Charlene Beach Gagliardi, RN,
Assistant Professor, Nursing BSN, MSN
Piedmont Virginia Community Assistant Professor
College Charlottesville, Virginia Mount Saint Mary’s University
Los Angeles, California
Nursing Faculty
Carol Girocco, RN, MSN, OCN Southern Union State Community
Professor of Nursing College
Lone Star College – Opelika, Alabama
Montgomery Conroe, Texas
Patricia A. Kelly, MSN, RN, APRN,
Cheryl Harrington, MSN/MHA FNP-BC
Assistant Professor of Nursing Lecturer
Morningside College Southern Illinois University
Sioux City, Iowa Edwardsville
Edwardsville, Illinois
Jackie Harris, MNSc, RN, CNE
Assistant Professor of Nursing Julie Kolker, MSN, BS, RN
Harding University Carr College Associate Degree Nursing Instructor
of Nursing North Iowa Area Community
Searcy, Arkansas College Mason City, Iowa
Stephanie D. Huff, RN, DNP, FNP-BC
vii
Reviewers County College of Morris
viii
Randolph, New Jersey
Mary Jo Konkloski, MSN, RN, ANP Susan M. Perry, MS, RN

Instructor Assistant Professor of Nursing
Pomeroy College of Nursing at Crouse SUNY Adirondack
Hospital Queensbury, New York
Syracuse, New York
Karen Kulhanek, BSN, MEd, MSN

Gina Purdue, DNP, RN, CNE
Nursing Professor
Associate Professor
Kellogg Community College
Eastern Kentucky University
Battle Creek, Michigan
Richmond, Kentucky
Donna E. McCabe, DNP, APRN-BC,
Lillian Rafeldt, RN, MA, CNE Professor of Nursing
GNP
Three Rivers Community College Norwich,
Clinical Assistant Professor
Connecticut
New York University College of Nursing
New York, New York
Lori Riden, MSN, RN, CNE
Nursing Professor
Ann Motycka, RN, MSN, CNE
Yavapai College
Professor
Prescott, Arizona
Ivy Tech Community College
Evansville, Indiana
Brenda Sloan, RN, MA
Assistant Professor
Michelle M. Murphy-Rozanski,
Indiana Wesleyan University
PhD, MSN, RN, CRNP
Marion, Indiana
Senior Level Coordinator
Temple University Health System
Cheryl Sorge, MA, BSN, RN
Northeastern School of Nursing
Associate Professor, Tenured
Philadelphia, Pennsylvania
Indiana University-Purdue University Fort Wayne
Fort Wayne, Indian
Lee Anne Nichols, PhD, RN
Associate Professor
Beryl Stetson, RNBC, MSN, CNE, LCCE, CLC
University of Tulsa
Chairperson, Health Science Education Department
Tulsa, Oklahoma
Associate Professor, Nursing
Raritan Valley Community College Branchburg, New
Laura C. Parker, MSN, RN,
Jersey
CCRN, CNE
Associate Professor, Nursing
Stephanie L. Turrise, PhD, RN, BC, APRN, CNE Renée Wright, EdD, RN
Assistant Professor Assistant Professor
University of North Carolina, Wilmington Wilmington, York College
North Carolina Jamaica, New York
Editors and
Contributors to Past
Editions
Medicine
Adult Nurse Practitioner
St. Luke’s Episcopal Hospital
Judy Callicoatt, RN, MS, CNS Houston, Texas
Associate Degree Nursing Leslie Prater, RN, MS, CNS, CDE
Instructor Trinity Valley Community Clinical Diabetes Educator
College Kaufman, Texas Associate Degree Nursing
Instructor Trinity Valley Community
Joan L. Consullo, RN, MS, CNRN College Kaufman, Texas
Advanced Clinical Nurse,
Neuroscience St. Luke’s Episcopal Helen Reid, RN, PhD
Hospital Dean, Health Occupations
Houston, Texas Trinity Valley Community College
Kaufman, Texas
Michelle L. Edwards, RN, MSN,
ACNP, FNP Elester E. Stewart, RRT, RN,
Advanced Practice Nurse, Cardiology MSN, FNP
Acute Care Nurse Practitioner/Family Advanced Practice Nurse,
Nurse Practitioner Pulmonary Family Nurse
St. Luke’s Episcopal Hospital Practitioner
Houston, Texas St. Luke’s Episcopal
Hospital Houston, Texas
Gail F. Graham, APRN, MS, NP-C
Advanced Practice Nurse, Internal
ix
Table of Contents
1 Test Taking ........................................................................................................................................ 1

INTRODUCTION ..................................................................................................................................... 1
GUIDELINES FOR USING THIS BOOK ........................................................................................... 1
PREPARING FOR LECTURE ............................................................................................................... 2
Sample Study Guide ........................................................................................................................ 2
PREPARING FOR AN EXAMINATION ............................................................................................... 3
Study ................................................................................................................................................... 3
Understanding What the Test Taker Does Not Know ............................................................... 3 The
Night Before the Exam ........................................................................................................... 4 The Day of
the Exam ....................................................................................................................... 4 Test-Taking Anxiety
.......................................................................................................................... 4 TAKING THE EXAM
............................................................................................................................... 4 Test-Taking Hints for the
Computerized NCLEX-RN Examination ........................................ 4 Understanding the Types of
Nursing Questions ........................................................................ 5 THE RACE MODEL: THE
APPLICATION OF CRITICAL THINKING
TO MULTIPLE-CHOICE QUESTIONS ............................................................................................. 6
CONCEPT-FOCUSED QUESTIONS .................................................................................................... 6
2 Neurological Disorders ............................................................................................................ 9

KEYWORDS/ABBREVIATIONS ............................................................................................................ 9
PRACTICE QUESTIONS ..................................................................................................................... 10
Cerebrovascular Accident (Stroke) ............................................................................................. 10
Head Injury ...................................................................................................................................... 11 Spinal
Cord Injury (Sci) ............................................................................................................... 12 Seizures
............................................................................................................................................ 14 Brain Tumors
................................................................................................................................... 15 Meningitis
........................................................................................................................................ 16 Parkinson’s
Disease ....................................................................................................................... 17 Substance
Abuse ............................................................................................................................ 19 Amyotrophic
Lateral Sclerosis (ALS or Lou Gehrig’s Disease) ............................................ 20 Encephalitis
..................................................................................................................................... 21
CONCEPTS ............................................................................................................................................ 22
PRACTICE QUESTIONS ANSWERS AND RATIONALES ............................................................
26 Cerebrovascular Accident (Stroke) ............................................................................................. 26
Head Injury ...................................................................................................................................... 29 Spinal
Cord Injury .......................................................................................................................... 32 Seizures
............................................................................................................................................ 34 Brain Tumors
................................................................................................................................... 37 Meningitis
........................................................................................................................................ 40 Parkinson’s Disease
....................................................................................................................... 43 Substance Abuse
............................................................................................................................ 45 Amyotrophic Lateral
Sclerosis (ALS or Lou Gehrig’s Disease) ............................................ 48 Encephalitis
..................................................................................................................................... 50 CONCEPTS
............................................................................................................................................ 53 NEUROLOGICAL
DISORDERS COMPREHENSIVE EXAMINATION ......................................... 57
NEUROLOGICAL DISORDERS COMPREHENSIVE EXAMINATION
ANSWERS AND RATIONALES ....................................................................................................... 63
xi
Table of Contents
xii
3 Cardiac Disorders ...................................................................................................................... 71

KEYWORDS/ABBREVIATIONS .......................................................................................................... 71
PRACTICE QUESTIONS ..................................................................................................................... 72
Congestive Heart Failure .............................................................................................................. 72
Angina/Myocardial Infarction ....................................................................................................... 73
Coronary Artery Disease ................................................................................................................ 74
Valvular Heart Disease .................................................................................................................. 75
Dysrhythmias and Conduction Problems .................................................................................. 77
Inflammatory Cardiac Disorders ................................................................................................. 78
CONCEPTS ............................................................................................................................................ 79
PRACTICE QUESTIONS ANSWERS AND RATIONALES ............................................................
82 Congestive Heart Failure .............................................................................................................. 82
Angina/Myocardial Infarction ....................................................................................................... 84
Coronary Artery Disease ................................................................................................................ 87
Valvular Heart Disease .................................................................................................................. 90
Dysrhythmias and Conduction Problems .................................................................................. 92
Inflammatory Cardiac Disorders ................................................................................................. 95
CONCEPTS ............................................................................................................................................ 98
CARDIAC DISORDERS COMPREHENSIVE EXAMINATION ....................................................
102 CARDIAC DISORDERS COMPREHENSIVE EXAMINATION ANSWERS
AND RATIONALES ......................................................................................................................... 106
4 Peripheral Vascular Disorders ...................................................................................... 111

KEYWORDS/ABBREVIATIONS ....................................................................................................... 111
PRACTICE QUESTIONS .................................................................................................................. 112 Arterial
Hypertension .................................................................................................................. 112
Arterial Occlusive Disease ......................................................................................................... 113
Atherosclerosis ............................................................................................................................. 114
Abdominal Aortic Aneurysm ..................................................................................................... 115
Deep Vein Thrombosis ............................................................................................................... 117
Peripheral Venous Disease ........................................................................................................ 118
CONCEPTS ......................................................................................................................................... 119
PRACTICE QUESTIONS ANSWERS AND RATIONALES ......................................................... 122
Arterial Hypertension .................................................................................................................. 122
Arterial Occlusive Disease ......................................................................................................... 124
Atherosclerosis ............................................................................................................................. 127
Abdominal Aortic Aneurysm ..................................................................................................... 129
Deep Vein Thrombosis ............................................................................................................... 132
Peripheral Venous Disease ........................................................................................................ 134
CONCEPTS ......................................................................................................................................... 137
PERIPHERAL VASCULAR DISORDERS COMPREHENSIVE EXAMINATION ......................
141 PERIPHERAL VASCULAR DISORDERS COMPREHENSIVE EXAMINATION
ANSWERS AND RATIONALES .................................................................................................... 145
5 Hematological Disorders ................................................................................................... 149

PRACTICE QUESTIONS .................................................................................................................. 150 Leukemia
....................................................................................................................................... 150
Lymphoma ..................................................................................................................................... 151
Anemia ........................................................................................................................................... 152
Bleeding Disorders ...................................................................................................................... 153
Blood Transfusions ...................................................................................................................... 154
Sickle Cell Anemia ...................................................................................................................... 156
CONCEPTS ......................................................................................................................................... 157
Leukemia ....................................................................................................................................... 159
Lymphoma ..................................................................................................................................... 161
Table of Contents
xiii
Anemia ........................................................................................................................................... 164

Bleeding Disorders ...................................................................................................................... 167
Blood Transfusions ...................................................................................................................... 169
Sickle Cell Anemia ...................................................................................................................... 173
CONCEPTS ......................................................................................................................................... 176
HEMATOLOGICAL DISORDERS COMPREHENSIVE EXAMINATION ....................................
179 HEMATOLOGICAL DISORDERS COMPREHENSIVE EXAMINATION
6 Respiratory Disorders .......................................................................................................... 189

PRACTICE QUESTIONS .................................................................................................................. 190 Upper
Respiratory Infection (URI) .......................................................................................... 190
Lower Respiratory Infection ...................................................................................................... 191
Chronic Obstructive Pulmonary Disease (Copd) ................................................................. 192
Reactive Airway Disease (Asthma) .......................................................................................... 194
Lung Cancer ................................................................................................................................. 195
Cancer of the Larynx .................................................................................................................. 198
Pulmonary Embolus .................................................................................................................... 199
Chest Trauma ............................................................................................................................... 200
Acute Respiratory Distress Syndrome .................................................................................... 201
CONCEPTS ......................................................................................................................................... 203
Upper Respiratory Infection ...................................................................................................... 206
Lower Respiratory Infection ...................................................................................................... 208
Chronic Obstructive Pulmonary Disease (COPD) ................................................................. 211
Reactive Airway Disease (Asthma) .......................................................................................... 214
Lung Cancer ................................................................................................................................. 216
Cancer of the Larynx .................................................................................................................. 219
Pulmonary Embolus .................................................................................................................... 222
Chest Trauma ............................................................................................................................... 224
Acute Respiratory Distress Syndrome (ARDS) ..................................................................... 227
RESPIRATORY DISORDERS COMPREHENSIVE EXAMINATION ..........................................
233 RESPIRATORY DISORDERS COMPREHENSIVE EXAMINATION
7 Gastrointestinal Disorders ............................................................................................... 249

PRACTICE QUESTIONS .................................................................................................................. 250
Gastroesophageal Reflux (GERD) ............................................................................................ 250
Inflammatory Bowel Disease .................................................................................................... 251
Peptic Ulcer Disease .................................................................................................................. 252
Colorectal Disease ....................................................................................................................... 253
Diverticulosis/Diverticulitis ........................................................................................................ 254
Gallbladder Disorders ................................................................................................................. 255
Liver Failure .................................................................................................................................. 256
Hepatitis ........................................................................................................................................ 258
Gastroenteritis .............................................................................................................................. 259
Abdominal Surgery ...................................................................................................................... 260
Eating Disorders .......................................................................................................................... 261
Constipation/Diarrhea Disorders .............................................................................................. 262
CONCEPTS ......................................................................................................................................... 263
Gastroesophageal Reflux (GERD) ............................................................................................ 265
Inflammatory Bowel Disease .................................................................................................... 267
Peptic Ulcer Disease .................................................................................................................. 269
Colorectal Disease ....................................................................................................................... 272
Table of Contents
xiv
Diverticulosis/Diverticulitis ........................................................................................................ 275

Gallbladder Disorders ................................................................................................................. 277
Liver Failure .................................................................................................................................. 280
Hepatitis ........................................................................................................................................ 282
Gastroenteritis .............................................................................................................................. 285
Abdominal Surgery ...................................................................................................................... 287
Eating Disorders .......................................................................................................................... 290
Constipation/Diarrhea Disorders .............................................................................................. 292
GASTROINTESTINAL DISORDERS COMPREHENSIVE EXAMINATION ..............................
298 GASTROINTESTINAL DISORDERS COMPREHENSIVE EXAMINATION
8 Endocrine Disorders ............................................................................................................. 313

PRACTICE QUESTIONS .................................................................................................................. 314 Diabetes
Mellitus ........................................................................................................................ 314
Pancreatitis ................................................................................................................................... 316
Cancer of the Pancreas .............................................................................................................. 317
Adrenal Disorders ........................................................................................................................ 319
Pituitary Disorders ....................................................................................................................... 320
Thyroid Disorders ........................................................................................................................ 321
CONCEPTS ......................................................................................................................................... 322
Diabetes Mellitus ........................................................................................................................ 325
Pancreatitis ................................................................................................................................... 330
Cancer of the Pancreas .............................................................................................................. 332
Adrenal Disorders ........................................................................................................................ 335
Pituitary Disorders ....................................................................................................................... 337
Thyroid Disorders ........................................................................................................................ 339
CONCEPTS ......................................................................................................................................... 343
ENDOCRINE DISORDERS COMPREHENSIVE EXAMINATION .............................................
346 ENDOCRINE DISORDERS COMPREHENSIVE EXAMINATION
9 Genitourinary Disorders ..................................................................................................... 355

PRACTICE QUESTIONS .................................................................................................................. 356 Acute
Renal Failure (ARF) ........................................................................................................ 356
Chronic Kidney Disease (CKD) ................................................................................................. 357
Fluid and Electrolyte Disorders ................................................................................................ 358
Urinary Tract Infection (Uti) .................................................................................................... 359
Benign Prostatic Hypertrophy .................................................................................................. 361
Renal Calculi ................................................................................................................................ 362
Cancer of the Bladder ................................................................................................................ 363
CONCEPTS ......................................................................................................................................... 365
Acute Renal Failure (ARF) ........................................................................................................ 368
Chronic Kidney Disease (CKD) ................................................................................................. 370
Fluid and Electrolyte Disorders ................................................................................................ 373
Urinary Tract Infection (UTI) .................................................................................................... 376
Benign Prostatic Hypertrophy .................................................................................................. 378
Renal Calculi ................................................................................................................................ 380
Cancer of the Bladder ................................................................................................................ 383
CONCEPTS ......................................................................................................................................... 386
GENITOURINARY DISORDERS COMPREHENSIVE EXAMINATION ....................................
389 GENITOURINARY DISORDERS COMPREHENSIVE EXAMINATION
Table of Contents
xv
10 Reproductive Disorders ..................................................................................................... 397

PRACTICE QUESTIONS .................................................................................................................. 398 Breast
Disorders .......................................................................................................................... 398
Pelvic Floor Relaxation Disorders ............................................................................................ 399
Uterine Disorders ........................................................................................................................ 400
Ovarian Disorders ........................................................................................................................ 401
Prostate Disorders ....................................................................................................................... 403
Testicular Disorders .................................................................................................................... 404
Sexually Transmitted Diseases ................................................................................................. 405
CONCEPTS ......................................................................................................................................... 406
Breast Disorders .......................................................................................................................... 409
Pelvic Floor Relaxation Disorders ............................................................................................ 412
Uterine Disorders ........................................................................................................................ 414
Ovarian Disorders ........................................................................................................................ 416
Prostate Disorders ....................................................................................................................... 419
Testicular Disorders .................................................................................................................... 422
Sexually Transmitted Diseases ................................................................................................. 424
CONCEPTS ......................................................................................................................................... 427
REPRODUCTIVE DISORDERS COMPREHENSIVE EXAMINATION ......................................
430 REPRODUCTIVE DISORDERS COMPREHENSIVE EXAMINATION
11 Musculoskeletal Disorders .............................................................................................. 439

Degenerative/Herniated Disk Disease ..................................................................................... 440
Osteoarthritis ................................................................................................................................ 441
Osteoporosis ................................................................................................................................. 442
Amputation ................................................................................................................................... 443
Fractures ....................................................................................................................................... 444
Joint Replacements .................................................................................................................... 446
CONCEPTS ......................................................................................................................................... 447
Degenerative/Herniated Disk Disease ..................................................................................... 450
Osteoarthritis ................................................................................................................................ 452
Osteoporosis ................................................................................................................................. 454
Amputation ................................................................................................................................... 457
Fractures ....................................................................................................................................... 459
Joint Replacements .................................................................................................................... 461
CONCEPTS ......................................................................................................................................... 464
MUSCULOSKELETAL DISORDERS COMPREHENSIVE EXAMINATION .............................
467 MUSCULOSKELETAL DISORDERS COMPREHENSIVE EXAMINATION
12 Integumentary Disorders .................................................................................................. 475

PRACTICE QUESTIONS .................................................................................................................. 475 Burns
.............................................................................................................................................. 475
Pressure Ulcers ............................................................................................................................ 477
Skin Cancer .................................................................................................................................. 478
Bacterial Skin Infection ............................................................................................................. 479
Viral Skin Infection ..................................................................................................................... 481
Fungal/Parasitic Skin Infection ................................................................................................ 482
CONCEPTS ......................................................................................................................................... 484
Table of Contents
xvi
Burns .............................................................................................................................................. 486

Pressure Ulcers ............................................................................................................................ 488
Skin Cancer .................................................................................................................................. 491
Bacterial Skin Infection ............................................................................................................. 493
Viral Skin Infection ..................................................................................................................... 496
Fungal/Parasitic Skin Infection ................................................................................................ 499
CONCEPTS ......................................................................................................................................... 501
INTEGUMENTARY DISORDERS COMPREHENSIVE EXAMINATION ...................................
504 INTEGUMENTARY DISORDERS COMPREHENSIVE EXAMINATION
13 Immune System Disorders .............................................................................................. 513

PRACTICE QUESTIONS .................................................................................................................. 514 Multiple
Sclerosis ........................................................................................................................ 514
Guillain-Barré Syndrome ........................................................................................................... 515
Myasthenia Gravis ....................................................................................................................... 516
Systemic Lupus Erythematosus ............................................................................................... 518
Acquired Immunodeficiency Syndrome ................................................................................. 519
Allergies and Allergic Reactions .............................................................................................. 521
Rheumatoid Arthritis (RA) ......................................................................................................... 522
CONCEPTS ......................................................................................................................................... 523
Multiple Sclerosis ........................................................................................................................ 526
Guillain-Barré Syndrome ........................................................................................................... 528
Myasthenia Gravis ....................................................................................................................... 531
Systemic Lupus Erythematosus ............................................................................................... 533
Acquired Immunodeficiency Syndrome ................................................................................. 536
Allergies and Allergic Reactions .............................................................................................. 538
Rheumatoid Arthritis (RA) ......................................................................................................... 541
CONCEPTS ......................................................................................................................................... 544
IMMUNE SYSTEM DISORDERS COMPREHENSIVE EXAMINATION ...................................
547 IMMUNE SYSTEM DISORDERS COMPREHENSIVE EXAMINATION
14 Sensory Deficits ....................................................................................................................... 557

PRACTICE QUESTIONS .................................................................................................................. 558 Eye
Disorders ................................................................................................................................ 558
Ear Disorders ................................................................................................................................ 559
CONCEPTS ......................................................................................................................................... 560
Eye Disorders ................................................................................................................................ 562
Ear Disorders ................................................................................................................................ 564
CONCEPTS ......................................................................................................................................... 567
SENSORY DEFICITS COMPREHENSIVE EXAMINATION ........................................................
569 SENSORY DEFICITS COMPREHENSIVE EXAMINATION ANSWERS
AND RATIONALES ......................................................................................................................... 572
15 Emergency Nursing .............................................................................................................. 577

PRACTICE QUESTIONS .................................................................................................................. 578 Shock
............................................................................................................................................. 578
Bioterrorism .................................................................................................................................. 579
Codes .............................................................................................................................................. 580
Disasters/Triage ............................................................................................................................ 581
Poisoning ....................................................................................................................................... 582
Violence, Physical Abuse, and Neglect .................................................................................. 584
Table of Contents
xvii
CONCEPTS ......................................................................................................................................... 585

Shock ............................................................................................................................................. 588
Bioterrorism .................................................................................................................................. 591
Codes .............................................................................................................................................. 594
Disasters/Triage ............................................................................................................................ 596
Poisoning ....................................................................................................................................... 599
Violence, Physical Abuse, and Neglect .................................................................................. 602
CONCEPTS ......................................................................................................................................... 605
EMERGENCY NURSING COMPREHENSIVE EXAMINATION .................................................
607 EMERGENCY NURSING COMPREHENSIVE EXAMINATION ANSWERS
AND RATIONALES ......................................................................................................................... 610
16 Perioperative Care .................................................................................................................. 615

Preoperative .................................................................................................................................. 616
Intraoperative ............................................................................................................................... 617
Postoperative ................................................................................................................................ 618
Acute Pain .................................................................................................................................... 619
CONCEPTS ......................................................................................................................................... 620
Preoperative .................................................................................................................................. 623
Intraoperative ............................................................................................................................... 625
Postoperative ................................................................................................................................ 628
Acute Pain .................................................................................................................................... 630
CONCEPTS ......................................................................................................................................... 633
PERIOPERATIVE CARE COMPREHENSIVE EXAMINATION ...................................................
635 PERIOPERATIVE CARE COMPREHENSIVE EXAMINATION ANSWERS
AND RATIONALES ......................................................................................................................... 638
17 Cultural and Spiritual Nursing and Alternative Health Care .............. 643
CONCEPTS ......................................................................................................................................... 647
CONCEPTS ANSWERS AND RATIONALES ................................................................................ 655
CULTURAL NURSING AND ALTERNATIVE HEALTH CARE
COMPREHENSIVE EXAMINATION ............................................................................................ 658
CULTURAL NURSING AND ALTERNATIVE HEALTH CARE COMPREHENSIVE
EXAMINATION ANSWERS AND RATIONALES ....................................................................... 661
18 End-of-Life Issues .................................................................................................................. 667

ABBREVIATIONS ............................................................................................................................... 667
PRACTICE QUESTIONS .................................................................................................................. 668 Advance
Directives ...................................................................................................................... 668
Death and Dying .......................................................................................................................... 669
Chronic Pain ................................................................................................................................. 670
Ethical/Legal Issues .................................................................................................................... 672
Organ/Tissue Donation ................................................................................................................ 673
CONCEPTS ......................................................................................................................................... 675
Advance Directives ...................................................................................................................... 676
Death and Dying .......................................................................................................................... 678
Chronic Pain ................................................................................................................................. 681
Ethical/Legal Issues .................................................................................................................... 684
Organ/Tissue Donation ................................................................................................................ 687
Table of Contents
xviii
CONCEPTS ANSWERS AND RATIONALES ................................................................................ 690

END-OF-LIFE ISSUES COMPREHENSIVE EXAMINATION .................................................... 692
END-OF-LIFE ISSUES COMPREHENSIVE EXAMINATION ANSWERS
AND RATIONALES ......................................................................................................................... 696
19 Pharmacology ............................................................................................................................ 701

TEST-TAKING HINTS FOR PHARMACOLOGY QUESTIONS ................................................... 702 Drug
Cards .................................................................................................................................... 702
Sample Drug Cards.........................................................................................................704
Example #1: Digoxin .................................................................................................................. 705
Example #2: Furosemide .......................................................................................................... 705
MEDICATIONS ADMINISTRATION IN A MEDICAL-SURGICAL SETTING
COMPREHENSIVE EXAMINATION ............................................................................................ 706
MEDICATIONS ADMINISTRATION IN A MEDICAL-SURGICAL SETTING
COMPREHENSIVE EXAMINATION ANSWERS AND RATIONALES ................................... 717
20 Comprehensive Final Examination ........................................................................... 733

COMPREHENSIVE FINAL EXAMINATION .................................................................................. 733
COMPREHENSIVE FINAL EXAMINATION ANSWERS AND RATIONALES .........................
744
Glossary of English Words Commonly Encountered

on Nursing Examinations ................................................................................................. 761
Appendix A: Normal Laboratory Values ............................................................... 765
Appendix B: Sample Nursing Concept Care Map ....................................... 767
Illustration Credits ................................................................................................................. 771
Index ................................................................................................................................................. 773
Test Taking
INTRODUCTION
This book is part of a series of books published by the F.A. Davis Company designed to assist the student
nurse to be successful in nursing school. This book focuses on critical thinking in regard to test taking.
There are the usual test questions found in review books, but the test taker will also find test-taking hints in
19 of 20 chapters. Table 1-1 indicates the breakdown of the content found on the NCLEX-RN. This book
has attempted to follow this blueprint. The 2016–2019 NCLEX-RN blueprint includes additional types of
alternative test ques
tions. The end of each chapter includes these new graphic types of test questions. The most important
aspect of taking any examination is to become knowledgeable about the subject matter the test will cover.
There is no substitute for studying the material. Book one of this series—Fundamentals Success: A Q
& A Review Applying Critical Thinking to Test Taking, 4th edition, by Patricia M. Nugent and Barbara A.
Vitale—defines critical thinking and the RACE model for applying critical thinking to test-taking skills, and
the specific topics in that volume will not be repeated in this book. This book will also assist the test taker
to apply critical-thinking skills directly to the questions found on nursing examinations.
GUIDELINES FOR USING THIS BOOK

This book is designed to assist the nursing student when preparing for and taking medical surgical
examinations as well as the graduate nurse who is preparing to take the national licensure examination.
The book is divided into chapters according to body systems and includes chapters on pharmacology,
end-of-life issues, emergency nursing, and alternative therapy; a 100-question final examination; and the
DavisPlus site containing 150 additional questions. Chapters 2 through 18 are further divided into disease
processes to more easily help the test taker identify specific content. A comprehensive final including other
content
areas as well as disease processes is included at the end of each chapter. In the Answers and Rationales
sections of the chapters, an explanation for the correct answer as well as the incorrect distracters is
provided. In Chapters 2 through 18, a Test-Taking Hint is provided for every question in the content area.
Each question is coded according to Bloom’s Taxonomy for categorizing levels of abstraction required for
the test taker to arrive at the correct answer. As specified by the National Council of State Boards of
Nursing (NCSBN) testing information, the questions are coded by Content, Integrated Nursing Process,
Client Needs, Cognitive Level (Bloom’s Taxonomy), and Concept. There are no test-taking hints provided
for the comprehensive final examinations or the questions on DavisPlus. In Chapter 19, the pharmacology
chapter, the test-taking hints are discussed in the beginning of the chapter.
1
1
Med-Surg Success
2
Table 1-1 Client Needs Categories and Percentage of Items

Client Needs Percentage of Items
SAFE AND EFFECTIVE CARE ENVIRONMENT

• Management of Care 17–23%
• Safety and Infection Control 9–15%
• Health Promotion and Maintenance 6–12%
• Psychosocial Integrity 6–12%
PHYSIOLOGICAL INTEGRITY
• Basic Care and Comfort 6–12%
• Pharmacological and Parenteral Therapies 12–18%
• Reduction of Risk Potential 9–15%
• Physiological Adaption 11–17%
The National Council of State Boards of Nursing, Inc., Chicago, IL, with permission.
PREPARING FOR LECTURE

In preparation for attending class on a specific topic, the student should have read the
as signment and prepared notes to take to class. Any information the student does not
under stand should be highlighted in order to clarify the information if the instructor
does not
cover it in class or if, after the lecture, the student still does not understand the concept.
A piece of paper, or study guide, divided into categories of information should be suf
ficient for most disease processes. If the student is unable to limit the information to
one page, the student is probably not being discriminatory when reading. The idea is
not to rewrite the textbook but rather to glean from the textbook the important,
need-to-know information.
Sample Study Guide
Medical Diagnosis: Definition:

DIAGNOSTIC TESTS: SIGNS AND SYMPTOMS: NURSING INTERVENTIONS: (List normal values)
(Include teaching)
PROCEDURES AND NURSING

IMPLICATIONS:
MEDICAL INTERVENTIONS:
Complete the study guide in one color of pen but take a different color or a pencil to
class along with a highlighter and the study guide. Whatever the instructor emphasizes
during the lecture on the study guide should be highlighted. Whatever information the
instruc tor emphasizes in the lecture that the student did not include on the study guide
should be
Chapter 1 Test Taking 3
written in the different color pen or pencil. The student should reread the information in
the textbook that was included in lecture but was not included on the study guide.
When studying for the examination, the student can identify the information obtained
from the textbook and the information obtained in class. The information on the study
guide that is highlighted represents information that the student thought was important
from reading the textbook and the instructor emphasized during the lecture. This is
important, need-to-know information for the examination. Please note, however, the
instructor may not emphasize laboratory tests and values but still expects the student
to realize the importance of this information.
The completed study guides can be carried with the student in a folder and reviewed
dur ing children’s sports practices, when waiting for an appointment, or at any time the
student finds a minute that is spent idly. This is making the most of limited time. The
study guides should also be carried to clinical assignments to use when caring for
clients in the hospital.
Students who prepare before attending class will find the lecture easier to
understand and, as a result, those students will score higher on examinations. Being
prepared allows the student to listen to the instructor and not sit in class trying to write
every word from the overhead presentation.
The student should recognize the importance of the instructor’s hints during the
lecture. The instructor may emphasize information by highlighting areas on overhead
slides, re peating information, or emphasizing a particular fact, which usually means the
instructor thinks the information is very important. Important information usually finds
its way onto tests at some point.
PREPARING FOR AN EXAMINATION

Study
The student should plan to study three (3) hours for every one (1) hour of class. For
example, a course that is three (3) hours of credit requires nine (9) hours of study each
week. Cram ming immediately before the test usually indicates the student is at risk for
being unsuc cessful on the examination. The information acquired during cramming is
not learned and will be quickly forgotten. Nursing examinations include material
required by the registered nurse when caring for clients at the bedside. The knowledge
required to care for clients builds on ALL previous knowledge as well as information
newly acquired.
Understanding What the Test Taker Does Not Know

The first time many students realize they do not understand the information is during
the examination, when it is too late. Nursing examinations contain high-level
application ques tions requiring the test taker not only to have memorized information
but also to be able to interpret the data and make a judgment as to the correct course
of action. Test takers must recognize their own areas of weakness before seeing an
examination for the first time. This book is designed to assist test takers to identify their
areas of weakness before the examination.
Two (2) to three (3) days before the examination, the student should compose a
practice test and take the examination. If a topic of study proves to be an area of
strength, as evi denced by selecting the correct answer to the question, then the
student should proceed to study other areas identified as weaknesses. Missing the
question identifies a weakness. If the test taker does not understand the rationale for
the correct answer, the test taker should read the appropriate textbook and try to
understand the rationale for the correct answer. The test taker should be cautious
about reading rationales for the incorrect distracters. During the examination, the test
taker may remember reading the information but could become confused about
whether the information applied to the correct answer or to the incorrect distracter.
Med-Surg Success
4
The Night Before the Exam

The night before the examination, the student should quit studying by 6:00 to 7:00 p.m.
The student should do something fun or relaxing up until bedtime and get a good
night’s rest before taking the examination. Studying until bedtime or in an all-night
cram session leaves the student tired and sleepy during the examination, which is just
when the mind should be at its top performance.
The Day of the Exam
The student should eat a meal before an examination; a source of carbohydrate for
energy along with a protein source makes a good meal. Skipping a meal before the
examination leaves the brain without nourishment. A bagel with peanut butter and milk
is an excel lent meal; it provides a source of protein and sustained release of
carbohydrates. Do not eat donuts or drink soft drinks. The energy from these is quickly
available but will not last throughout the time required for an examination. Excessive
fluid intake may cause the need to urinate during the examination and make it hard for
the test taker to concentrate.
Test-Taking Anxiety
If the student has test-taking anxiety, then it is advisable for the student to arrive at the
test ing site 45 minutes before the examination. Find a seat for the examination and
place books there to reserve the desk. The student should walk for 15 minutes at a
fast pace away from the testing site and at the end of the 15 minutes the student
should turn and walk back. This exercise literally walks anxiety away.
If other test takers getting up and leaving the room bothers the test taker, the test
taker should try to get a desk away from the group, in front of the room or facing a
wall. Most schools allow students to wear hunter’s ear plugs during a test if noise
bothers the student. Most NCLEX-RN test sites will provide ear plugs if the graduate
requests them.
TAKING THE EXAM

During the examination, if the test taker finds a question that contains totally unknown
in formation and the test taker is taking a pencil-and-paper test, the test taker should
circle the question and skip it. Another question may help to answer the skipped
question. Delaying moving on and worrying over a question will place the next few
questions in jeopardy. The mind will not let go of the worry, and the test taker may miss
important information in the subsequent questions.
During the NCLEX-RN computerized test, the test taker should take some deep
breaths and then select an answer. The computer does not allow the test taker to
return to a question. Test takers who become anxious during an examination should
stop, put their hands in their lap, shut their eyes, and take a minimum of five (5) deep
breaths before resuming the examination. The test taker must become aware of
personal body signals that indicate in creasing stress levels. Some people get
gastrointestinal symptoms and others feel a tighten ing of muscles.
Test-Taking Hints for the Computerized NCLEX-RN Examination

A computer administers the NCLEX-RN examination. Here are some test-taking hints
that specifically apply to examination by computer.
• The test is composed of 75 to 265 questions. The computer determines with a 95%
cer tainty that the test taker’s ability is above the passing standard before the
examination will conclude. The minimum number of questions the test taker will
receive is 75 questions.
• The examination comprises multiple-choice questions and may include several types
of alternate questions:
• Fill-in-the-blank questions, which test math abilities.
• “Select all that apply” questions, which require the test taker to select more than
one distracter as the correct answer. In a “Select All” question, a minimum of two
an swers will be correct and in some questions all of the options may be correct.
This is a new revision of the NCLEX-RN examination. Previously, there had to be
at least one incorrect option. Click-and-drag questions, which require the test
taker to identify a specific area of the body as the correct answer.
• An audio component, which requires the test taker to identify body sounds.
Examples of most of these types of questions are included in this book. In an
attempt to illustrate the click-and-drag questions, this book has pictures with lines
to delineate A, B, C, and D. A fifth type of question which prioritizes the answers
1, 2, 3, 4, and 5 in order of when the nurse would implement the intervention is
also included in this book. Finally, the audio questions can be found on the F.A.
Davis Web site.
• Test takers should not be overly concerned if they possess rudimentary computer
skills. The test taker must use the mouse to select the correct answer. Every
question asks for a confirmation before being submitted as the answer.
• Other than typing pertinent personal information, the test taker must be able to type
numbers and use the drop-down computer calculator. The test taker can request an
erase slate to calculate math problems by hand.
• The test taker should practice taking tests on the computer before taking the
NCLEX-RN examination. Many textbooks contain computer disks with test
questions, and there are many online review opportunities.
• The test taker should refer to the Web site for the National Council of State Boards of
Nursing (http://www.ncsbn.org) for additional information on the NCLEX-RN
examination.
Understanding the Types of Nursing Questions
Components of a Multiple-Choice Question

A multiple-choice question is called an item. Each item has two parts. The stem is the
part that contains the information that identifies the topic and its parameters and then
asks a question. The second part consists of one or more possible responses, which
are called options. One of the options is the correct answer and the others are the
wrong answers, called distracters.
The client diagnosed with angina complains of chest pain while ambulating
in the hall. Which intervention should the nurse implement first?Stem
a. Have the client sit down. Correct answer
Options
b. Monitor the pulse oximeter reading.
c. Administer sublingual nitroglycerin. Distracters
d. Apply oxygen via nasal cannula.
Cognitive Levels of Nursing Questions

Questions on nursing examinations reflect a variety of thinking processes that nurses
use when caring for clients. These thinking processes are part of the cognitive domain,
and they progress from the simple to the complex, from the concrete to the abstract,
and from the
Med-Surg Success
6
tangible to the intangible. There are four types of thinking processes represented by
nursing questions:
• Knowledge Questions—The emphasis is on recalling remembered information.
• Comprehension Questions—The emphasis is on understanding the meaning and
intent of remembered information.
• Application Questions—The emphasis is on remembering understood information
and utilizing the information in new situations.
• Analysis Questions—The emphasis is on comparing and contrasting a variety of
elements of information.
THE RACE MODEL: THE APPLICATION OF CRITICAL

THINKING TO MULTIPLE-CHOICE QUESTIONS
Answering a test question is like participating in a race. Of course, the test taker wants
to come in first and be the winner. However, the thing to remember about a race is that
success is not based just on speed but also on strategy and tactics. The same is true
about nursing examinations. Although speed may be a variable that must be
considered when tak
ing a timed test, so that the amount of time spent on each question is factored into the
test strategy, the emphasis on RACE is the use of critical-thinking techniques to answer
multiple-choice questions. The RACE Model presented next is a critical-thinking
strategy to use when answering nursing multiple-choice questions. If the test taker
follows the RACE model every time when examining a test question, its use will
become second nature. This methodical approach will improve the test taker’s abilities
to critically analyze a test question and improve chances of selecting the correct
answer.
The RACE Model has four steps to answering a test question. The best way to
remember the four steps is to refer to the acronym RACE.
R—Recognize what information is in the stem.
• Recognize the key words in the stem.
• Recognize who the client is in the stem.
• Recognize what the topic is about.
A—Ask what is the question asking?
• Ask what are the key words in the stem that indicate the need for a response?
• Ask what is the question asking the nurse to implement?
C—Critically analyze the options in relation to the question asked in the stem.
• Critically scrutinize each option in relation to the information in the stem.
• Critically identify a rationale for each option.
• Critically compare and contrast the options in relation to the information in the
stem and their relationships to one another.
E—Eliminate as many options as possible.
• Eliminate one option at a time.
The text Fundamentals Success: A Q & A Review Applying Critical Thinking to Test
Taking, 4th edition, by Patricia M. Nugent and Barbara A. Vitale, includes an in-depth
discus sion exploring the RACE Model in relation to the thinking processes as
represented in multiple-choice nursing questions.
CONCEPT-FOCUSED QUESTIONS
A number of states and nursing programs within the states have chosen to use a
Concept-based curriculum approach to nursing education. Oregon, North Carolina,
and Texas are among these states. This is a change from the disease-based model of
nursing education that followed a disease-based approach. Over the years of
curriculum development in nursing, the number of topics has expanded under the
disease-based curriculum to become burdensome and unwieldy
for students and faculty. These schools have transitioned to teaching “concepts” of
client needs, utilizing specific exemplars of commonly occurring disease processes to
represent the concept to students. This is not a new idea but rather a return to a
previous method of nursing curriculum.
For example, if the curriculum being taught is Oxygenation, it would be taught using
the exemplars of pneumonia or chronic obstructive pulmonary disease (COPD). Under
the concept, there are similarities of nursing assessment guidelines and nursing
interventions. Assessing the client’s lung fields, elevating the head of the bed for
maximum lung expansion, and administering oxygen are applicable for both exemplars
and also for asthma, respiratory distress, myasthenia gravis with respiratory
involvement, and others that require these same interventions. The exemplars require
the nurse to determine what makes this Oxygenation problem different from a client
with myasthenia. The concept problem focus is designed to encourage critical thinking
and problem solving. This book includes questions at the end of most chapters that
focus on the larger concept with the use of exemplars.
Neurological
Disorders
The first step toward knowledge is to know that we are not ignorant.
—Richard Cecil
2
Test-taking hints are useful to discriminate information, but they cannot substitute for
knowledge. The student should refer to Chapter 1 for assistance in preparing for class,
studying, and taking an examination.
This chapter focuses on disorders that affect the neurological system. It provides a
list of keywords and abbreviations, practice questions focused on disease processes,
and a com prehensive examination that includes other content areas involving the
neurological system and the disease processes addressed in the practice questions.
Answers and reasons why the answer options provided are either correct or incorrect
are also provided, as are test-taking hints. Subsequent chapters (Chapters 3 through
14) focus on disorders that affect other body systems and function.
KEYWORDS ABBREVIATIONS
Activities of daily living (ADLs)
Agnosia Amyotrophic lateral sclerosis (ALS) Blood
Akinesia pressure (BP)
Aphasia Cerebrovascular accident (CVA)
Apraxia Computed tomography (CT)
Areflexia Electroencephalogram (EEG)
Ataxia Electromyogram (EMG)
Autonomic dysreflexia Bradykinesia Emergency department (ED)
Decarboxylase Enzyme-linked immunosorbent assay
Diplopia (ELISA) Health-care provider (HCP)
Dysarthria Intensive care department (ICD)
Dysphagia Intracranial pressure (ICP)
Echolalia Intravenous (IV)
Epilepsy Magnetic resonance imaging (MRI)
Papilledema Nonsteroidal anti-inflammatory drug
Paralysis (NSAID) Nothing by mouth (NPO)
Paresthesia Parkinson’s disease (PD)
Paroxysms Pulse (P)
Penumbra Range of motion (ROM)
Postictal Respiration (R)
9
Med-Surg Success Temperature (T)
10
Transient ischemic attack
(TIA) Traumatic brain injury
(TBI)
Rule out (R/O)
Unlicensed assistive personnel (UAP)
Spinal cord injury (SCI)
STAT—immediately (STAT)
Please note: The term health-care provider, as used in this text, refers to a nurse
practitioner (NP), a physician (MD), an osteopath (DO), or a physician assistant (PA)
who has prescrip tive authority. These providers are responsible for directing the care
and providing orders for the clients.
PRACTICE QUESTIONS
emergency department (ED) with numbness
Cerebrovascular Accident (Stroke) and weakness of the left arm and slurred
speech. Which nursing intervention is
priority?
1. A 78-year-old client is admitted to the
1. Prepare to administer recombinant client’s right axilla to move up in bed.
tissue plasminogen activator (rt-PA). 4. The assistant praises the client for
2. Discuss the precipitating factors that attempting to perform ADLs independently.
caused the symptoms.
3. Schedule for a STAT computed
tomography (CT) scan of the head. 7. The client diagnosed with atrial fibrillation has
4. Notify the speech pathologist for an experienced a transient ischemic attack (TIA).
emergency consult. Which medication would the nurse anticipate
2. The nurse is assessing a client experiencing being ordered for the client on discharge? 1.
motor loss as a result of a left-sided An oral anticoagulant medication.
cerebrovascular accident (CVA). Which 2. A beta blocker medication.
clinical manifestation would the nurse 3. An anti-hyperuricemic medication.
document? 1. Hemiparesis of the client’s left 4. A thrombolytic medication.
arm and apraxia. 2. Paralysis of the right side 8. The client has been diagnosed with a
of the body and ataxia. cerebrovascular accident (stroke).
3. Homonymous hemianopsia and diplopia. 4. The
Impulsive behavior and hostility toward family. client’s wife is concerned about her husband’s
3. Which client would the nurse identify as being generalized weakness. Which home
most at risk for experiencing a modification should the nurse suggest to the
cerebrovascular accident (CVA)? wife prior to discharge?
1. A 55-year-old African American male. Chapter 2 Neurological Disorders 11 Head Injury
2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female. 13. The client diagnosed with a mild concussion
4. The client diagnosed with a right-sided is being discharged from the emergency
cerebrovascular accident is admitted to the department. Which discharge instruction should
the nurse teach the client’s significant other? 1.
rehabilitation unit. Which interventions should be
Awaken the client every two (2) hours.
included in the nursing care plan? Select all
that apply. 2. Monitor for increased intracranial
pressure (ICP).
1. Position the client to prevent
shoulder adduction. 3. Observe frequently for hypervigilance.
4. Offer the client food every three (3) to four
2. Turn and reposition the client every shift. 3.
(4) hours.
Encourage the client to move the affected side.
4. Perform quadriceps exercises three (3) 14. The resident in a long-term care facility fell
times a day. during the previous shift and has a laceration
5. Instruct the client to hold the fingers in a fist. in
1. Obtain a rubber mat to place under the
5. The nurse is planning care for a client
dinner plate.
experiencing agnosia secondary to a
cerebrovascular accident. Which collaborative 2. Purchase a long-handled bath sponge
for showering.
intervention will be included in the plan of
care? 3. Purchase clothes with Velcro closure
devices. 4. Obtain a raised toilet seat for the
1. Observe the client swallowing for
client’s bathroom.
possible aspiration.
2. Position the client in a semi-Fowler’s 9. The client is diagnosed with expressive
position when sleeping. aphasia. Which psychosocial client problem
3. Place a suction setup at the client’s would the nurse include in the plan of care?
bedside during meals. 1. Potential for injury.
4. Refer the client to an occupational therapist 2. Powerlessness.
for evaluation. 3. Disturbed thought processes.
4. Sexual dysfunction.
6. The nurse and an unlicensed assistive
personnel (UAP) are caring for a client with 10. Which assessment data would indicate to
right-sided paralysis. Which action by the UAP the nurse that the client would be at risk
requires the nurse to intervene? for a hemorrhagic stroke?
1. The assistant places a gait belt around 1. A blood glucose level of 480 mg/dL.
the client’s waist prior to ambulating. 2. A right-sided carotid bruit.
2. The assistant places the client on the back 3. A blood pressure (BP) of 220/120 mm
with the client’s head to the side. Hg. 4. The presence of bronchogenic
3. The assistant places a hand under the carcinoma.
3. No eye activity is observed when the
11. The 85-year-old client diagnosed with a stroke
cold caloric test is performed.
is complaining of a severe headache. Which
4. The client assumes decorticate
intervention should the nurse implement first? 1.
posturing when painful stimuli are
Administer a nonnarcotic analgesic.
applied.
2. Prepare for STAT magnetic Med-Surg Success
resonance imaging (MRI). 12
3. Start an intravenous infusion with D5W at
100 mL/hr. 17. The client is admitted to the medical floor with
4. Complete a neurological assessment. a diagnosis of closed head injury. Which
12. A client diagnosed with a subarachnoid nursing intervention has priority?
hemorrhage has undergone a 1. Assess neurological status.
craniotomy for repair of a ruptured 2. Monitor pulse, respiration, and
aneurysm. Which intervention will the blood pressure.
intensive care nurse implement? 3. Initiate an intravenous access.
1. Administer a stool softener bid. 4. Maintain an adequate airway.
2. Encourage the client to cough hourly. 18. The client diagnosed with a closed head
3. Monitor neurological status every shift. injury is admitted to the rehabilitation
4. Maintain the dopamine drip to keep department. Which medication order would
BP at 160/90. the nurse question?
the occipital area that has been closed with 1. A subcutaneous anticoagulant.
steri strips. Which signs/symptoms would 2. An intravenous osmotic diuretic.
warrant transferring the resident to the 3. An oral anticonvulsant.
emergency department? 4. An oral proton pump inhibitor.
1. A 4-cm area of bright red drainage on
the dressing. 19. The client diagnosed with a gunshot wound to
2. A weak pulse, shallow respirations, and the head assumes decorticate posturing when
cool pale skin. the nurse applies painful stimuli. Which
3. Pupils that are equal, react to light, assessment data obtained three (3) hours
and accommodate. later would indicate the client is improving?
4. Complaints of a headache that resolves 1. Purposeless movement in response to
with medication. painful stimuli.
2. Flaccid paralysis in all four extremities. 3.
15. The nurse is caring for several clients. Which Decerebrate posturing when painful stimuli
client would the nurse assess first after are applied.
receiving the shift report? 4. Pupils that are 6 mm in size and
1. The 22-year-old male client diagnosed nonreactive on painful stimuli.
with a concussion who is complaining
someone is waking him up every two (2) 20. The nurse is caring for a client diagnosed
hours. with an epidural hematoma. Which
2. The 36-year-old female client admitted with nursing interventions should the nurse
complaints of left-sided weakness who is implement? Select all that apply.
scheduled for a magnetic resonance 1. Maintain the head of the bed at 60 degrees
imaging (MRI) scan. of elevation.
3. The 45-year-old client admitted with blunt 2. Administer stool softeners daily.
trauma to the head after a motorcycle 3. Ensure the pulse oximeter reading is
accident who has a Glasgow Coma higher than 93%.
Scale (GCS) score of 6. 4. Perform deep nasal suction every two
4. The 62-year-old client diagnosed with (2) hours.
a cerebrovascular accident (CVA) who 5. Administer mild sedatives.
has expressive aphasia. 21. The client with a closed head injury has
16. The client has sustained a severe closed clear fluid draining from the nose. Which action
head injury and the neurosurgeon is should the nurse implement first?
determining if the client is “brain dead.” 1. Notify the health-care provider
Which data support that the client is brain immediately. 2. Prepare to administer an
dead? antihistamine. 3. Test the drainage for
1. When the client’s head is turned to the presence of glucose. 4. Place a 2 × 2 gauze
right, the eyes turn to the right. under the nose to collect drainage.
2. The electroencephalogram (EEG) 22. The nurse is enjoying a day at the lake and
has identifiable waveforms.
witnesses a water skier hit the boat ramp. The expect to find to support the diagnosis of
water skier is in the water not responding to neurogenic shock?
verbal stimuli. The nurse is the first health-care 1. No reflex activity below the waist.
2. Inability to move upper extremities.
3. Complaints of a pounding headache.
provider to respond to the accident. Which 4. Hypotension and bradycardia.
intervention should be implemented first? 1.
Assess the client’s level of consciousness. 2.
Organize onlookers to remove the client from 27. The rehabilitation nurse caring for the client
the lake. with an Lumbar SCI is developing the
3. Perform a head-to-toe assessment to nursing care plan. Which intervention should
determine injuries. the nurse implement?
4. Stabilize the client’s cervical spine. 1. Keep oxygen via nasal cannula on at
all times.
23. The client is diagnosed with a closed head 2. Administer low-dose subcutaneous
injury and is in a coma. The nurse writes anticoagulants.
the client problem as “high risk for 3. Perform active lower extremity
immobility complications.” Which ROM exercises.
intervention would be included in the plan 4. Refer to a speech therapist for
of care? ventilator assisted speech.
1. Position the client with the head of the
bed elevated at intervals. 28. The nurse in the neurointensive care unit is
2. Perform active range-of-motion (ROM) caring for a client with a new Cervical SCI who is
exercises every four (4) hours. breathing independently. Which nursing
3. Turn the client every shift and massage Chapter 2 Neurological Disorders 13
bony prominences.
4. Explain all procedures to the client 32. The client with a cervical fracture is being
before performing them. discharged in a halo device. Which
24. The 29-year-old client who was employed as a teaching instruction should the nurse
discuss with the client?
forklift operator sustains a traumatic brain
injury (TBI) secondary to a motor-vehicle 1. Discuss how to correctly remove the
insertion pins.
accident. The client is being discharged from
the rehabilitation unit after three (3) months 2. Instruct the client to report reddened or
and has cognitive deficits. Which goal would irritated skin areas.
be most realistic for this client? 3. Inform the client that the vest liner cannot
be changed.
1. The client will return to work within six (6)
months. 4. Encourage the client to remain in the
recliner as much as possible.
2. The client is able to focus and stay on task
for 10 minutes. 33. The intensive care nurse is caring for a client
3. The client will be able to dress self with a T1 SCI. When the nurse elevates the head
without assistance. of the bed 30 degrees, the client complains of
4. The client will regain bowel and interventions should be implemented? Select
bladder control. all that apply.
1. Monitor the pulse oximetry reading.
Spinal Cord Injury (SCI) 2. Provide pureed foods six (6) times a
day. 3. Encourage coughing and deep
breathing. 4. Assess for autonomic
25. The nurse arrives at the site of a one-car motor dysreflexia.
vehicle accident and stops to render aid. The 5. Administer intravenous corticosteroids.
driver of the car is unconscious. After
stabilizing the client’s cervical spine, which 29. The home health nurse is caring for a
action should the nurse take next? 28-year old client with a T10 SCI who says,
1. Carefully remove the driver from the “I can’t do anything. Why am I so
car. 2. Assess the client’s pupils for worthless?” Which statement by the nurse
reaction. would be the most therapeutic?
3. Assess the client’s airway. 1. “This must be very hard for you.
4. Attempt to wake the client up by shaking him. You’re feeling worthless?”
2. “You shouldn’t feel worthless—you are
26. In assessing a client with a Thoracic SCI, still alive.”
which clinical manifestation would the nurse 3. “Why do you feel worthless? You still have
the use of your arms.”
4. “If you attended a work rehab program 36. The 34-year-old male client with an SCI is
you wouldn’t feel worthless.”
sharing with the nurse that he is worried about
30. The client is diagnosed with an SCI and is finding employment after being discharged
scheduled for a magnetic resonance imaging from the rehabilitation unit. Which intervention
(MRI) scan. Which question would be most should the nurse implement?
appropriate for the nurse to ask prior to 1. Refer the client to the American Spinal
taking the client to the diagnostic test? Cord Injury Association (ASIA).
1. “Do you have trouble hearing?” 2. Refer the client to the state
2. “Are you allergic to any type of dairy rehabilitation commission.
products?” 3. Ask the social worker (SW) about applying
3. “Have you eaten anything in the last eight for disability.
(8) hours?” 4. Suggest that the client talk with his
4. “Are you uncomfortable in closed spaces?” significant other about this concern.
31. The client with a C6 SCI is admitted to the
emergency department complaining of a Seizures
severe pounding headache and has a BP of
180/110. Which intervention should the 37. The male client is sitting in the chair and his
emergency department nurse implement? entire body is rigid with his arms and legs
1. Keep the client flat in bed. contracting and relaxing. The client is not
2. Dim the lights in the room. aware of what is going on and is making
3. Assess for bladder distention. guttural sounds. Which action should the
4. Administer a narcotic analgesic. nurse implement first?
light-headedness and dizziness. The client’s 1. Push aside any furniture.
vital signs are T 99.2°F, P 98, R 24, and BP 2. Place the client on his side.
84/40. Which action should the nurse 3. Assess the client’s vital signs.
implement? 1. Notify the health-care provider 4. Ease the client to the floor.
as soon as possible (ASAP).
2. Calm the client down by talking 38. The occupational health nurse is concerned
therapeutically. about preventing occupation-related
3. Increase the IV rate by 50 mL/hour. acquired seizures. Which intervention
4. Lower the head of the bed immediately. should the nurse implement?
1. Ensure that helmets are worn in
34. The nurse is caring for clients on the appropriate areas.
rehabilitation unit. Which clients should the 2. Implement daily exercise programs for
nurse assess first after receiving the the staff.
change of-shift report? 3. Provide healthy foods in the cafeteria.
1. The client with a C6 SCI who is complaining 4. Encourage employees to wear safety glasses.
of dyspnea and has crackles in the lungs.
2. The client with an L4 SCI who is crying and 39. The client is scheduled for an electroenceph
very upset about being discharged home. 3. alogram (EEG) to help diagnose a seizure
The client with an L2 SCI who is disorder. Which preprocedure teaching
complaining of a headache and feeling should the nurse implement?
very hot. 1. Tell the client to take any routine
4. The client with a T4 SCI who is unable to antiseizure medication prior to the EEG.
move the lower extremities. 2. Tell the client not to eat anything for eight (8)
hours prior to the procedure.
35. Which nursing task would be most 3. Instruct the client to stay awake for 24
appropriate for the nurse to delegate to the hours prior to the EEG.
unlicensed assistive personnel? 4. Explain to the client that there will be
1. Teach Credé’s maneuver to the client some discomfort during the procedure.
needing to void.
2. Administer the tube feeding to the client 40. The nurse enters the room as the client is
who is quadriplegic. beginning to have a tonic-clonic seizure. What
3. Assist with bowel training by placing action should the nurse implement first?
the client on the bedside commode. 1. Note the first thing the client does in the
4. Observe the client demonstrating seizure.
self catheterization technique. 2. Assess the size of the client’s pupils.
Med-Surg Success
14
Chapter 2 Neurological Disorders 15 50. The client has been
3. Determine if the client is incontinent of urine diagnosed with a brain

or stool.
4. Provide the client with privacy during the epilepsy. Which discharge instructions should
seizure. be taught to the client? Select all that apply.
41. The client who just had a three (3)-minute 1. Keep a record of seizure activity.
seizure has no apparent injuries and is 2. Take tub baths only; do not take
oriented to name, place, and time but is very showers. 3. Avoid over-the-counter
lethargic and just wants to sleep. Which medications.
intervention should the nurse implement? 4. Have anticonvulsant medication serum
1. Perform a complete neurological levels checked regularly.
assessment. 2. Awaken the client every 30 5. Do not drive alone; have someone in the car.
minutes. 46. Which statement by the female client indicates
3. Turn the client to the side and allow the that the client understands factors that may
client to sleep. precipitate seizure activity?
4. Interview the client to find out what 1. “It is all right for me to drink coffee for
caused the seizure. breakfast.”
42. The unlicensed assistive personnel (UAP) is 2. “My menstrual cycle will not affect my
attempting to put an oral airway in the mouth seizure disorder.”
of a client having a tonic-clonic seizure. 3. “I am going to take a class in stress
Which action should the primary nurse take? management.”
1. Help the UAP to insert the oral airway in 4. “I should wear dark glasses when I am out
the mouth. in the sun.”
2. Tell the UAP to stop trying to insert anything 47. The nurse asks the male client with epilepsy if
in the mouth. he has auras with his seizures. The client says,
3. Take no action because the UAP is “I don’t know what you mean. What are
handling the situation. auras?” Which statement by the nurse would
4. Notify the charge nurse of the be the best response?
situation immediately. 1. “Some people have a warning that the
43. The client is prescribed phenytoin (Dilantin), an seizure is about to start.”
anticonvulsant, for a seizure disorder. 2. “Auras occur when you are physically
Which statement indicates the client and psychologically exhausted.”
understands the discharge teaching 3. “You’re concerned that you do not have
concerning this medication? auras before your seizures?”
1. “I will brush my teeth after every 4. “Auras usually cause you to be sleepy after
meal.” 2. “I will check my Dilantin level you have a seizure.”
daily.” 48. The nurse educator is presenting an in-service
3. “My urine will turn orange while on on seizures. Which disease process is the
Dilantin.” leading cause of seizures in the elderly?
4. “I won’t have any seizures while on 1. Alzheimer’s disease.
this medication.” 2. Parkinson’s disease (PD).
44. The client is admitted to the intensive care unit 3. Cerebral Vascular Accident (CVA,
(ICU) experiencing status epilepticus. Which stroke). 4. Brain atrophy due to aging.
collaborative intervention should the nurse
anticipate?
Brain Tumors
1. Assess the client’s neurological status
every hour.
49. The client is being admitted to rule out a
2. Monitor the client’s heart rhythm via
brain tumor. Which classic triad of symptoms
telemetry.
supports a diagnosis of brain tumor?
3. Administer an anticonvulsant medication
1. Nervousness, metastasis to the lungs,
by intravenous push.
and seizures.
4. Prepare to administer a
2. Headache, vomiting, and papilledema.
glucocorticosteroid orally.
3. Hypotension, tachycardia, and tachypnea.
4. Abrupt loss of motor function, diarrhea,
and changes in taste.
45. The client has been newly diagnosed with tumor. Which presenting signs and
symptoms help to localize the tumor the upper extremities.
position? 3. The client is aimlessly thrashing in the
1. Widening pulse pressure and bounding bed. 4. The client has become flaccid and
pulse. 2. Diplopia and decreased visual does not respond to stimuli.
acuity.
56. The client is diagnosed with a pituitary
3. Bradykinesia and scanning speech.
tumor and is scheduled for a transsphenoidal
4. Hemiparesis and personality changes.
hypophysectomy. Which preoperative
51. The male client diagnosed with a brain tumor instruction is important for the nurse to
is scheduled for a magnetic resonance teach? 1. There will be a large turban
imaging (MRI) scan in the morning. The dressing around the skull after surgery.
client tells the nurse that he is scared. Which 2. The client will not be able to eat for four (4)
response by the nurse indicates an or five (5) days postop.
appropriate therapeutic response? 3. The client should not blow the nose for
1. “MRIs are loud but there will not be any two (2) weeks after surgery.
invasive procedure done.” 4. The client will have to lie flat for 24 hours
2. “You’re scared. Tell me about what is following the surgery.
scaring you.”
57. The client has undergone a craniotomy
3. “This is the least thing to be scared
for a brain tumor. Which data indicate
about— there will be worse.”
a
4. “I can call the MRI tech to come and talk to
complication of this surgery?
you about the scan.”
1. The client complains of a headache at “3”
52. The client diagnosed with breast cancer to “4” on a 1-to-10 scale.
has developed metastasis to the brain. Which 2. The client has an intake of 1,000 mL and
prophylactic measure should the nurse an output of 3,500 mL.
implement? 3. The client complains of a raspy, sore
1. Institute aspiration precautions. throat. 4. The client experiences dizziness
2. Refer the client to Reach to when trying to get up too quickly.
Recovery. 3. Initiate seizure
58. The client diagnosed with a brain tumor has a
precautions.
diminished gag response and weakness on
4. Teach the client about mastectomy care.
the left side of the body. Which intervention
53. The significant other of a client diagnosed with should the nurse implement?
a brain tumor asks the nurse for help 1. Make the client NPO until seen by
identifying resources. Which would be the the health-care provider.
most appropriate referral for the nurse to 2. Position the client in low Fowler’s position for
make? 1. Social worker. all meals.
2. Chaplain. 3. Place the client on a mechanically
3. Health-care provider. ground diet.
4. Occupational therapist. 4. Teach the client to direct food and
fluid toward the right side.
54. The nurse has written a care plan for a client
diagnosed with a brain tumor. Which is an 59. The client is diagnosed with a metastatic
important goal regarding self-care deficit? 1. brain tumor, and radiation therapy is scheduled.
The client will maintain body weight within The client asks the nurse, “Why not try
two (2) pounds. chemotherapy first? It has helped my other
2. The client will execute an advance tumors.” The nurse’s response is based on
directive. 3. The client will be able to perform which scientific rationale?
three (3) ADLs with assistance. 1. Chemotherapy is only used as a last resort
4. The client will verbalize feeling of loss by in caring for clients with brain tumors.
the end of the shift. 2. The blood–brain barrier prevents
M -S S medications from reaching the brain.
16 ed urg uccess
55. The client diagnosed with a brain tumor was

3. Radiation therapy will have fewer side
admitted to the intensive care unit with
effects than chemotherapy.
decorticate posturing. Which indicates that
4. Metastatic tumors become resistant
the client’s condition is becoming worse?
to chemotherapy and it becomes
1. The client has purposeful movement
useless.
with painful stimuli.
2. The client has assumed adduction of 60. The client is being discharged following a
transsphenoidal hypophysectomy. Which septic meningitis?
discharge instructions should the nurse teach 1. Standard Precautions.
the client? Select all that apply. 2. Airborne Precautions.
1. Sleep with the head of the bed 3. Contact Precautions.
elevated. 2. Keep a humidifier in the 4. Droplet Precautions.
room.
66. The nurse is developing a plan of care for a
3. Use caution when performing oral
client diagnosed with aseptic meningitis
care. 4. Stay on a full liquid diet until
secondary to a brain tumor. Which nursing
seen by
goal would be most appropriate for the
the HCP.
client problem “altered cerebral tissue
5. Notify the HCP if developing a cold or fever.
perfusion”? 1. The client will be able to
complete activities of daily living.
Meningitis 2. The client will be protected from injury if
seizure activity occurs.
61. The wife of the client diagnosed with septic 3. The client will be afebrile for 48 hours prior
meningitis asks the nurse, “I am so scared. to discharge.
What is meningitis?” Which statement would 4. The client will have elastic tissue turgor
be the most appropriate response by the with ready recoil.
nurse? 1. “There is bleeding into his brain 67. The nurse is preparing a client diagnosed
causing irritation of the meninges.” with rule-out meningitis for a lumbar puncture.
2. “A virus has infected the brain and Which interventions should the nurse
meninges, causing inflammation.” implement? Select all that apply.
3. “It is a bacterial infection of the tissues 1. Obtain an informed consent from the
that cover the brain and spinal cord.” client or significant other.
4. “It is an inflammation of the brain Chapter 2 Neurological Disorders 17
parenchyma caused by a mosquito bite.”
62. The public health nurse is giving a lecture 70. Which statement best describes the
on potential outbreaks of infectious meningitis. scientific rationale for alternating a
Which population is most at risk for an nonnarcotic
outbreak? antipyretic and a nonsteroidal
1. Clients recently discharged from the anti-inflammatory drug (NSAID) every two (2)
hospital. 2. Residents of a college dormitory. hours to a female client diagnosed with
3. Individuals who visit a third world bacterial meningitis?
country. 4. Employees in a high-rise office 1. This regimen helps to decrease the
building. purulent exudate surrounding the
meninges.
63. The nurse is assessing the client diagnosed
2. These medications will decrease
with bacterial meningitis. Which clinical
intracranial pressure and brain
manifestations would support the diagnosis
metabolism.
of bacterial meningitis?
3. These medications will increase the
1. Positive Babinski’s sign and
client’s memory and orientation.
peripheral paresthesia.
4. This will help prevent a yeast infection
2. Negative Chvostek’s sign and facial
secondary to antibiotic therapy.
tingling. 3. Positive Kernig’s sign and nuchal
rigidity. 4. Negative Trousseau’s sign and 71. The client diagnosed with septic meningitis
nystagmus. is admitted to the medical floor at noon.
Which health-care provider’s order would
64. The nurse is assessing the client diagnosed
have the highest priority?
with meningococcal meningitis. Which
1. Administer an intravenous antibiotic.
assessment data would warrant notifying the
2. Obtain the client’s lunch tray.
HCP?
3. Provide a quiet, calm, and dark room.
1. Purpuric lesions on the face.
4. Weigh the client in hospital attire.
2. Complaints of light hurting the eyes.
3. Dull, aching, frontal headache. 72. The 29-year-old client is admitted to the
4. Not remembering the day of the week. medical floor diagnosed with meningitis.
Which assessment by the nurse has
priority?
65. Which type of precautions should the nurse 1. Assess lung sounds.
implement for the client diagnosed with 2. Assess the six cardinal fields of gaze.
2. Have the client empty the bladder prior to the
procedure. of care?
3. Place the client in a side-lying position 1. Consult the occupational therapist
with the back arched. for adaptive appliances for eating.
4. Instruct the client to breathe rapidly and 2. Request a low-fat, low-sodium diet from
deeply during the procedure. the dietary department.
5. Explain to the client what to expect 3. Provide three (3) meals per day that
during the procedure. include nuts and whole-grain breads.
4. Offer six (6) meals per day with a soft
68. The nurse is caring for a client diagnosed
consistency.
with meningitis. Which collaborative
intervention should be included in the plan of 76. The nurse and the unlicensed assistive
care? personnel (UAP) are caring for clients on a
1. Administer antibiotics. medical surgical unit. Which task should not
2. Obtain a sputum culture. be assigned to the UAP?
3. Monitor the pulse oximeter. 1. Feed the 69-year-old client diagnosed
4. Assess intake and output. with Parkinson’s disease who is having
difficulty swallowing.
69. The client is diagnosed with meningococcal
2. Turn and position the 89-year-old client
meningitis. Which preventive measure would
diagnosed with a pressure ulcer
the nurse expect the health-care provider to
secondary to Parkinson’s disease.
order for the significant others in the home?
3. Assist the 54-year-old client diagnosed
1. The Haemophilus influenzae vaccine.
with Parkinson’s disease with toilet-training
2. Antimicrobial chemoprophylaxis.
activities.
3. A 10-day dose pack of corticosteroids.
4. Obtain vital signs on a 72-year-old
4. A gamma globulin injection.
client diagnosed with pneumonia
3. Assess apical pulse.
secondary to
4. Assess level of consciousness.
Parkinson’s disease.
77. The charge nurse is making assignments.
Parkinson’s Disease Which client should be assigned to the new
graduate nurse?
73. The client diagnosed with Parkinson’s 1. The client diagnosed with aseptic
disease (PD) is being admitted with a fever meningitis who is complaining of a
and patchy infiltrates in the lung fields on the headache and the light bothering his
chest x-ray. Which clinical manifestations of eyes.
PD would explain these assessment data? 2. The client diagnosed with Parkinson’s
1. Masklike facies and shuffling gait. disease who fell during the night and is
2. Difficulty swallowing and immobility. complaining of difficulty walking.
3. Pill rolling of fingers and flat affect. 3. The client diagnosed with a cerebrovascular
4. Lack of arm swing and bradykinesia. accident whose vitals signs are P 60, R 14,
74. The client diagnosed with PD is being and BP 198/68.
discharged on carbidopa/levodopa 4. The client diagnosed with a brain tumor who
(Sinemet), an antiparkinsonian drug. Which has a new complaint of seeing spots before
statement is the scientific rationale for the eyes.
combining these medications? 78. The nurse is planning the care for a client
1. There will be fewer side effects with diagnosed with Parkinson’s disease. Which
this combination than with carbidopa would be a therapeutic goal of treatment
alone. for the disease process?
2. Dopamine D requires the presence of both 1. The client will experience periods of
of these medications to work. akinesia throughout the day.
3. Carbidopa makes more levodopa available 2. The client will take the prescribed
to the brain. medications correctly.
4. Carbidopa crosses the blood–brain barrier 3. The client will be able to enjoy a
to treat Parkinson’s disease. family outing with the spouse.
Med-Surg Success 4. The client will be able to carry out
18
activities of daily living.
75. The nurse caring for a client diagnosed

with Parkinson’s disease writes a problem
of “impaired nutrition.” Which nursing 79. The nurse researcher is working with clients
intervention would be included in the plan diagnosed with Parkinson’s disease. Which is an
example of an experimental therapy? scale.
1. Stereotactic pallidotomy/thalamotomy. 2. The 24-year-old client diagnosed with a T10
2. Dopamine receptor agonist medication. spinal cord injury who cannot move his toes.
3. Physical therapy for muscle 3. The 58-year-old client diagnosed with
strengthening. 4. Fetal tissue Parkinson’s disease who is crying and worried
transplantation. about her facial appearance.
4. The 62-year-old client diagnosed with a
80. The client diagnosed with Parkinson’s disease
cerebrovascular accident who has a
is being discharged. Which statement made
resolving left hemiparesis.
by the significant other indicates an
understanding of the discharge
instructions? Substance Abuse
1. “All of my spouse’s emotions will slow
down now just like his body movements.” 85. The friend of an 18-year-old male client
2. “My spouse may experience brings the client to the emergency department
hallucinations until the medication starts (ED). The client is unconscious and his
working.” breathing is slow and shallow. Which
3. “I will schedule appointments late in action should the nurse implement first?
the morning after his morning bath.” 1. Ask the friend what drugs the client has
4. “It is fine if we don’t follow a strict medication been taking.
schedule on weekends.” 2. Initiate an IV infusion at a keep-open rate.
81. The nurse is admitting a client with the 3. Call for a ventilator to be brought to
diagnosis of Parkinson’s disease. the ED. 4. Apply oxygen at 100% via nasal
Which cannula.
assessment data support this diagnosis? 86. The chief executive officer (CEO) of a large
1. Crackles in the upper lung fields and Chapter 2 Neurological Disorders 19
jugular vein distention.
2. Muscle weakness in the upper extremities
and ptosis. 88. A 20-year-old female client who tried lysergic
3. Exaggerated arm swinging and acid diethylamide (LSD) as a teen tells the
scanning speech. nurse that she has bad dreams that make her
4. Masklike facies and a shuffling gait. want to kill herself. Which is the explanation
for this occurrence?
82. Which is a common cognitive problem 1. These occurrences are referred to as
associated with Parkinson’s disease? “holdover reactions” to the drug.
1. Emotional lability. 2. These are flashbacks to a time when the
2. Depression. client had a “bad trip.”
3. Memory deficits. 3. The drug is still in the client’s body and
4. Paranoia. causing these reactions.
83. The nurse is conducting a support group for 4. The client is suicidal and should be on
clients diagnosed with Parkinson’s disease one-to-one precautions.
and their significant others. Which information 89. The nurse observes a coworker acting
regarding psychosocial needs should be erratically. The clients assigned to this coworker
included in the discussion? don’t
1. The client should discuss feelings about seem to get relief when pain medications
being placed on a ventilator. are administered. Which action should the
2. The client may have rapid mood swings nurse implement?
and become easily upset. 1. Try to help the coworker by confronting the
3. Pill-rolling tremors will become worse coworker with the nurse’s suspicions.
when the medication is wearing off. 2. Tell the coworker that the nurse will give
4. The client may automatically start to all narcotic medications from now on.
repeat what another person says. 3. Report the nurse’s suspicions to the
nurse’s supervisor or the facility’s peer
review.
84. The nurse is caring for clients on a medical 4. Do nothing until the nurse can prove
surgical floor. Which clients should be the coworker has been using drugs.
assessed first? 90. The client is diagnosed with Wernicke
1. The 65-year-old client diagnosed with Korsakoff syndrome as a result of
seizures who is complaining of a chronic
headache that is a “2” on a 1-to-10
manufacturing plant presents to the he is ill or he will lose his job.” Which would be
occupational health clinic with chronic rhinitis the nurse’s best response?
and requesting medication. On inspection, the 1. “I am sure that this must be hard for
nurse notices holes in the septum that you. Tell me about your concerns.”
separates the nasal passages. The nurse also 2. “You are afraid he will lose his source
notes dilated pupils and tachycardia. The of income.”
facility has a “No Drug” policy. Which 3. “Why would you call in for your
intervention should the nurse implement? husband? Can’t he do this?”
1. Prepare to complete a drug screen urine 4. “Are you aware that when you do this
test. 2. Discuss the client’s use of illegal you are enabling him?”
drugs. 3. Notify the client’s supervisor about 94. The nurse caring for a client who has been
the situation. abusing amphetamines writes a problem of
4. Give the client an antihistamine and “cardiovascular compromise.” Which nursing
say nothing. interventions should be implemented?
87. The nurse is working with several clients in a 1. Monitor the telemetry and vital signs
substance abuse clinic. Client A tells the every four (4) hours.
nurse that another client, Client B, has 2. Encourage the client to verbalize the
“started using again.” Which action should reason for using drugs.
the nurse implement? 3. Provide a quiet, calm atmosphere for
1. Tell Client A the nurse cannot discuss the client to rest.
Client B with him. 4. Place the client on bedrest and a low
2. Find out how Client A got this information. 3. sodium diet.
Inform the HCP that Client B is using again. 4. 95. The client diagnosed with substance
Get in touch with Client B and have the client abuse is being discharged from a drug and
come to the clinic. alcohol rehabilitation facility. Which
alcoholism. For which symptoms would information should the nurse teach the client?
the nurse assess? 1. “Do not go anyplace where you can
1. Insomnia and anxiety. be tempted to use again.”
2. Visual or auditory hallucinations. 2. “It is important that you attend a
3. Extreme tremors and agitation. 12-step meeting regularly.”
4. Ataxia and confabulation. 3. “Now that you are clean, your family will
91. The client diagnosed with delirium tremens be willing to see you again.”
when trying to quit drinking cold turkey is admitted 4. “You should explain to all your
to the medical unit. Which medications would the coworkers what has happened.”
nurse anticipate administering? 1. Thiamine 96. The nurse is working with clients and their
(vitamin B6) and librium, a families regarding substance abuse. Which
benzodiazepine. statement is the scientific rationale for teaching
2. Dilantin, an anticonvulsant, and Feosol, the children new coping mechanisms?
an iron preparation. 1. The child needs to realize that the
3. Methadone, a synthetic narcotic, and parent will be changing behaviors.
Depakote, a mood stabilizer. 2. The child will need to point out to the
4. Mannitol, an osmotic diuretic, and Ritalin, parent when the parent is not coping.
a stimulant. 3. Children tend to mimic behaviors of
92. The client is withdrawing from a heroin parents when faced with similar situations.
addiction. Which interventions should the 4. Children need to feel like they are a part
nurse implement? Select all that apply. of the parent’s recovery.
1. Initiate seizure precautions.
2. Check vital signs every eight (8) hours. 3.
Place the client in a quiet, calm atmosphere. Amyotrophic Lateral Sclerosis
4. Have a consent form signed for HIV
testing. 5. Provide the client with sterile
(ALS or Lou Gehrig’s Disease)
needles.
Med-Surg Success 97. Which diagnostic test is used to confirm the
20 diagnosis of Amyotropic Lateral Sclerosis
(ALS)?
93. The wife of the client diagnosed with chronic 1. Electromyogram (EMG).
alcoholism tells the nurse, “I have to call his 2. Muscle biopsy.
work just about every Monday to let them know 3. Serum creatine kinase (CK).
4. Pulmonary function test.
98. The client is diagnosed with ALS. Which client
problem would be most appropriate for this 108. The client diagnosed with ALS is prescribed
client? an antiglutamate, riluzole (Rilutek). Which
1. Disuse syndrome. instruction should the nurse discuss with
2. Altered body image. the client?
3. Fluid and electrolyte imbalance. 1. Take the medication with food.
4. Alteration in pain. 2. Do not eat green, leafy vegetables.
3. Use SPF 30 when going out in the sun.
99. The client is being evaluated to rule out ALS. 4. Report any febrile illness.
Which signs/symptoms would the nurse
note to confirm the diagnosis?
1. Muscle atrophy and flaccidity.
Encephalitis
2. Fatigue and malnutrition.
109. The nurse is admitting the client for rule out
3. Slurred speech and dysphagia.
4. Weakness and paralysis. encephalitis. Which interventions should the
nurse assess to support the diagnosis of
100. The client diagnosed with ALS asks the 1. Discuss the need to be placed in a
nurse, “I know this disease is going to kill long-term care facility.
me. What will happen to me in the end?” 2. Explain how to care for a sigmoid
Which statement by the nurse would be colostomy.
most appropriate? 3. Assist the client to prepare an
1. “You are afraid of how you will die?” advance directive.
2. “Most people with ALS die of respiratory 4. Teach the client how to use a
failure.” motorized wheelchair.
3. “Don’t talk like that. You have to stay
positive.” 105. The client is in the terminal stage of ALS.
4. “ALS is not a killer. You can live a long life.” Which intervention should the nurse
implement?
101. The client with ALS is admitted to the medical 1. Perform passive ROM every two (2)
unit with shortness of breath, dyspnea, and hours. 2. Maintain a negative nitrogen
respiratory complications. Which intervention balance.
should the nurse implement first? 3. Encourage a low-protein,
1. Elevate the head of the bed 30 soft-mechanical diet.
degrees. 2. Administer oxygen via 4. Turn the client and have him cough
nasal cannula. and deep breathe every shift.
3. Assess the client’s lung sounds.
4. Obtain a pulse oximeter reading. 106. The son of a client diagnosed with ALS asks
the nurse, “Is there any chance that I could
102. The client is to receive a 100-mL intravenous get this disease?” Which statement by the
antibiotic over 30 minutes via an intravenous nurse would be most appropriate?
pump. At what rate should the nurse set the 1. “It must be scary to think you might get
IV pump? ___________ this disease.”
2. “No, this disease is not genetic or
contagious.”
103. The nurse is caring for several clients on a 3. “ALS does have a genetic factor and runs
medical unit. Which client should the in families.”
nurse assess first? 4. “If you are exposed to the same virus,
1. The client with ALS who is refusing to turn you may get the disease.”
every two (2) hours.
107. The client with end-stage ALS requires a
2. The client with abdominal pain who is
gastrostomy tube feeding. Which finding
complaining of nausea.
would require the nurse to hold a bolus
3. The client with pneumonia who has a
tube feeding?
pulse oximeter reading of 90%.
1. A residual of 125 mL.
4. The client who is complaining about not
receiving any pain medication. 2. The abdomen is soft.
3. Three episodes of diarrhea.
104. The client is diagnosed with ALS. As the 4. The potassium level is 3.4 mEq/L.
disease progresses, which intervention encephalitis? Select all that apply.
should the nurse implement? 1. Determine if the client has recently
Chapter 2 Neurological Disorders 21 received any immunizations.
2. Ask the client if he or she has had a cold
in the last week.
3. Check to see if the client has active 4. Monitor vital signs every shift.
herpes simplex 1.
115. The public health department nurse is
4. Find out if the client has traveled to the
preparing a lecture on prevention of West Nile
Great Lakes region.
virus. Which information should the nurse include?
5. Assess for exposure to soil with fungal spores.
1. Change water daily in pet dishes and
110. The nurse is assessing the client admitted birdbaths.
with encephalitis. Which data require 2. Wear thick, dark clothing when outside
immediate nursing intervention? The client to avoid bites.
has bilateral facial palsies. 3. Apply insect repellent over face and
1. The client has a recurrent temperature arms only.
of 100.6°F. 4. Explain that mosquitoes are more
2. The client has a decreased complaint prevalent in the morning.
of headache.
116. Which problem is the highest priority for the
3. The client comments that the meal has
client diagnosed with West Nile virus?
no taste.
1. Alteration in body temperature.
111. The client admitted to the hospital to rule out 2. Altered tissue perfusion.
encephalitis is being prepared for a lumbar 3. Fluid volume excess.
puncture. Which instructions should the 4. Altered skin integrity.
nurse teach the client regarding care
117. The nurse is developing a plan of care for a
postprocedure? 1. Instruct that all invasive
client diagnosed with West Nile virus. Which
procedures require a written permission.
intervention should the nurse include in this
2. Explain that this allows analysis of a
plan? 1. Monitor the client’s respirations
sample of the cerebrospinal fluid.
frequently. 2. Refer to a dermatologist for
3. Tell the client to increase fluid intake to
treatment of maculopapular rash.
300 mL for the next 48 hours.
3. Treat hypothermia by using ice packs
4. Discuss that lying supine with the head
under the client’s arms.
flat will prevent all hematomas.
4. Teach the client to report any swollen
112. The nurse is caring for a client lymph glands.
diagnosed with encephalitis. Which is
an expected outcome for the client?
1. The client will regain as much
neurological function as possible. CONCEPTS
2. The client will have no short-term memory
loss.
3. The client will have improved renal 118. Which collaborative intervention should the
function. 4. The client will apply nurse implement when caring for the client
hydrocortisone cream daily. with West Nile virus?
Med-Surg Success 1. Complete neurovascular examinations
22
every eight (8) hours.
2. Maintain accurate intake and output at
113. Which intervention should the nurse the end of each shift.
implement when caring for the client diagnosed 3. Assess the client’s symptoms to
with encephalitis? Select all that apply. determine if there is improvement.
1. Turn the client every two (2) hours. 4. Administer intravenous fluids while
2. Encourage the client to increase assessing for overload.
fluids. 3. Keep the client in the supine
position. 119. The nurse is caring for the client diagnosed
4. Assess for deep vein thrombosis with West Nile virus. Which assessment
(DVT). 5. Assess for any alterations in data would require immediate intervention
elimination. from the nurse?
1. The vital signs are documented as T
114. The nurse is caring for the client with 100.2°F, P 80, R 18, and BP 136/78.
encephalitis. Which intervention 2. The client complains of generalized
should body aches and pains.
the nurse implement first if the client is 3. Positive results are reported from
experiencing a complication? the enzyme-linked immunosorbent
1. Examine pupil reactions to light. assay
2. Assess level of consciousness. (ELISA).
3. Observe for seizure activity. 4. The client becomes lethargic and is
difficult to arouse using verbal stimuli. bites and not between humans.
3. Transmission can occur from human to
120. Which rationale explains the transmission of
human in blood products and breast milk.
the West Nile virus?
4. Transmission occurs with direct contact
1. Transmission occurs through exchange of
from the maculopapular rash drainage.
body fluids when sneezing and coughing. 2.
Transmission occurs only through mosquito
In this section of the practice questions, the focus is on a particular concept. The concepts of intracranial
regulation, functional ability, and cognition along with the exemplars (example disease processes) are
directed toward the test taker recognizing the commonality that exists between one exemplar and another
under the concept. There are also interrelated concepts that may be presented in a question to help the
test taker under
stand how the concepts intertwine. The test taker must also recognize that in order to perform individualized
client care, all aspects of the client’s beliefs, developmental stage, and culture as well as the disease
process must be considered.
left arm and leg. The nurse assesses facial
drooping on the left side and slight slurring
121. The male client is admitted to the of speech. Which nursing interventions
emergency department following a should the nurse implement first?
motorcycle accident. 1. Schedule a STAT Magnetic
Chapter 2 Neurological Disorders 23 Resonance Imaging of the brain.
2. Call a Code STROKE.
3. Notify the health-care provider (HCP).
125. The concept of intracranial regulation is 4. Have the client swallow a glass of
identified for a client diagnosed with a water.
brain
The client was not wearing a helmet and 123. The nurse identifies the concept of
struck his head on the pavement. The nurse intracranial regulation disturbance in a client
identifies the concept as impaired diagnosed with Parkinson’s Disease. Which
intracranial regulation. priority intervention should the nurse
Which interventions should the implement? 1. Keep the bed low and call
emergency department nurse implement light in reach. 2. Provide a regular diet of
in the first five (5) minutes? Select all three (3) meals per day.
that apply. 3. Obtain an order for home health to see
1. Stabilize the client’s neck and spine. the client.
2. Contact the organ procurement 4. Perform the Braden scale skin assessment.
organization to speak with the family. 124. The client newly diagnosed with
3. Elevate the head of the bed to 70 Parkinson’s Disease (PD) asks the nurse,
degrees. 4. Perform a Glasgow Coma Scale “Why can’t I control these tremors?”
assessment. 5. Ensure the client has a Which is the nurse’s best response?
patent peripheral venous catheter in place. 1. “You can control the tremors when you
6. Check the client’s driver’s license to see if learn to concentrate and focus on the
he will accept blood. cause.” 2. “The tremors are caused by a lack
122. The client diagnosed with atrial fibrillation of the chemical dopamine in the brain;
complains of numbness and tingling of her medication may help.”
3. “You have too much acetylcholine in
your brain causing the tremors but they 1. Occupational Therapist (OT).
will get better with time.” 2. Physical therapist (PT).
4. “You are concerned about the tremors? 3. Registered dietitian (RD).
If you want to talk I would like to hear 4. Rehabilitation physician.
how you feel.” 5. Social Worker (SW).
tumor. Which intervention should the 6. Patient care tech (PCT).
nurse include in the client’s plan of care?
128. Which diagnostic evaluation tool would
1. Tell the client to remain on bedrest.
the nurse use to assess the client’s cognitive
2. Maintain the intravenous rate at 150
functioning? Select all that apply.
mL/hour. 3. Provide a soft, bland diet with
1. The Geriatric Depression Scale
three (3) snacks per day.
(GDS). 2. The St. Louis University
4. Place the client on seizure precautions.
Mental Status (SLUMS) scale.
126. The 80-year-old male client on an 3. The Mini-Mental Status Examination
Alzheimer’s unit is agitated and asking the (MMSE) scale.
nurse to get his father to come and see 4. The Manic Depression vs Elderly
him. Which is the nurse’s best response? Depression (MDED) scale.
1. Tell the client his father is dead and 5. The Functional Independence
cannot come to see him. Measurement Scale (FIMS).
2. Give the client the phone and have
129. Which priority goal would the nurse identify
him attempt to call his father.
for a client diagnosed with Parkinson’s
3. Ask the client to talk about his father
Disease (PD)?
with the nurse.
1. The client will be able to maintain mobility
4. Call the family so they can tell the
and swallow without aspiration.
client why his father cannot come to see
2. The client will verbalize feelings about
him.
the diagnosis of Parkinson’s Disease.
127. The 28-year-old client is on the rehabilitation 3. The client will understand the purpose
unit post spinal cord injury at level T10. of medications administered for PD.
Which collaborative team members should 4. The client will have a home health
participate with the nurse at the case agency for monitoring at home.
conference? Select all that apply.
Med-Surg Success
24
130. The intensive care unit nurse is admitting a client with a traumatic brain injury. Which
health-care provider medication order would the nurse question?
Client Name: ABCD Client Number Allergies Diagnosi
1234567 NKA s
Angina
Date Medication 0701–1500 1501–2300

2301–0700
Today Dexamethasone 4 mg IVP 2400

every 6 hours 0600
1200
1800
Today 0.9% saline continuous 1600

infusion at 25 mL/hour
Today Nicotine patch 15 mg per day 0900

Apply at 0800; discontinue at 2100 2100
Today Morphine sulfate 4 mg IVP

every 3 hours prn
Signature of Nurse: Day Nurse RN/DN

1. Dexamethasone.
2. 0.9% NS.
3. Nicotine patch.
4. Morphine sulfate.
131. The charge nurse on a medical-surgical unit is reviewing client diagnostic reports. Which
report warrants immediate intervention?
1. Client A—Male 64.
Complete Blood
Count Client Value Normal Values
RBC (106) 5 Male: 4.7–6.1 (106)
Female: 4.2–5.4 (106)
Hemoglobin 13.4 Male: 13.5–17.5 g/dL
Female: 11.5–15.5 g/dL
Hematocrit 39.5 Male: 40%–52%
Female: 36%–48%
Platelet (103) 110 150–400 (103)/mm3
WBC (103) 9.2 4.5–11 (103)/mm3
2. Client B—Female 34.
Chemistry Client Value Normal Values

Sodium 142 135–145 mEq/L
Potassium 3.5 3.5–5.5 mEq/L
Chloride 98 97–107 mEq/L
CO2 26 22–30 mEq/L
3. Client C—Male 45.
Laboratory Test Client Value Normal Values

Glucose 94 70–110 mg/dL
Hemoglobin A 1C 13.2 4%–6%
4. Client D—Female 56.
Patient MRI Findings

exerting pressure on the cerebellum and
MRI of brain with and without
contrast occluding the anterior portion of the L lateral
MRI brain—Finding of 5 3 4 cm mass located ventricle.
in the L frontal lobe; a shift in the brain tissue
hour ago was scored
at 10. Which datum indicates the client
132. The nurse is caring for a client with is improving?
increased intracranial pressure (ICP) who has 1. The current GSC rating is 3.
secretions pooled in the throat. Which 2. The current GSC rating is 9.
intervention should the nurse implement first? 3. The current GSC rating is 10.
1. Set the ventilator to hyperventilate 4. The current GSC rating is 12.
the client in preparation for suctioning. Chapter 2 Neurological Disorders 25
2. Assess the client’s lung sounds and check
for peripheral cyanosis. 134. The client diagnosed with a brain abscess
3. Turn the client to the side to allow is experiencing a tonic-clonic seizure.
the secretions to drain from the mouth. Which
4. Suction the client using the in-line interventions should the nurse implement?
suction, wait 30 seconds, and repeat. Rank in order of performance.
1. Assess the client’s mouth.
133. The nurse is performing a Glascow
2. Loosen restrictive clothing.
Coma Scale (GCS) assessment on a
3. Administer phenytoin IVP.
client with a problem with intracranial
4. Turn the client to the side.
regulation. The client’s GCS one (1)
5. Protect the client’s head from injury.
bed up 30 degrees.
135. Which intervention should the nurse
2. Cluster activities of care.
implement to decrease increased
3. Suction the client every three (3) hours.
intracranial pressure (ICP) for a client on a
4. Administer soapsuds enemas until clear.
ventilator?
5. Place the client in Trendelenburg position.
Select all that apply.
1. Position the client with the head of the
PRACTICE QUESTIONS ANSWERS
AND RATIONALES
task, is a com munication loss, not a motor
loss.
This section provides the answers for the questions 2. The most common motor dysfunction of
given in the previous section. The correct answers a CVA is paralysis of one side of the body,
and why they are correct are provided in blue hemiplegia; in this case with a left-sided
boldface. The reason why each of the other answer CVA, the paralysis would affect the right
options is not the correct or the best answer is also side. Ataxia is an impaired ability to
given. coordi nate movement.
3. Homonymous hemianopsia (loss of half of
the visual field of each eye) and diplopia
Cerebrovascular Accident (Stroke) (double vision) are visual field deficits that a
client with a CVA may experience, but they
1. 1. The drug rt-PA may be administered, but a are not motor losses.
cerebrovascular accident (CVA) must be veri 4. Personality disorders occur in clients with
fied by diagnostic tests prior to administering a right-sided CVA and are cognitive
it. The drug rt-PA helps dissolve a blood clot, deficits; hostility is an emotional deficit.
and it may be administered if an ischemic TEST TAKING HINT: Be sure to always notice
CVA is verified; rt-PA is not given if the client adjectives describing something. In this
is ex periencing a hemorrhagic stroke. case, “left-sided” describes the type of
2. Teaching is important to help prevent CVA. Also be sure to identify exactly what
another CVA, but it is not the priority the question is asking—in this case, about
intervention on admission to the emergency “motor loss,” which will help rule out
department. Slurred speech indicates many of the possible answer options.
problems that may interfere with teaching.
Content – Medical: Integrated Nursing
3. A CT scan will determine if the client is Process – Implementation: Client Needs –
having a stroke or has a brain tumor or Safe Effective Care Environment, Management
another neurological disorder. If a CVA is of Care: Cognitive Level – Application:
diagnosed, the CT scan can determine if Concept – Neurologic Regulation.
it is a hemorrhagic or an ischemic
accident and guide treatment. 3. 1. African Americans have twice the rate of
4. The client may be referred for speech CVAs as Caucasians and men have a
deficits and/or swallowing difficulty, but higher incidence than women; African
referrals are not the priority in the emergency Americans also suffer more extensive
department. damage from a CVA than do people of
other cultural groups.
TEST TAKING HINT: When “priority” is used in
2. Females are less likely to have a CVA than
the stem, all answer options may be ap
males, but advanced age does increase the
propriate for the client situation, but only
risk for CVA. The Asian population has a
one option is the priority. The client must
lower risk, possibly as a result of their
have a documented diagnosis before
relatively high intake of omega-3 fatty acids,
treatment is started.
antioxidants found in fish.
Content – Medical: Integrated Nursing Process – 3. Caucasians have a lower risk of CVA than
Implementation: Client Needs – Safe Effective Care
do African Americans, Hispanics, and
Envi ronment, Management of Care: Cognitive
Native Pa cific Islanders.
Level – Synthesis: Concept – Neurologic
Regulation.
4. Pregnancy is a minimal risk for having a CVA.
TEST TAKING HINT: Note the age of the cli ent
2. 1. A left-sided cerebrovascular accident (CVA) if this information is given, but take this
will result in right-sided motor deficits; hemi information in context with the additional in
paresis is weakness of one-half of the body, formation provided in the answer options.
not just the upper extremity. Apraxia, the The 84-year-old may appear to be the best
inability to perform a previously learned answer but not if the client is a female and
Asian, which rules out this option for the Assessment: Client Needs – Health Promotion and
client most at risk. Mainte nance: Cognitive Level – Knowledge:
Concept – Neurologic Regulation.
Content – Medical: Integrated Nursing Process –
26
require a nurse to intervene to correct a
subordinate. Remember to read every
4. 1. Placing a small pillow under the shoulder possible answer option before deciding
will prevent the shoulder from adduct on a correct one.
ing toward the chest and developing a Content – Medical: Integrated Nursing Process –
contracture. Implementation: Client Needs – Safe Effective Care
2. The client should be repositioned at least Envi ronment, Management of Care: Cognitive
every two (2) hours to prevent Level – Synthesis: Concept – Neurologic
Regulation.
contractures, pneumonia, skin breakdown,
and other com plications of immobility. 7. 1. The nurse would anticipate an oral antico
3. The client should not ignore the para agulant, warfarin (Coumadin), to be pre
lyzed side, and the nurse must scribed to help prevent thrombi formation in
encourage the client to move it as the atria secondary to atrial fibrillation.
much as possible; a written schedule Management of Care: Cognitive Level – Synthesis:
may assist the client in exercising. Concept – Neurologic Regulation.
4. These exercises are recommended, but they
5. 1. Agnosia is the failure to recognize familiar
must be done at least five (5) times a day
objects; therefore, observing the client for pos
for 10 minutes to help strengthen the
sible aspiration is not appropriate.
muscles for walking.
2. A semi-Fowler’s position is appropriate for
5. The fingers are positioned so that they are
sleeping, but agnosia is the failure to
barely flexed to help prevent contracture of the
recognize familiar objects; therefore, this
hand. TEST TAKING HINT: Be sure to look at
intervention is inappropriate.
the in tervals of time for any intervention;
3. Placing suction at the bedside will help if the
note that “every shift” and “three (3) times
client has dysphagia (difficulty swallowing),
a day” are not appropriate time intervals for
not agnosia, which is failure to recognize
this client. Because this is a “select all that
familiar objects.
apply” ques tion, the test taker must read
4. A collaborative intervention is an
each answer option and decide if it is
inter vention in which another
correct; one will not eliminate another.
health-care
Content – Medical: Integrated Nursing Process – discipline—in this case, occupational
Planning: Client Needs – Safe Effective Care therapy—is used in the care of the client.
Environment,
TEST TAKING HINT: Be sure to look at what
Chapter 2 Neurological Disorders 27
the question is asking and see if the answer
can be determined even if some terms are
6. 1. Placing a gait belt prior to ambulating is an not understood. In this case, note that the
appropriate action for safety and would ques tion refers to “collaborative
not require the nurse to intervene.
intervention.” Only option “4” refers to
2. Placing the client in a supine position with
collaboration with another discipline.
the head turned to the side is not a problem
posi tion, so the nurse does not need to Content – Medical: Integrated Nursing Process –
intervene. Planning: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
3. This action is inappropriate and would
require intervention by the nurse because
Regulation.
pulling on a flaccid shoulder joint could
cause shoulder dislocation; the client The thrombi can become embolic and
should be pulled up by placing the arm may cause a TIA or CVA (stroke).
underneath the back or using a lift 2. Beta blockers slow the heart rate and
sheet. 4. The client should be encouraged decrease blood pressure but would not be
and praised for attempting to perform any an anticipated medication to help prevent a
activities inde pendently, such as combing hair TIA secondary to atrial fibrillation.
or brushing teeth. 3. An anti-hyperuricemic medication is admin
istered for a client experiencing gout and
TEST TAKING HINT: This type of question
de creases the formation of tophi.
has three answer options that do not
4. A thrombolytic medication is administered to depression, and the inability to
dissolve a clot, and it may be ordered during verbalize needs, which, in turn, causes
the initial presentation for a client with a the client to have a lack of control and
CVA but not on discharge. feel powerless.
TEST TAKING HINT: In the stem of this 3. A disturbance in thought processes is a
question, there are two disease processes cogni tive problem; with expressive
mentioned—atrial fibrillation and TIA. The aphasia the cli ent’s thought processes are
reader must determine how one process intact.
affects the other before answering the ques 4. Sexual dysfunction can have a psychosocial
tion. In this question, the test taker must or physical component, but it is not related
know atrial fibrillation predisposes the client to expressive aphasia.
to the formation of thrombi, and, therefore, TEST TAKING HINT: The test taker should
the nurse should anticipate the health-care always make sure that the choice selected
provider ordering a medication to prevent as the correct answer matches what the
clot formation, an anticoagulant. ques tion is asking. The stem has the
Med-Surg Success adjective “psychosocial,” so the correct
28
answer must address psychosocial
needs.
Content – Medical: Integrated Nursing Process Content – Medical: Integrated Nursing Process –
– Planning: Client Needs – Physiological Diagnosis: Client Needs – Psychosocial Integrity:
Integrity, Pharma cological and Parenteral Cognitive Level – Analysis: Concept –
Therapies: Cognitive Level – Synthesis: Neurologic Regulation.
8. 1. The rubber mat will stabilize the plate and

prevent it from slipping away from the 10. 1. This glucose level is elevated and could
client learning to feed himself, but this pre dispose the client to ischemic neurological
does not ad dress generalized weakness. changes due to blood viscosity, but it is not a
2. A long-handled bath sponge will assist risk factor for a hemorrhagic stroke.
the client when showering hard-to-reach 2. A carotid bruit predisposes the client to an
areas, but it is not a home modification embolic or ischemic stroke but not to a
nor will it help with generalized hem orrhagic stroke.
weakness. 3. Uncontrolled hypertension is a risk
3. Clothes with Velcro closures will make factor for hemorrhagic stroke, which
dress ing easier, but they do not constitute is a ruptured blood vessel inside the
a home modification and do not address cranium.
gen eralized weakness. 4. Cancer is not a precursor to developing
4. Raising the toilet seat is modifying the a hemorrhagic stroke.
home and addresses the client’s
TEST TAKING HINT: Both options “1” and
weakness in being able to sit down and
get up with out straining muscles or “2” are risk factors for an ischemic or
requiring lifting assistance from the embolic type of stroke. Knowing this, the
wife. test taker can rule out these options as
incorrect. Content – Medical: Integrated
TEST TAKING HINT: The test taker must read
Nursing Process – Assessment: Client Needs –
the stem of the question carefully and note
Physiological Integrity, Reduction of Risk
that the intervention must be one in which
Potential: Cognitive Level – Analysis: Concept –
the home is modified in some way. This Perfusion.
would eliminate three of the options,
leaving the correct answer. 11. 1. The nurse should not administer any medi
Content – Medical: Integrated Nursing cation to a client without first assessing
Process – Planning: Client Needs – the cause of the client’s complaint or
Physiological Integrity, problem.
Physiological Adaptation: Cognitive Level – 2. An MRI scan may be needed, but the
Synthesis: Concept – Neurologic Regulation. nurse must determine the client’s
neurological status prior to diagnostic
9. 1. Potential for injury is a physiological, not a tests.
psychosocial, problem.
3. Starting an IV infusion is appropriate, but it
2. Expressive aphasia means that the client is not the action the nurse should implement
cannot communicate thoughts but under
when assessing pain, and 100 mL/hr might be
stands what is being communicated;
too high a rate for an 85-year-old client.
this leads to frustration, anger,
4. The nurse must complete a neurological
assessment to help determine the what these signs and medical terms mean.
cause of the headache before taking 3. Hypervigilance, increased alertness and
any further action. super-awareness of the surroundings, is a
TEST TAKING HINT: The test taker should al sign of amphetamine or cocaine abuse, but
ways apply the nursing process when it would not be expected in a client with a
answer ing questions. If the test taker head injury.
narrows down the choices to two possible 4. The client can eat food as tolerated, but
answer options, always select the feeding the client every three (3) to four (4)
assessment option as the first hours does not affect the development of
intervention. postconcussion syndrome, the signs of
which are what should be taught to the
Process – Implementation: Client Needs – significant other.
Safe Effective Care Environment, Management TEST TAKING HINT: Remember to pay close
of Care: Cognitive Level – Synthesis: attention to answer options that have
Concept – Neurologic Regulation. times (e.g., “every two [2] hours,” “every
three [3] to four [4] hours”). Also
12. 1. The client is at risk for increased intra
consider the likeli
cranial pressure whenever performing the
Valsalva maneuver, which will occur when hood of the options listed. Would a nurse
teach the significant other terms such as
straining during defecation. Therefore, stool
increased intracranial pressure or
softeners would be appropriate.
hypervigi lance? Probably not, so options
2. Coughing increases intracranial pressure
“2” and “3” should be eliminated.
and is discouraged for any client who has
had a craniotomy. The client is Content – Medical: Integrated Nursing Process
encouraged to turn and breathe deeply – Planning: Client Needs – Physiological Integrity,
Physiologi cal Adaptation: Cognitive Level –
but not to cough.
Synthesis:
3. Monitoring the neurological status is
appro priate for this client, but it should be
14. 1. The scalp is a very vascular area and a
done much more frequently than every shift.
mod erate amount of bleeding would be expected.
4. Dopamine is used to increase blood
2. These signs/symptoms—weak pulse, shal
pressure or to maintain renal perfusion,
low respirations, cool pale skin—indicate
and a BP of 160/90 is too high for this
increased intracranial pressure from cere bral
client.
edema secondary to the fall, and they require
TEST TAKING HINT: The test taker should immediate attention.
always notice if an answer option has a 3. This is a normal pupillary response and
time frame—every shift, every four (4) would not warrant intervention.
hours, or daily. Whether or not the time 4. A headache that resolves with medication
frame is cor rect may lead the test taker is not an emergency situation, and the
to the correct answer. nurse
Content – Medical: Integrated Nursing would expect the client to have a headache
Process – Implementation: Client Needs – after the fall; a headache not relieved with
Safe Effective Care Environment, Management Tylenol would warrant further
of Care: Cognitive Level – Implementation:
investigation. TEST TAKING HINT: The test
taker is looking for an answer option that
is not normal for the client’s situation. Of
Head Injury the options listed, three would be
expected and would not war rant a trip to
13. 1. Awakening the client every two (2) hours the emergency department. Content –
allows the identification of head ache, Medical: Integrated Nursing Process –
dizziness, lethargy, irritability, and Assessment: Client Needs – Safe Effective Care
anxiety—all signs of post-concussion Environment, Management of Care: Cognitive
syndrome—that would warrant the Level – Analysis: Concept – Neurologic
signifi cant other’s taking the client Regulation.
back to the emergency department. 15. 1. A client with a head injury must be
2. The nurse should monitor for signs of in awakened every two (2) hours to
creased intracranial pressure (ICP), but a lay determine alertness;
man, the significant other, would not know decreasing level of consciousness is the first
indicator of increased intracranial pressure. over assessment.
2. A diagnostic test, MRI, would be an 2. Monitoring vital signs is important, but main
expected test for a client with left-sided taining an adequate airway is higher priority. 3.
weakness and would not require immediate Initiating an IV access is an intervention the
attention. nurse can implement, but it is not the priority
3. The Glasgow Coma Scale is used to de intervention.
termine a client’s response to stimuli (eye 4. The most important nursing goal in
opening response, best verbal response, the management of a client with a head
and best motor response) secondary injury is to establish and maintain an
to a neurological problem; scores adequate airway.
range from 3 (deep coma) to 15 (intact TEST TAKING HINT: If the question asks for
neurological a priority intervention, it means that all of
function). A client with a score of 6 the options would be appropriate for the
should be assessed first by the nurse. client but only one intervention is priority.
4. The nurse would expect a client diagnosed Always
with a CVA (stroke) to have some sequelae of apply Maslow’s hierarchy of needs—an
the problem, including the inability to speak. ad equate airway is first.
TEST TAKING HINT: This is a prioritiz Content – Medical: Integrated Nursing
ing question that asks the test taker to Process – Implementation: Client Needs –
determine which client has priority when Safe Effective Care Environment, Management
assessing all four clients. The nurse of Care: Cognitive Level – Synthesis:
should assess the client who has Concept – Neurologic Regulation.
abnormal data for the disease process. 18. 1. The client in rehabilitation is at risk for the
Content – Medical: Integrated Nursing Process – development of deep vein thrombosis; there fore,
Assessment: Client Needs – Safe Effective Care this is an appropriate medication.
Environ ment, Management of Care: Cognitive 2. An osmotic diuretic would be ordered in
the acute phase to help decrease
Regulation.
cerebral edema, but this medication
M -S S
30 ed urg uccess would not be expected to be ordered
in a rehabilita tion unit.
16. 1. This is an oculocephalic test (doll’s eye
move ment) that determines brain activity. If the
eyes move with the head, it means the brain stem 3. Clients with head injuries are at risk for
is intact and there is no brain death. post-traumatic seizures; thus an oral
2. Waveforms on the EEG indicate that there anticon vulsant would be administered for
is brain activity. seizure prophylaxis.
3. The cold caloric test, also called the ocu 4. The client is at risk for a stress ulcer; there
lovestibular test, is a test used to deter fore, an oral proton pump inhibitor would
mine if the brain is intact or dead. No be an appropriate medication.
eye activity indicates brain death. If the TEST TAKING HINT: The client is in the reha
cli ent’s eyes moved, that would bilitation unit and therefore must be
indicate that the brainstem is intact. stable. The use of any intravenous
4. Decorticate posturing after painful stimuli medication should be questioned under
are applied indicates that the brainstem is those circum stances, even if the test
intact; flaccid paralysis is the worse taker is not sure why the medication may
neurological response when assessing a be considered.
client with a head injury. Content – Medical: Integrated Nursing
TEST TAKING HINT: The test taker needs to Process – Implementation: Client Needs –
know what the results of the cold caloric Safe Effective Care Environment, Management
test signify—in this case, no eye activity of Care: Cognitive Level – Application:
indicates brain death. Concept – Neurologic Regulation.
Content – Medical: Integrated Nursing 19. 1. Purposeless movement indicates that the
Process – Assessment: Client Needs – Safe cli ent’s cerebral edema is decreasing.
Effective Care Environ ment, Management of The best motor response is purposeful
Care: Cognitive Level – Analysis: Concept –
movement, but purposeless movement
Neurologic Regulation.
indicates an improve ment over
17. 1. Assessing the neurological status is impor decorticate movement, which, in turn, is
tant, but ensuring an airway is a priority an improvement over decerebrate
movement or flaccidity. Effective Care Environ ment, Management of
2. Flaccidity would indicate a worsening of Care: Cognitive Level – Analysis: Concept –
the client’s condition. Trauma.
3. Decerebrate posturing would indicate a
20. 1. The head of the bed should be elevated
wors ening of the client’s condition.
no more than 30 degrees to help
4. The eyes respond to light, not painful
decrease ce rebral edema by gravity.
stimuli, but a 6-mm nonreactive pupil
2. Stool softeners are initiated to prevent
indicates severe neurological deficit.
the Valsalva maneuver, which increases
TEST TAKING HINT: The test taker must intra cranial pressure.
have strong assessment skills and know 3. Oxygen saturation higher than 93%
what spe cific signs/symptoms signify for ensures oxygenation of the brain
each of the body systems—in this case, tissues; decreasing oxygen levels
the significance of different stages of increase cerebral edema.
posturing/ 4. Noxious stimuli, such as suctioning,
movement in assessing neurological increase intracranial pressure and should be
status. Content – Medical: Integrated Nursing avoided.
Process – Assessment: Client Needs – Safe
Client Needs – Safe Effective Care
Level – Application: Concept – Neurologic
5. Mild sedatives will reduce the client’s
Regulation.
agitation; strong narcotics would not
be administered because they 21. 1. Prior to notifying the HCP, the nurse
decrease the client’s level of should always make sure that all the
consciousness. needed assess ment information is
TEST TAKING HINT: In “select all that apply” available to discuss with the HCP.
questions, the test taker should look at 2. With head injuries, any clear drainage
each answer option as a separate entity. may indicate a cerebrospinal fluid leak; the
In option nurse should not assume the drainage is
“1” the test taker should attempt to get a secondary to allergies and administer an
mental picture of the client’s position in antihistamine.
the bed. A 60-degree angle is almost 3. The presence of glucose in drainage
upright in the bed. Would any client from the nose or ears indicates
diagnosed with a head injury be placed cerebrospinal fluid, and the HCP should
this high? The client would be at risk for be notified im mediately once this is
slumping over because of the inability to determined.
control the body position. 4. This would be appropriate, but it is not
Chapter 2 Neurological Disorders 31 the first intervention. The nurse must
determine where the fluid is coming
from.
3. Assessing the client for further injury is ap
propriate, but the first intervention is to TEST TAKING HINT: The question is asking
sta which intervention should be
bilize the spine because the impact was strong implemented first, and the nurse should
enough to render the client unconsciousness. always assess the situation before
4. The nurse should always assume that a calling the HCP or taking an action.
client with traumatic head injury may have Content – Medical: Integrated Nursing
sustained spinal cord injury. Moving the Process – Implementation: Client Needs –
client could further injure the spinal Safe Effective Care Environment,
Management of Care: Cognitive Level –
cord and cause paralysis; therefore,
Synthesis: Concept – Neurologic Regulation.
the nurse
should stabilize the cervical spinal cord 22. 1. Assessment is important, but with clients
as best as possible prior to removing with head injury the nurse must assume
the client from the water. spinal cord injury until it is ruled out
TEST TAKING HINT: When two possible an with x-ray; therefore, stabilizing the
swer options contain the same directive spinal cord is the priority.
Nasal suctioning, option “4,” which 2. Removing the client from the water is an
increases intracranial pressure, should ap propriate intervention, but the nurse
also be avoided. Content – Medical: must assume spinal cord injury until it is
Integrated Nursing Process – Implementation: ruled out with x-ray; therefore,
stabilizing the spinal cord is the priority.
word—in this case, “assess”—the test bladder control does not address
taker can either rule out these two as cognitive deficits.
incorrect or prioritize between the two TEST TAKING HINT: The test taker must
assessment responses. note adjectives closely. The question is
Content – Medical: Integrated Nursing asking about “cognitive” deficits;
Process – Implementation: Client Needs – therefore, the cor rect answer must
Safe Effective Care Environment, address cognition.
Process – Diagnosis: Client Needs –
23. 1. The head of the client’s bed should be el Physiological Integrity, Physi ological
evated to help the lungs expand and prevent Adaptation: Cognitive Level – Analysis:
stasis of secretions that could lead to pneu Concept – Neurologic Regulation.
monia, a complication of immobility.
2. Active range-of-motion exercises require
that the client participate in the activity. This
Spinal Cord Injury
is not possible because the client is in a
25. 1. The nurse should stabilize the client’s
coma.
neck prior to removal from the car.
3. The client is at risk for pressure ulcers
and should be turned more frequently 2. The nurse must stabilize the client’s
neck before doing any further
than every shift, and research now
assessment. Most nurses don’t carry
shows that massaging bony
penlights, and the cli
prominences can increase the risk for
tissue breakdown. ent’s pupil reaction can be determined
after stabilization.
4. The nurse should always talk to the client,
even if he or she is in a coma, but this will 3. The nurse must maintain a patent
airway. Airway is the first step in
not address the problem of immobility.
resuscitation. 4. Shaking the patient could
TEST TAKING HINT: Whenever a client cause further dam age, possibly leading to
prob lem is written, interventions must paralysis.
address the specific problem, not the
TEST TAKING HINT: Remember that, in a
disease. Posi
tioning the client addresses the question asking about which action
possibility of immobility complications, should be taken first, all of the answers
whereas talking to a comatose client are interven tions, but only one should
addresses communication deficit and be implemented first. There are very few
psychosocial needs, not immobil ity “always” situations in the health-care
issues. profession, but in this situation, unless
the client’s car is on fire or under water,
stabilizing the client’s neck is always
Process – Diagnosis: Client Needs – Safe
the priority, followed by airway. Content –
Effective Care Environ ment, Management of
Medical: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective
Care Environment, Management of Care:
24. 1. The client is at risk for seizures and does Cognitive Level – Synthesis: Concept –
not process information appropriately. Allowing Neurologic Regulation.
him to return to his occupation as a forklift 26. 1. Neurogenic shock associated with
operator is a safety risk for him and other em SCI represents a sudden
ployees. Vocational training may be required. depression of re
Med-Surg Success
32 flex activity below the level of the
injury. T12 is just above the waist;
therefore, no reflex activity below
2. “Cognitive” pertains to mental
the waist would be expected.
processes of comprehension,
2. Assessment of the movement of the
judgment, memory, and reasoning.
upper extremities would be more
Therefore, an appropriate goal would
appropriate with a higher level injury; an
be for the client to stay on task for 10
injury in the cervical area might cause
minutes.
an inability to move the up per
3. The client’s ability to dress self extremities.
addresses self care problems, not a
cognitive problem.
4. The client’s ability to regain bowel and
tial complication of immobility, which
can occur because the client cannot
move the lower extremities as a result of
3. Complaints of a pounding headache are
the L1 SCI. Low-dose anticoagulation
not typical of a T12 spinal injury.
therapy (Lovenox) helps prevent blood
4. Hypotension (low blood pressure) and
from co agulating, thereby preventing
tachy cardia (rapid heart rate) are signs of
DVTs.
hypovolemic or septic shock, but these
do not occur in spinal shock. 3. The client is unable to move the
lower extremities. The nurse should
TEST TAKING HINT: If the test taker does do passive ROM exercises.
not have any idea what the answer is, an 4. A client with a spinal injury at C4 or
attempt to relate the anatomical position above would be dependent on a
of keywords in the question stem to ventilator for
words in the answer options is breathing, but a client with an L1 SCI
appropriate. In this case, T12, mentioned would not.
in the stem, is around the waist, so
TEST TAKING HINT: The test taker should
answer options involving the anatomy
notice any adjectives such as
above that level (e.g., the upper
“rehabilitation,” which should clue the
extremities) can be eliminated.
test taker into rul ing out oxygen, which
Content – Medical: Integrated Nursing is for the acute phase. The test taker
Process – Assessment: Client Needs –
should also be very selective if choosing
Safe Effective Care
an answer with a definitive word such as
Environment, Management of Care:
Cognitive Level – Analysis: Concept – “all” (option “1”).
Mobility. Content – Medical: Integrated Nursing
Process – Implementation: Client Needs –
27. 1. Oxygen is administered initially to Safe Effective Care Environment,
maintain a high arterial partial pressure of Management of Care: Cognitive Level –
oxygen Application: Concept – Mobility.
) because hypoxemia can worsen
(PaO2 28. 1. Oxygen is administered initially to
a neu prevent hypoxemia, which can worsen
rological deficit to the spinal cord the spinal cord injury; therefore, the
initially, but this client is in the nurse should determine how much
rehabilitation depart ment and thus not oxygen is reaching the periphery.
in the initial stages of the injury.
2. Deep vein thrombosis (DVT) is a poten
TEST TAKING HINT: The test taker must no
tice where the client is receiving care,
2. A C6 injury would not affect the client’s abil which may be instrumental in being
Chapter 2 Neurological Disorders 33TEST TAKING HINT: able to rule out incorrect answer
options and help in identifying the
The nurse must be correct answer. Remember Maslow’s
hierarchy of needs—oxygen and
breathing are priority nursing
ity to chew and swallow, so pureed food interventions. Content – Medical: Integrated
is not necessary. Nursing Process – Implementation: Client
3. Breathing exercises are Needs – Safe Effective Care Environment,
supervised by the nurse to increase Management of Care: Cognitive Level –
the strength and endurance of Application: Concept – Oxygenation.
inspiratory muscles,
especially those of the diaphragm. 29. 1. Therapeutic communication
4. Autonomic dysreflexia occurs during addresses the client’s feelings and attempts
the rehabilitation phase, not the to allow the client to verbalize feelings; the
acute phase. nurse should be a therapeutic listener.
5. Corticosteroids are administered to 2. This is belittling the client’s feelings.
de crease inflammation, which will 3. The client does not owe the nurse an
decrease edema, and help prevent explanation of his feelings; “why” is
edema from never therapeutic.
ascending up the spinal cord, 4. This is advising the client and is not
causing breathing difficulties. therapeutic.
TEST TAKING HINT: When the question re
quests a therapeutic response, the test
32. 1. The halo device is applied by inserting
taker should select the answer option
pins into the skull, and the client cannot
that has “feelings” in the response.
remove them; the pins should be
Content – Medical: Integrated Nursing checked for signs of infection.
2. Reddened areas, especially under the
Psychosocial Integrity: Cognitive Level –
brace, must be reported to the HCP
Application: Concept – Mood.
because pressure ulcers can occur when
30. 1. The machine is very loud and the wearing this appliance for an extended
technician will offer the client ear plugs, period.
but hearing dif ficulty will not affect the 3. The vest liner should be changed for
MRI scan. hygiene reasons, but the halo part is not
2. Allergies to dairy products will not affect removed. 4. The client should be
the MRI scan. encouraged to ambulate to prevent
3. The client does not need to be NPO for complications of immobility.
this procedure. TEST TAKING HINT: The test taker would
4. MRI scans are often done in a very need basic knowledge about a halo
con fined space; many people who device to answer this question easily,
have claus trophobia must be but some clues are in the stem. A
medicated or even rescheduled for cervical fracture is in the upper portion
the procedure in an open MRI of the spine or neck area, and most
machine, which may be available if people understand that a halo is
needed. something that surrounds the forehead
knowledgeable of diagnostic tests to or higher. So the test taker could get a
prepare the client for the tests safely. mental image of a device that must span
The test taker must be realistic in this area of the body and maintain
determining answers—is there any test alignment of the neck. If an HCP
in which a hear ing problem would attaches pins into the head, then the test
make the diagnostic test taker could assume that they were
contraindicated? Med-Surg Success
34
Physiological Integrity, Reduction of Risk not to be removed by the client.
Potential: Cognitive Level – Application: Redness usually indicates some sort
Concept – Neurologic Regulation. of problem with the skin.
31. 1. This action will not address the Content – Medical: Integrated Nursing
client’s pounding headache and Process – Planning: Client Needs –
hypertension. Physiological Integrity, Reduction of Risk
2. Dimming the lights will not help the Potential: Cognitive Level – Synthesis:
client’s condition. Concept – Mobility.
3. This is an acute emergency caused by 33. 1. This is not an emergency; therefore,
ex aggerated autonomic responses to the nurse should not notify the
stimuli and only occurs after spinal health-care
shock has resolved in the client with provider.
a spinal cord injury above T6. The 2. A physiological change in the client
most common cause is a full bladder. requires more than a therapeutic
4. The nurse should always assess the conversation.
client be fore administering medication. 3. Increasing the IV rate will not address
TEST TAKING HINT: The test taker the cause of the problem.
should apply the nursing process 4. For the first two (2) weeks after an SCI
when answering questions, and above T7, the blood pressure tends to
assessing the client comes first, be unstable and low; slight elevations
before administering any type of of the head of the bed can cause
medication. profound hypo tension; therefore, the
Content – Medical: Integrated Nursing nurse should lower the head of the
Process – Implementation: Client Needs – bed immediately.
Safe Effective Care Environment, TEST TAKING HINT: The test taker should
Management of Care: Cognitive Level – notice that the only answer option that
Application: Concept – Neurologic ad dresses the “bed” is the correct
Regulation.
answer. This does not always help
identify the correct answer, but it is a TEST TAKING HINT: Although each state
hint that should be used if the test taker has its own delegation rules, teaching,
has no idea what the correct answer is. assessing, evaluating, and medication
Content – Medical: Integrated Nursing administration are nursing interventions
that cannot be del egated to unlicensed
Physiological Integrity, Physiological
assistive personnel. Content – Medical:
Adaptation: Cognitive Level – Application:
Concept – Mobility. Integrated Nursing Process – Planning: Client
Needs – Safe Effective Care Environment,
34. 1. This client has signs/symptoms of a Management of Care: Cognitive Level –
respiratory complication and should Synthesis: Concept – Nursing Roles.
be as sessed first.
36. 1. The ASIA is an appropriate referral for
2. This is a psychosocial need and should living with this condition, but it does not help
be ad dressed, but it does not have
find gainful employment after the injury.
priority over a physiological problem.
2. The rehabilitation commission of
3. A client with a lower SCI would not be at each state will help evaluate and
risk for autonomic dysreflexia; therefore,
determine if the client can receive
a com plaint of headache and feeling hot
training or educa tion for another
would not be a priority over an airway
occupation after injury.
problem.
3. The client is not asking about disability;
4. The client with a T4 SCI would not he is concerned about employment.
be expected to move the lower
Therefore, the nurse needs to make a
extremities.
referral to the appro priate agency.
TEST TAKING HINT: The nurse should 4. This does not address the client’s
assess the client who is at risk for concern about gainful employment.
dying or having some type of
TEST TAKING HINT: If the question
complication that requires in
mentions a specific age for a client, the
tervention. Remember Maslow’s nurse should consider it when attempt
hierarchy of needs, in which
ing to answer the question. This is a
physiological problems are always
young person who needs to find gainful
priority and airway is the top physi
employment. Remember Erickson’s
ological problem.
stages of growth and development.
Effective Care Environ ment, Management of
Application: Concept – Health Care System.
Ph Regulation.
35. 1. The nurse cannot delegate

assessment or teaching. Seizures
37. 1. The nurse needs to protect the client
from injury. Moving furniture would help
2. Tube feedings should be treated as if ensure that the client would not hit something
they were medications, and this task accidentally, but this is not done first.
cannot be delegated. 2. This is done to help keep the airway
3. The assistant can place the client on patent, but it is not the first intervention in
the bedside commode as part of this
bowel train ing; the nurse is specific situation.
responsible for the train ing but can 3. Assessment is important but when the
delegate this task. cli ent is having a seizure, the nurse
4. Evaluating the client’s ability to self should not touch him.
catheterize must be done by the nurse.
taker should go back to the stem of the
question and note that the question asks
4. The client should not remain in the chair which inter vention has priority. “In the
during a seizure. He should be brought chair” is the key to this question because
safely to the floor so that he will have the nurse should always think about
room to move the extremities. safety, and a client having a seizure is not
safe in a chair.
TEST TAKING HINT: All of the answer options
are possible interventions, so the test Content – Medical: Integrated Nursing
Process – Implementation: Client Needs – 4. Electrodes are placed on the client’s
Safe Effective Care Environment, Management scalp, but there are no electroshocks or
of Care: Cognitive Level – Synthesis: any type of discomfort.
highlight the words “diagnose a seizure
disorder” in the stem and ask which
Reduction of Risk Potential: Cognitive Level –
answer option would possibly cause a
seizure. Content – Medical: Integrated
40. 1. Noticing the first thing the client does Nursing Process – Planning: Client Needs –
during a seizure provides information and Physiological Integrity,
clues as to the location of the seizure in the ers, but the nurse should always
brain. It is important to document whether the address the client first.
beginning of the seizure was observed. TEST TAKING HINT: This is a prioritizing
2. Assessment is important, but during the sei question that asks the test taker which in
zure the nurse should not attempt to restrain tervention to implement first. All four inter
the head to assess the eyes; muscle contrac ventions would be appropriate, but only
tions are strong, and restraining the client one should be implemented first. If the
could cause injury. test taker cannot decide between two
3. This should be done, but it is not the first choices, always select the one that
intervention when walking into a room directly affects the client or the
where the client is beginning to have a condition; privacy is important, but
seizure. helping determine the origin of the
4. The client should be protected from onlook seizure is priority.
38. 1. Head injury is one of the main reasons Content – Medical: Integrated Nursing
for epilepsy that can be prevented Process – Implementation: Client Needs –
through occupational safety Safe Effective Care Environment,
precautions and high way safety Management of Care: Cognitive Level –
programs. Synthesis: Concept – Neurologic Regulation.
2. Sedentary lifestyle is not a cause of 41. 1. The client is exhausted from the seizure
epilepsy. 3. Dietary concerns are not a and should be allowed to sleep.
cause of epilepsy. 4. Safety glasses will 2. Awakening the client every 30 minutes
help prevent eye injuries, pos sibly could induce another seizure
but such injuries are not a cause of as a result of sleep deprivation.
epilepsy. TEST TAKING HINT: The nurse 3. During the postictal (after-seizure)
must be aware of risk factors that cause phase, the client is very tired and should
diseases. If the test taker does not know be
the correct answer, thinking about which allowed to rest quietly; placing the
body system the ques tion is asking client on the side will help prevent
about may help rule out or rule in some aspiration and maintain a patent
of the answer options. Only options “1” airway.
and “4” have anything to do with the 4. The client must rest, and asking
head, and only helmets on the head are questions about the seizure will keep
connected with the neurological system. the client awake, which may induce
Content – Medical: Integrated Nursing Process another seizure as a result of sleep
– Implementation: Client Needs – Health deprivation.
Promotion and Maintenance: Cognitive Level – TEST TAKING HINT: Options “1,” “2,” and
Application: Concept – Neurologic Regulation. “4” all have something to do with
39. 1. Antiseizure drugs, tranquilizers, keeping the client awake. This might
stimulants, and depressants are withheld before lead the test taker to choose the option
an EEG because they may alter the brain wave that is different from the other three.
patterns. Content – Medical: Integrated Nursing
2. Meals are not withheld because altered Process – Implementation: Client Needs –
blood glucose level can cause changes Safe Effective Care Environment,
in brain wave patterns. Management of Care: Cognitive Level –
Application: Concept – Neurologic
3. The goal is for the client to have a
Regulation.
seizure during the EEG. Sleep
Med-Surg Success
deprivation, hyper ventilating, or 36
flashing lights may induce a seizure.
Nursing Process – Evaluation: Client Needs –
Physiological Integrity, Pharmacological and
42. 1. Once the seizure has started, no one Parenteral Therapies: Cognitive Level –
should attempt to put anything in the Evaluation: Concept – Nursing Roles.
client’s mouth. 2. The nurse should tell
the UAP to stop trying to insert anything
in the mouth of the client experiencing a
seizure. Broken teeth and injury to the 44. 1. Assessment is an independent
lips and tongue may result from trying nursing action, not a collaborative one.
to place anything in the clenched jaws 2. All clients in the ICD will be placed on
of a client having a tonic-clonic seizure. telemetry, which does not require an
3. The primary nurse is responsible for the order by another health-care provider or
ac tion of the UAP and should stop the collaboration with one.
UAP from doing anything potentially 3. Administering an anticonvulsant
dangerous to the client. No one should medi cation by intravenous push
attempt to pry open the jaws that are requires the nurse to have an order or
clenched in a spasm to insert anything. confer with an other member of the
4. The primary nurse must correct the action health-care team.
of the UAP immediately, prior to any 4. A glucocorticoid is a steroid and is not
injury oc curring to the client and before used to treat seizures.
notifying the charge nurse. TEST TAKING HINT: The keyword in the
TEST TAKING HINT: The nurse is stem of this question is the adjective
responsible for the actions of the “collabora tive.” The test taker would
unlicensed assistive personnel and eliminate the options “1” and “2”
must correct the behavior immediately. because these do not require
collaboration with another member of
Process – Implementation: Client Needs – the health-care team and would
Safe Effective Care Environment, eliminate option “4” because it is not
Management of Care: Cognitive Level – used to treat seizures.
Application: Concept – Neurologic Content – Medical: Integrated Nursing
Regulation. Process – Planning: Client Needs –
Safe Effective Care
43. 1. Thorough oral hygiene after each Environment, Management of Care:
meal, gum massage, daily flossing, Cognitive Level – Synthesis: Concept –
and regu lar dental care are Neurologic Regulation.
essential to prevent or control
gingival hyperplasia, which is a 45. 1. Keeping a seizure and medication chart
common occurrence in clients will be helpful when keeping follow-up
taking Dilantin. appointments with the health-care pro
2. A serum (venipuncture) Dilantin vider and in identifying activities that
level is checked monthly at first may trigger a seizure.
and then, after 2. The client should take showers, rather
a therapeutic level is attained, every than tub baths, to avoid drowning if a
six (6) months. seizure
3. Dilantin does not turn the urine orange. 4. occurs. The nurse should also instruct
The use of Dilantin does not ensure that the the cli ent never to swim alone.
client will not have any seizures, and, in 3. Over-the-counter medications may
contain ingredients that will interact with
some instances, the dosage may need to
antisei zure medications or, in some
be adjusted or another medication may
cases, as with use of stimulants,
need to be used. TEST TAKING HINT: The
possibly cause a seizure.
test taker should realize that monitoring 4. Most of the anticonvulsant
blood glucose levels using a glucometer medications have therapeutic serum
is about the only level that is monitored levels that should be maintained, and
daily; therefore, option “2,” which calls regular checks of the se rum levels help
for daily monitoring of Dilantin levels, to ensure the correct level.
could be eliminated. Remember, there 5. A newly diagnosed client would have just
are very few absolutes in the health-care been put on medication, which may
field; therefore, option “4” could be ruled cause drowsiness. Therefore, the client
out because “won’t have any” is an should avoid activities that require
absolute. Content – Medical: Integrated alertness and coordi nation and should
not be driving at all until after the effects the client to lie down on the floor or find a
of the medication have been evaluated. safe place to have the seizure.
TEST TAKING HINT: The test taker must 2. An aura is not dependent on the client
select all interventions that are being physically or psychologically
exhausted.
appropriate for the question. A key word
3. This is a therapeutic response, reflecting
is the adverb “newly.” Content – Medical:
feel ings, which is not an appropriate
Integrated Nursing Process – Planning: Client
response when answering a client’s
Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – question.
Synthesis: Concept – Nursing Roles. 4. Sleepiness after a seizure is very
common, but the aura does not itself cause
the sleepiness. TEST TAKING HINT: If the
stem of the ques tion has the client
46. 1. The client with a seizure disorder
should avoid stimulants, such as caffeine. asking a question, then the nurse needs
2. The onset of menstruation can cause to give factual information, and option
seizure activity in the female client. “3,” a therapeutic response, would not
3. Tension states, such as anxiety and be appropriate. Neither would option “2”
frus tration, induce seizures in some or “4” because these options are worded
clients, so stress management may in such a way as to imply incorrect
be helpful in preventing seizures. information. Content – Medical: Integrated
4. Bright flickering lights, television viewing, Nursing Process – Implementation: Client
Chapter 2 Neurological Disorders 37 Needs – Physiological Integrity, Physiological
Adaptation: Cognitive Level – Application:
TEST TAKING HINT: All four answer options
are associated with the brain, 48. 1. Alzheimer’s disease does not lead to
neurological system, and aging. seizures. 2. Parkinson’s disease does not cause
However, options “1,” “2,” and “4” seizures. 3. A CVA (stroke) is the leading
usually occur over time, with the cause of sei
condition gradually getting worse, and zures in the elderly; increased
thus can be eliminated as a cause of intracranial pressure associated with
seizures, the stroke can lead to seizures.
which are usually sudden. 4. Brain atrophy is not associated with seizures.
Content – Medical: Integrated Nursing Process – Maintenance: Cognitive Level – Knowledge:
Implementation: Client Needs – Health Promotion Concept – Neurologic Regulation.
and
and some other photic (light) stimulation
may cause seizures but sunlight does Brain Tumors
not. Wearing dark glasses or covering
one eye during po tential 49. 1. Nervousness is not a symptom of a brain
seizure-stimulating activities may help tumor, and brain tumors rarely metastasize
prevent seizures. outside of the cranium. Brain tumors kill by
occupying space and increasing intracranial
TEST TAKING HINT: Caffeine is a stimulant
pressure. Although seizures are not uncom mon
and its use is not recommended in many
with brain tumors, seizures are not part of the
dis ease processes. Menstrual cycle
classic triad of symptoms.
changes are known to affect seizure
2. The classic triad of symptoms
disorders. Therefore, options “1” and
suggesting a brain tumor includes a
“2” can be eliminated, as can option “4”
headache that is dull, unrelenting, and
because sunlight does not cause
worse in the morn ing; vomiting
seizures.
unrelated to food intake; and
Content – Medical: Integrated Nursing edema of the optic nerve
Process – Evaluation: Client Needs –
(papilledema), which occurs in 70% to
75% of clients diagnosed with brain
Adaptation: Cognitive Level – Evaluation:
tumors. Papilledema causes visual
disturbances such as de
47. 1. An aura is a visual, an auditory, or an creased visual acuity and diplopia.
olfactory occurrence that takes place prior to 3. Hypertension and bradycardia, not
a seizure and warns the client a seizure is hypoten sion and tachycardia, occur
about to occur. The aura often allows time for with increased intracranial pressure
resulting from pressure on the 4. This is not dealing with the client’s
cerebrum. Tachypnea does not occur concerns and is passing the buck. The
with brain tumors. nurse should ex plore the client’s feeling
4. Abrupt loss of motor function occurs with to determine what is concerning the
a stroke; diarrhea does not occur with a client. The MRI may or may not be the
brain tumor, and the client with a brain problem. The client may be afraid of the
tumor does not experience a change in results of the MRI.
taste. TEST TAKING HINT: When the question
TEST TAKING HINT: The test taker can asks the test taker for a therapeutic
rule out option “4” because of the response, the test taker should choose
symptom of diarrhea, which is a the response that directly addresses the
gastrointestinal symp client’s feelings. Content – Medical:
tom, not a neurological one. Considering Integrated Nursing Process – Implementation:
the other three possible choices, the Client Needs – Physiological Integrity,
symptom of “headache” would make Reduction of Risk Potential: Cognitive Level –
sense for a client with a brain tumor. Application: Concept – Cellular Regulation.
Content – Medical: Integrated Nursing 52. 1. Nothing in the stem indicates the client has
a problem with swallowing, so aspiration
pre cautions are not needed.
Adaptation: Cognitive Level – Analysis:
Concept – Cellular Regulation. 2. Reach to Recovery is an American
Cancer Society–sponsored program for
50. 1. A widening pulse pressure and bounding clients with breast cancer, but it is not
pulse indicate increased intracranial pressure prophylactic.
but do not localize the tumor. 3. The client diagnosed with
2. Diplopia and decreased visual pressure metastatic lesions to the brain is
are symptoms indicating papilledema, a at high risk for
general symptom in the majority of all seizures.
brain tumors. 4. Teaching about mastectomy care is not
Med-Surg Success prophylactic, and the stem did not
38
indicate whether the client had a
mastectomy.
3. Bradykinesia is slowed movement, a
symptom of Parkinson’s disease, and
not read into a question—for example,
scanning speech is symptomatic of
about mastectomy care. The test taker
multiple sclerosis.
should be careful to read the descriptive
4. Hemiparesis would localize a tumor words in the
to a motor area of the brain, and
personality changes localize a
tumor to the frontal lobe.
stem; in this case, “prophylactic” is the
TEST TAKING HINT: The test taker could
key to answering the question correctly.
arrive at the correct answer if the test
taker realized that specific regions of the Content – Medical: Integrated Nursing
Process – Planning: Client Needs –
brain control motor function and
Physiological Integrity, Reduction of Risk
hemiparesis and that other re gions are Potential: Cognitive Level – Synthesis:
involved in personality changes. Content – Concept – Cellular Regulation.
Medical: Integrated Nursing Process –
Assessment: Client Needs – Physiological 53. 1. A social worker is qualified to assist the
Integrity, Physiological Adaptation: Cognitive client with referrals to any agency or
Level – Analysis: Concept – Cellular Regulation. personnel that is needed.
2. The chaplain should be referred if
51. 1. This is providing information and is not
spiritual guidance is required, but the
com pletely factual. MRIs are loud, but
stem did not specify this need.
frequently the client will require an IV
3. The HCP also can refer to the social
access (an inva sive procedure) to be
worker, but the nurse can make this
started for a contrast medium to be
referral independently.
injected.
4. The occupational therapist assists
2. This is restating and offering self.
with cognitive functioning, activities
Both are therapeutic responses.
of daily
3. This statement is belittling the
living (ADLs), and modification of the
client’s feeling.
home, but the stem did not define these self-care deficit.
needs. Content – Medical: Integrated Nursing
TEST TAKING HINT: The test taker must Process – Planning: Client Needs –
decide what each discipline has to offer Physiological Integrity,
the client; an SW has the broadest Physiological Adaptation: Cognitive Level –
range of referral capabilities. Synthesis: Concept – Cellular Regulation.
Content – Medical: Integrated Nursing 55. 1. Purposeful movement following painful

Process – Implementation: Client Needs – stimuli would indicate an improvement in
Safe Effective Care Environment, the client’s condition.
Management of Care: Cognitive Level – 2. Adducting the upper extremities while
Application: Concept – Health Care System. inter nally rotating the lower extremities is
54. 1. Maintaining weight is a nutritional decor ticate positioning and would
goal. 2. Completing an advance directive is indicate that the client’s condition had
an end-of-life or psychosocial goal. not changed.
3. Performing activities of daily living 3. Aimless thrashing would indicate an
is a goal for self-care deficit. improve ment in the client’s condition.
4. Verbalizing feelings is a psychosocial 4. The most severe neurological impair
goal. TEST TAKING HINT: The test taker ment result is flaccidity and no
should read the stem of the question response to stimuli. This indicates
that the client’s condition has
carefully. All of the goals could be
worsened.
appropriate for a client diagnosed with a
brain tumor, but only one applies to
question, but anatomical posi tioning of
the pituitary gland (just above the
TEST TAKING HINT: Neurological sinuses) could help to eliminate option
assessment includes assessing the client “1,” which calls for a large turban
for levels of dressing. Content – Surgical: Integrated
Chapter 2 Neurological Disorders 39 Nursing Process – Planning: Client Needs –
Physiological Integrity,
Physiological Adaptation: Cognitive Level –
58. 1. Making the client NPO will not help the
Synthesis: Concept – Nursing Roles.
client to swallow.
consciousness; the nurse must 57. 1. A headache after this surgery would be
memorize the stages of neurological an ex pected occurrence, not a complication.
progression toward a coma and death. 2. An output much larger than the intake
Content – Medical: Integrated Nursing could indicate the development of
Process – Assess ment: Client Needs – Safe diabe tes insipidus. Pressure on the
Effective Care Environment, Management of pituitary gland can result in
Care: Cognitive Level – Analysis: Concept – decreased production of
Cellular Regulation. vasopressin, the antidiuretic
hormone (ADH).
56. 1. A transsphenoidal hypophysectomy
is done by an incision above the gumline 3. A raspy sore throat is common after
surgery due to the placement of the
and through the sinuses to reach the
endotracheal tube during anesthesia.
sella turcica, where the pituitary is
located. 4. Dizziness on arising quickly is expected;
the client should be taught to rise slowly
2. The client will be given regular food
and call for assistance for safety.
when awake and able to tolerate food.
3. Blowing the nose creates increased TEST TAKING HINT: The test taker could
intracranial pressure and could result eliminate options “1” and “3” as
in a cerebrospinal fluid leak. expected occurrences following the
4. The client will return from surgery surgery and not complications.
with the head of the bed elevated to Option “4” can also be expected.
about Content – Surgical: Integrated Nursing
30 degrees; this allows for gravity to Process – Assessment: Client Needs –
assist in draining the cerebrospinal Physiological Integrity, Reduc tion of Risk
fluid. Potential: Cognitive Level – Analysis:
Concept – Cellular Regulation.
TEST TAKING HINT: The test taker must
2. A low Fowler’s position would make it
know the procedures for specific
easier for the client to aspirate.
disease processes to answer this
3. The consistency of the food is not an Cellular Regulation.
issue; the client will have difficulty Med-Surg Success
40
swallowing this food as well as
regular-consistency food.
4. To decrease the risk of aspiration, the 60. 1. The client should sleep with the head
cli ent should direct food to the of the bed elevated to promote
unaffected side of the throat; this drainage of the cerebrospinal fluid.
helps the client to be able to use the 2. Humidified air will prevent drying of
side of the throat that is functioning. the nasal passages.
TEST TAKING HINT: The test taker 3. Because the incision for this surgery
should try to visualize the position of is just above the gumline, the client
the client in the bed. A mostly should not brush the front teeth. Oral
recumbent position (low Fowler’s) care
would increase the chance should be performed using a sponge
of aspiration; thus option “2” should until the incision has healed.
be eliminated. 4. The client can eat a regular diet.
5. The HCP should be notified if the cli
ent develops an infection of any kind. A
cold with sinus involvement and
Safe Effective Care Environment,
Management of Care: Cognitive Level – sneezing places the client at risk for
Application: Concept – Cellular Regulation. opening the incision and developing a
brain infection.
59. 1. Chemotherapy is systemic therapy that is
TEST TAKING HINT: The test taker could
used extensively in the care of clients
choose option “5” because this is a
diag nosed with cancer. However, most
standard instruction for any surgery.
drugs have difficulty in crossing the
The test taker should look for more
blood–brain barrier and are not useful in
than one correct an swer in an
treating brain tumors unless delivered by
alternative-type question.
direct placement into the spinal column
or directly to the ventricles of the brain Content – Surgical: Integrated Nursing
by a device called an Omaya reservoir.
Physiological Integrity, Physi ological
2. The blood–brain barrier is the body’s Adaptation: Cognitive Level – Synthesis:
de fense mechanism for protecting Concept – Nursing Roles.
the brain from chemical effects; in
this case, it pre vents the
chemotherapy from being able to Meningitis
work on the tumor in the brain.
3. Radiation has about the same amount of 61. 1. This is a definition of aseptic meningitis,
side effects as chemotherapy, but the which refers to irritated meninges from
effects of ra diation tend to last for a viral or noninfectious sources.
much longer time. 2. This is another example of aseptic
4. Some tumors do become resistant to the meningitis, which refers to irritated
che motherapy agents used. When this meninges from viral or noninfectious
happens, the oncologist switches to sources.
different drugs. 3. Septic meningitis refers to meningitis
TEST TAKING HINT: The test taker can caused by bacteria; the most common
elimi nate option “1” as a possible form of bacterial meningitis is caused
answer because it states that by the Neisseria meningitides bacteria.
chemotherapy is used to treat brain 4. This is the explanation for encephalitis.
tumors, but it does not tell the client TEST TAKING HINT: The nurse should
why it is not being used. Option “2” is explain the client’s diagnosis in
the only one that actually informs the layperson’s terms when the stem is
client of a medical reason for not identifying the significant other as
administering chemo therapy for a brain asking the question. Be sure to no tice
tumor. that the adjective “septic” is the key to
Content – Medical: Integrated Nursing answering this question, ruling out
Process – Diagnosis: Client Needs – options “1” and “2.”
Pharmacological and Parenteral Therapies: Content – Medical: Integrated Nursing
Cognitive Level – Analysis: Concept – Process – Implementation: Client Needs –
Adaptation: Cognitive Level – Application: assess for bacterial meningitis.
Concept – Neurologic Regulation. 3. A positive Kernig’s sign (client unable
62. 1. Clients who have been hospitalized are to extend leg when lying flat) and
weak ened, but they are not at risk for nuchal rigidity (stiff neck) are signs
contracting any type of meningitis. of bacterial meningitis, occurring
2. Outbreaks of infectious meningitis because the menin ges surrounding
are most likely to occur in dense the brain and spinal col umn are
community irritated.
4. Trousseau’s sign is used to assess
for hypo calcemia, and nystagmus is
abnormal eye movement. Neither of
groups such as college campuses, these is a clinical
jails, and military installations. manifestation of bacterial meningitis.
3. Third world countries do not pose a risk
TEST TAKING HINT: If two answer options
fac tor for meningitis. They provide a
test for the same thing (Trousseau’s and
risk for hepatitis or tuberculosis.
Ch vostek’s signs), then the test taker
4. Employees in a high-rise building do not
can rule out these as possible answers
live together and they have their own
because there cannot be two correct
space; therefore, they are not at risk for
answers in the ques tion, unless the
developing meningitis.
question tells the test taker that it is a
TEST TAKING HINT: The test taker must re “select all that apply” question. Content
member that the NCLEX-RN tests all – Medical: Integrated Nursing Process –
areas of nursing, so always notice the Assessment: Client Needs – Safe Effective
type of nurse if this is mentioned in the Care Environ ment, Management of Care:
stem. A public health nurse would not Cognitive Level – Analysis: Concept –
be concerned with third world countries. Neurologic Regulation.
Content – Medical: Integrated Nursing 64. 1. In clients with meningococcal meningitis,
Process – Plan ning: Client Needs – Health purpuric lesions over the face and extremity
Promotion and Maintenance: Cognitive Level
are the signs of a fulminating infection that can
– Synthesis Concept – Nursing Roles.
lead to death within a few hours.
63. 1. Babinski’s sign is used to assess 2. Photophobia is a common clinical
brainstem activity, and paresthesia manifesta tion of all types of meningitis
is tingling, which is not a clinical and would be expected.
manifestation of bacterial meningitis. 3. Inflammation of the meninges results in
2. Chvostek’s sign is used to assess for in creased intracranial pressure, which
hypocal cemia, and facial tingling is a causes a
sign of hypo calcemia. It is not used to
headache. This would be an expected Effective Care Environ ment, Management of
occur rence and would not warrant Care: Cognitive Level – Synthesis: Concept
– Neurologic Regulation.
notifying the HCP.
4. A client not being able to identify the day of 65. 1. Standard Precautions are mandated
Chapter 2 Neurological Disorders 41 for all clients, but a client with septic
meningitis will require more than the
3. This would be an appropriate goal for the cli Standard
ent who has a problem of infection. Precautions.
4. This would be an appropriate goal for the cli 2. Airborne Precautions are for
ent who has a problem of dehydration. contagious organisms that are
the week would not in itself warrant spread on air currents and require
notifying the HCP. the hospital personnel to wear an
ultra-high filtration mask; these
TEST TAKING HINT: The stem is asking the
precau tions would be applied for
nurse to identify which assessment data
diseases such as tuberculosis.
are abnormal for the disease process
and require an immediate medical 3. Contact Precautions are for contagious
or ganisms that are spread by blood
intervention to pre vent the client from
and body fluids, such as those that
experiencing a complica tion or possible
occur with wounds or diarrhea.
death.
4. Droplet Precautions are respiratory
pre cautions used for organisms that Safe Effective Care Environment,
have a limited span of transmission. Management of Care: Cognitive Level –
Precautions include staying at least Analysis: Concept – Neurologic Regulation.
four (4) feet away from the client or 68. 1. A nurse administering antibiotics is a
wearing a standard iso lation mask col laborative intervention because
and gloves when coming in close the HCP must write an order for the
contact with the client. Clients are in intervention; nurses cannot
isolation for 24 to 48 hours after prescribe medications un
initia tion of antibiotics. less they have additional education
TEST TAKING HINT: The test taker must and licensure and are nurse
know the types of isolation precautions practitioners with prescriptive
used for different diseases and note the authority.
adjective— “septic”—in the stem of the 2. The nurse needs an order to send a
question. culture to the laboratory for payment
Content – Medical: Integrated Nursing purposes, but the nurse can obtain a
Process – Implementation: Client Needs – specimen without an order. A sputum
Safe Effective Care Envi ronment, Safety and specimen is not appropriate for
Infection Control: Cognitive Level – meningitis.
Application: Concept – Neurologic Regulation. 3. A pulse oximeter measures the amount
66. 1. This goal is not related to altered cerebral of oxygen in the periphery and does not
tis sue perfusion, but it would be a goal require an HCP to order.
for self care deficit. 4. Intake and output are independent
2. A client with a problem of altered cere nursing interventions and do not
bral tissue perfusion is at risk for require an HCP’s order.
seizure activity secondary to focal TEST TAKING HINT: The test taker must
areas of cortical irritability; therefore, note adjectives and understand that a
the client should be on seizure collabora tive nursing intervention is
precautions. dependent on another member of the
TEST TAKING HINT: The goal must be health-care team; an independent
related to the problem—in this case, nursing intervention does not require
“altered cere bral tissue perfusion.” collaboration.
Med-Surg Success
Content – Medical: Integrated Nursing 42
Concept – Cellular Regulation.
67. 1. A lumbar puncture is an invasive Adaptation: Cognitive Level – Analysis:
procedure; therefore, an informed Concept – Neurologic Regulation.
consent is required. 2. This could be 69. 1. This vaccine must be administered prior
offered for client comfort during the to exposure to build up an immunity to
procedure. pre vent meningitis resulting from
3. This position increases the space Haemophilus influenzae.
between the vertebrae, which allows 2. Chemoprophylaxis includes
the HCP eas ier entry into the spinal administering medication that will
column. prevent infection or eradicate the
4. The client is encouraged to relax and bacteria and the develop ment of
breathe normally; hyperventilation may symptoms in people who have been in
lower an elevated cerebrospinal fluid close proximity to the client.
pressure. Medications include rifampin
5. The nurse should always explain to (Rifadin), ciprofloxacin (Cipro),
the client what is happening prior to and ceftriaxone (Rocephin).
and dur ing a procedure. 3. Steroids are used as an adjunct therapy
TEST TAKING HINT: This is an in treatment of clients diagnosed with
alternative-type question, which acute bacterial meningitis. They would
requires the test taker to se lect more not be given as a prophylactic measure
than one answer option. to others
Content – Medical: Integrated Nursing in the home.
Process – Implementation: Client Needs – 4. Gamma globulin provides passive
immunity to clients who have been ated without knowing the client’s
exposed to hepatitis. It is not admission weight.
appropriate in this situation. TEST TAKING HINT: The nurse must know
TEST TAKING HINT: The key word in the how to prioritize care. Which
stem is “preventive.” The test taker intervention has the potential to avoid
must pay close attention to the a complication re lated to the disease
adjectives. process? Remember the word
Content – Medical: Integrated Nursing “priority.”
Process – Planning: Client Needs – Safe Content – Medical: Integrated Nursing
Effective Care Environment, Safety and Process – Planning: Client Needs – Safe
Infection Control: Cognitive Level – Synthesis: Effective Care Environment, Management of
Concept – Neurologic Regulation. Care: Cognitive Level – Synthesis: Concept –
70. 1. Antibiotics would help decrease the
bacterial infection in meningitis, which 72. 1. The client’s lung sounds should be clear
would cause the exudate. The drugs with meningitis, and nothing in the question
mentioned in the question would not. stem indicates a comorbid condition. Therefore,
2. Fever increases cerebral metabolism assessing lung sounds is not a priority.
and intracranial pressure. Therefore, 2. The client may experience photophobia
measures are taken to reduce body and visual disturbances, but assessing the
temperature as soon as possible, and six fields of gaze will not affect the client’s
alternating Tylenol and Motrin would condition.
be appropriate. 3. The client’s cardiac status is not affected
3. A nonnarcotic antipyretic (Tylenol) and by meningitis. Therefore, the apical
an NSAID (Motrin) will not address the pulse would not be a priority.
client’s memory or orientation. 4. Meningitis directly affects the client’s
4. These medications do not prevent or brain. Therefore, assessing the
treat a yeast infection. neurologi cal status would have
TEST TAKING HINT: The test taker must priority for
have a basic knowledge of the disease this client.
process and medications that are TEST TAKING HINT: The test taker should
prescribed to treat a disease. Purulent apply a systemic approach to
drainage would require an antibiotic. discerning the priority response.
Therefore, option “1” should be Maslow’s hierarchy of needs would put
eliminated as a possible answer option “1” as correct, but the disease
because the question is asking about process of meningitis does not include
NSAIDs and a non narcotic antipyretic signs or symptoms of a respiratory
(Tylenol). component. The next highest priority
would be the neurological component,
and menin gitis definitely is a
Content – Medical: Integrated Nursing neurological disease. Content – Medical:
Process – Diagnosis: Client Needs – Integrated Nursing Process – Assessment:
Physiological Integrity, Client Needs – Safe Effective Care Environ
Pharmacological and Parenteral ment, Management of Care: Cognitive Level –
Therapies: Cognitive Level – Analysis: Synthesis: Concept – Neurologic Regulation.
71. 1. The antibiotic has the highest priority be

cause failure to treat a bacterial infection can Parkinson’s Disease
result in shock, systemic sepsis, and death.
2. The lunch tray is important and may 73. 1. Masklike facies is responsible for lack of
actually arrive prior to the antibiotic, but expression and is part of the motor
the priority for the nurse must be the mani festations of Parkinson’s disease
medication. but is not related to the symptoms
3. The client’s room should be kept dark listed. Shuffling is also a motor deficit
be cause of photophobia, but and does pose a risk for falling, but
photophobia is a symptom that is not fever and patchy infiltrates on a chest
life threatening. x-ray do not result from a gait prob lem.
4. Knowledge of the client’s weight is They are manifestations of a pulmonary
necessary, but initial antibiotic therapy can complication.
be initi 2. Difficulty swallowing places the client at
Chapter 2 Neurological Disorders 43 blood–brain barrier.
TEST TAKING HINT: The nurse must be
75. 1. Adaptive appliances will not help the knowledgeable of the rationale for
client’s shaking movements and are not used adminis tering a medication for a
for specific disease.
clients with Parkinson’s disease. Content – Medical: Integrated Nursing
2. Clients with Parkinson’s disease are Process – Diagnosis: Client Needs –
placed on high-calorie, high-protein, soft or Physiological Integrity,
liquid diets. Supplemental feedings may Pharmacological and Parenteral
also be ordered. If liquids are ordered Therapies: Cognitive Level – Analysis:
because of difficulty Concept – Neurologic Regulation.
chewing, then the liquids should be would get cold before the client can
thickened to a honey or pudding consume the meal, and one-half or
consistency. more of the food would be wasted.
3. Nuts and whole-grain food would require 4. The client’s energy levels will not
ex tensive chewing before swallowing and sustain eating for long periods.
would not be good for the client. Three Offering frequent and easy-to-chew
large meals (soft) meals of small proportions is
risk for aspiration. Immobility the preferred
predisposes the client to pneumonia. dietary plan.
Both clinical manifestations place the TEST TAKING HINT: The correct answer
client at risk for pulmonary for a nursing problem question must
complications. address the actual problem.
3. Pill rolling of fingers and flat affect do Content – Medical: Integrated Nursing
not have an impact on the Process – Diagnosis: Client Needs –
development of pul monary Physiological Integrity,
complications. Physiological Adaptation: Cognitive Level
4. Arm swing and bradykinesia are – Analysis: Concept – Neurologic
motor deficits. Regulation.
TEST TAKING HINT: The nurse must recog 76. 1. The nurse should not delegate
nize the clinical manifestations of a feeding a client who is at risk for
disease and the resulting bodily complications during feeding. This
compromise. In this situation, fever and requires judgment that the UAP is not
patchy infiltrates on a chest x-ray expected to possess.
indicate a pulmonary complica tion. 2. Unlicensed assistive personnel can turn
Options “1,” “3,” and “4” focus on mo and position clients with pressure ulcers.
tor problems and could be ruled out as The nurse should assist in this at least
too similar. Only option “2” includes once during the shift to assess the
dissimilar information. wound area.
Content – Medical: Integrated Nursing 3. The UAP can assist the client to the
Process – Assessment: Client Needs – bath room every two (2) hours and
Physiological Integrity, Physiological document the results of the attempt.
Adaptation: Cognitive Level – Analysis: 4. The UAP can obtain the vital signs
Concept – Neurologic Regulation. on a stable client.
74. 1. Carbidopa is never given alone. TEST TAKING HINT: When reading the
Carbidopa is given together with answer options in a question in which
levodopa to help the levodopa cross the nurse is delegating to an
the blood–brain barrier. unlicensed-assistive person nel, read
2. Levodopa is a form of dopamine given the stem carefully. Is the question
orally to clients diagnosed with PD. asking what to delegate or what not to
3. Carbidopa enhances the effects of del egate? Anything requiring
levodopa by inhibiting professional judg ment should not be
decarboxylase in the periphery, delegated.
thereby making more Content – Medical: Integrated Nursing
levodopa available to the central Process – Planning: Client Needs – Safe
nervous system. Sinemet is the Effective Care Environment, Management of
most effective Care: Cognitive Level – Synthesis: Concept –
treatment for PD. Nursing Roles.
4. Carbidopa does not cross the Med-Surg Success
44
produce lesions in groups of brain cells through
electrical stimulation or thermoco agulation.
77. 1. Headache and photophobia are
These procedures are done when medication
expected clinical manifestations of
has failed to control tremors.
meningitis.
2. Dopamine receptor agonists are
The new graduate could care for this
medications that activate the dopamine
client.
receptors in the striatum of the brain.
2. This client has had an unusual
occurrence (fall) and now has a
potential complication (a fracture).
The experienced nurse should take 3. Physical therapy is a standard therapy
care of this client. used to improve the quality of life for
3. These vital signs indicate increased clients diag nosed with PD.
intracranial pressure. The more 4. Fetal tissue transplantation has
experienced nurse should care for this shown some success in PD, but it is
client. an ex
4. This could indicate a worsening of the perimental and highly controversial
tumor. This client is at risk for seizures procedure.
and herniation of the brainstem. The TEST TAKING HINT: The test taker should
more expe rienced nurse should care not overlook the adjective
for this client. “experimental.” This would eliminate at
TEST TAKING HINT: The test taker should least option “3,” physi cal therapy, and
de termine if the clinical manifestations option “2,” which refers to standard
are ex pected as part of the disease dopamine treatment, even if the test
process. If they taker was not familiar with all of the
are, a new graduate can care for the procedures.
client; if they are not expected Content – Medical: Integrated Nursing
occurrences, a more experienced nurse Process – Planning: Client Needs –
should care for the client. Content – Physiological Integrity, Physi ological
Medical: Integrated Nursing Process – Adaptation: Cognitive Level – Synthesis:
Planning: Client Needs – Safe Effective Care Concept – Neurologic Regulation.
80. 1. The emotions of a person diagnosed with
Level – Synthesis: Concept – Nursing Roles.
PD are labile. The client has rapid mood
78. 1. Akinesia is lack of movement. The swings and is easily upset.
goal in treating PD is to maintain mobility. 2. Hallucinations are a sign that the client
2. This could be a goal for a problem of is ex periencing drug toxicity.
non compliance with the treatment 3. Scheduling appointments late in the
regimen but not a goal for treating the morning gives the client a chance to
disease process. com plete ADLs without pressure
3. This might be a goal for a psychosocial and allows the medications time to
prob lem of social isolation. give the best
4. The major goal of treating PD is to benefits.
maintain the ability to function. 4. The client should take the prescribed
Clients diagnosed with PD medica tions at the same time each day
experience slow, jerky movements to provide a continuous drug level.
and have difficulty performing routine TEST TAKING HINT: The test taker could
daily tasks. elim inate option “2” because
TEST TAKING HINT: The test taker hallucinations are never an expected
should match the goal to the part of legal medication administration.
problem. A “thera peutic goal” is the Content – Medical: Integrated Nursing
key to answering this question. Process – Evaluation: Client Needs –
Content – Medical: Integrated Nursing Physiological Integrity, Physiological
Process – Planning: Client Needs – Safe Adaptation: Cognitive Level – Evaluation:
Effective Care Environment, Management of Concept – Neurologic Regulation.
Care: Cognitive Level – Synthesis: Concept –
81. 1. Crackles and jugular vein distention
indicate heart failure, not PD.
79. 1. A stereotactic pallidotomy and/or thalamot 2. Upper extremity weakness and ptosis
omy are surgeries that use CT or MRI scans to are clin ical manifestations of myasthenia
localize specific areas of the brain in which to gravis.
3. The client has very little arm swing, and be discussed in the sup port
scan ning speech is a clinical manifestation meeting.
of multiple sclerosis. 3. The reduction in the unintentional pill
4. Masklike facies and a shuffling gait rolling movement of the hands is
are two clinical manifestations of PD. controlled at times by the medication;
TEST TAKING HINT: Option “3” refers to this is a physi ological problem.
arm swing and speech, both of which 4. Echolalia is a speech deficit in which
are affected by PD. The test taker the client automatically repeats the
needs to de cide if the adjectives used words or sentences of another
to describe these person; this is a physi ological
activities—“exaggerated” and problem.
“scanning”— are appropriate. They are TEST TAKING HINT: Psychosocial
not, but masklike facies and shuffling problems should address the client’s
gait are. feelings or inter actions with another
person.
Content – Medical: Integrated Nursing Process – Planning: Client Needs –
Process – Assessment: Client Needs – Psychosocial Integrity:
Physiological Integrity, Physi ological Cognitive Level – Synthesis: Concept –
Adaptation: Cognitive Level – Analysis: Neurologic Regulation.
84. 1. A headache of “2” on a 1-to-10 scale is a
82. 1. Emotional lability is a psychosocial mild headache.
problem, not a cognitive one. 2. A spinal cord injury at T10 involves
2. Depression is a psychosocial deficits at approximately the waist
problem. 3. Memory deficits are area. Inability to move the toes would
cognitive impair ments. The client be expected.
may also develop a dementia. 3. Body image is a concern for clients
4. Paranoia is a psychosocial problem. diagnosed with PD. This client is the
Chapter 2 Neurological Disorders 45 one client who is not experiencing
expected sequelae of the disease.
TEST TAKING HINT: At times a 4. This client is getting better; “resolving”
psychological problem can have indicates an improvement in the client’s
priority. All the physi clini cal manifestations.
cal problems are expected and are 85. 1. This should be done so that appropriate
not life threatening or life altering. care can be provided, but it is not a priority
Content – Medical: Integrated Nursing Process – action. 2. This should be done before the
Assessment: Client Needs – Safe Effective client ceases breathing and a cardiac arrest
Care Environ ment, Management of Care: follows, but it is not the first action.
Cognitive Level – Analysis: Concept – 3. This would be a good step to take to
Neurologic Regulation. prepare for the worst-case scenario, but
it can be done last among these answer
options.
Substance Abuse 4. Applying oxygen would be the priority
ac tion for this client. The client’s
TEST TAKING HINT: The test taker must breathing is slow and shallow. The
know the definitions of common greater amount of inhaled oxygen,
medical terms. “Cognitive” refers to the better the client’s prognosis.
mental capacity to function.
TEST TAKING HINT: When the test taker is
de ciding on a priority, some guidelines
should be used. Maslow’s hierarchy of
Adaptation: Cognitive Level – Analysis: needs places oxygen at the top of the
Concept – Neurologic Regulation. priority list.
83. 1. This is information that should be Process – Implementation: Client Needs –
discussed when filling out an advance Safe Effective Care Environment,
directive form. A ventilator is used to Management of Care: Cognitive Level –
treat a physiological problem. Synthesis: Concept – Neurologic
2. These are psychosocial Regulation.
manifestations of PD. These should
Application: Concept – Legal.
86. 1. No employee of a facility is above
certain rules. In a company with a “No 88. 1. These reactions are called “flashbacks.”
Drugs” policy, this includes the CEO. This 2. Flashback reactions occur after the
client is exhibiting symptoms of cocaine use of hallucinogens in which the client
abuse. relives a bad episode that occurred
2. The nurse does not have a definitive while using the drug.
knowl edge that the client is using 3. The drug is gone from the body, but the
drugs until a positive drug screen mind-altering effects can occur at any
result is obtained. If the nurse is not a time in the form of memory flashbacks.
trained substance abuse coun selor, 4. The client stated that the dreams are
this intervention would be out of the causing her distress. She is asking for
realm of the nurse’s expertise. help with the dreams, not planning her
3. The client is the CEO of the facility; suicide.
only the board of directors or parent TEST TAKING HINT: The client is 20 years
company is above this client in old and took the drug in her teens;
supervisory rank. drugs do not stay in the body for
4. Giving an antihistamine is prescribing extended periods. This eliminates
with out a license, and the nurse is option “3.”
obligated to intervene in this situation. Content – Medical: Integrated Nursing
TEST TAKING HINT: The title of the Process – Assessment: Client Needs –
client— CEO—eliminates option “3.” Physiological Integrity, Physiological
The nurse has noted a potential illegal Adaptation: Cognitive Level – Analysis:
situation. Concept – Addiction.
Content – Medical: Integrated Nursing 89. 1. The nurse is not the coworker’s
Process – Implementation: Client Needs – supervisor, and confronting the coworker about
Safe Effective Care Environment, the sus picions could lead to problems if the
nurse is not trained to deal with substance
Application: Concept – Addiction.
abusers.
Med-Surg Success
46 2. This is circumventing the problem. The
co worker will find another source of
drugs if needed, and it is finding the
87. 1. The Health Insurance Portability and
coworker guilty without due process.
Accountability Act (HIPAA) requires
3. The coworker’s supervisor or peer
that a health-care professional not
review committee should be aware
divulge information about one
of the nurse’s
person to an unau thorized person.
2. This would be discussing Client B
and a violation of HIPAA.
3. The nurse does not know Client B is suspicions so that the suspicions
using drugs, so notifying the HCP is can be investigated. This is a
not appropriate. client safety and care concern.
4. Client B would require an explanation 4. The nurse is obligated to report
for coming to the clinic, for which, if suspicious behavior to protect the
the nurse has not violated HIPAA, clients the coworker is caring for.
there is no explanation. TEST TAKING HINT: The test taker can
TEST TAKING HINT: Nurses are required to eliminate option “4” based on “do noth
practice within the laws of the state and ing.” In this instance, direct
within federal laws. HIPAA is a federal confrontation is not recommended, but
law and applies to all health-care the nurse must do something—namely,
professionals in the United States. report the suspicions to the supervisor
Legally the nurse can not use the or peer review.
information provided by Client A, but Content – Medical: Integrated Nursing
morally the nurse might try to identify Process – Implementation: Client Needs –
behavior in Client B that would warrant Safe Effective Care Environment,
the nurse’s intervention. Management of Care: Cognitive Level –
Content – Medical: Integrated Nursing Application: Concept – Communication.
Process – Implementation: Client Needs – 90. 1. Insomnia and anxiety are symptoms of
Safe Effective Care Environment, al cohol withdrawal, not
Wernicke-Korsakoff syndrome.
2. Visual and auditory hallucinations are not necessary.
symp toms of delirium tremens. 2. Vital signs should be taken more
3. Extreme tremors and agitation are frequently, every two (2) to four (4)
symptoms of delirium tremens. hours, depending on the client’s
4. Ataxia, or lack of coordination, and condition.
con fabulation, making up elaborate 3. The client should be in an
stories to explain lapses in memory, are atmosphere with little stimulation.
both symp toms of Wernicke-Korsakoff The client will be irritable and
syndrome. fearful.
TEST TAKING HINT: The test taker can 4. Heroin is administered intravenously.
elimi nate options “2” and “3” if the Heroin addicts are at high risk for HIV
test taker knows the symptoms of as a result of shared needles and
thus should be tested for HIV.
delirium tremens. Content – Medical:
Integrated Nursing Process – Assessment:
5. The client is withdrawing from heroin, so
Client Needs – Physiological Integrity, providing needles is inappropriate.
Physiological Adaptation: Cognitive Level – Providing sterile needles to IV drug
Analysis: Concept – Addiction. users is controver sial, but it attempts to
decrease the incidence of HIV among
91. 1. Thiamine is given in high doses to de drug users.
crease the rebound effect on the
TEST TAKING HINT: A “select all that
nervous system as it adjusts to the
apply” question will usually have more
absence of alco hol, and a
than one correct answer. One option
benzodiazepine is given in high
cannot eliminate another.
doses and titrated down over several
days for the tranquilizing effect to Content – Medical: Integrated Nursing
prevent de lirium tremens.
Safe Effective Care Environment,
2. The client may have seizures, but Valium
would control this. The client does not
Application: Concept – Addiction.
need a long-term anticonvulsant
medication (Dilan tin), and it is not known 93. 1. This is a therapeutic response. The
that the client needs an iron preparation spouse is not expressing feelings but is stating
(Feosol). The vitamin deficiency a fact. The nurse should address the problem.
associated with delirium tremens is lack 2. This is a therapeutic response. The
of thiamine, not iron. spouse is not expressing feelings but is
3. Methadone is used for withdrawing stating a fact. The nurse should address
clients from heroin, and Depakote can the problem.
be used as a mood stabilizer in 3. The spouse is not required to give an
bipolar disorder or as an expla nation to the nurse.
anticonvulsant. 4. The spouse’s behavior is enabling
4. The client does not need a diuretic, and a the cli ent to continue to drink until
stimulant would produce an effect he cannot function.
opposite to what is desired. TEST TAKING HINT: The stem of the question
TEST TAKING HINT: Option “3” could be Amphetamine use causes tachycardia, vaso
elim inated if the test taker knew the constriction, hypertension, and arrhythmias.
treatment for heroin withdrawal, and 2. This might be an intervention for a
option “4” could be reasoned out problem of altered coping.
because a stimulant would produce an 3. This would be an intervention for a
undesired effect. problem of insomnia.
Content – Medical: Integrated Nursing 4. These are interventions for heart failure.
Process – Planning: Client Needs – TEST TAKING HINT: The correct answer
must address the problem of
Pharmacological and Parenteral
cardiovascular compromise, which
Therapies: Cognitive Level – Synthesis:
eliminates options
Concept – Addiction.
“2” and “3.”
92. 1. Chills, sweats, and gooseflesh occur Content – Medical: Integrated Nursing Process –
with heroin withdrawal, but seizures Implementation: Client Needs –
do not Physiological Integrity, Physiological
usually occur, so seizure precautions are Adaptation: Cognitive Level – Application:
Concept – Addiction. Synthesis: Concept – Nursing Roles.
Med-Surg Success
95. 1. This is unrealistic. Most restaurants 48
serve some form of alcoholic
beverage. It is good
advice for the client to try to avoid
Amyotrophic Lateral Sclerosis
situations that provide the temptation to (ALS or Lou Gehrig’s Disease)
use drugs or
alcohol again. 97. 1. EMG is done to differentiate a
2. The client will require a follow-up neuropathy from a myopathy, but it
program such as 12-step meetings if the does not confirm ALS.
client is not to relapse. 2. Biopsy confirms changes consistent
3. The nurse does not know that this is true. with atrophy and loss of muscle
4. The client should discuss the history with fiber, both characteristic of ALS.
the people the client chooses. 3. CK may or may not be elevated in ALS
TEST TAKING HINT: The test taker must no so it cannot confirm the diagnosis of ALS.
tice descriptive words such as “all” or 4. This is done as ALS progresses to
“do not go anywhere.” These words or determine respiratory involvement, but
phrases are absolutes that should cause it does not con firm ALS.
the test taker to eliminate the options TEST TAKING HINT: The test taker must be
containing them. clear as to what the question is asking.
Content – Medical: Integrated Nursing Process – The word “confirm” is the key to
Planning: Client Needs – Physiological Integrity, answering this question correctly. The
Physiological Adaptation: Cognitive Level – Analysis: test taker would need to know that this
Concept – Nursing Roles. disease affects the muscle tissue to
correctly identify the answer.
96. 1. The child will realize the changed
behaviors when and if they happen.
2. This could cause problems between Physiological Integrity,
the par ent and child. Reduction of Risk Potential: Cognitive Level
3. Most coping behaviors are learned – Analysis: Concept – Neurologic
from parents and guardians. Regulation.
Children of sub
stance abusers tend to cope with life 98. 1. Disuse syndrome is associated with
situ ations by becoming substance com plications of bedrest. Clients with ALS
abusers cannot move and reposition themselves,
unless taught healthy coping and they frequently have altered nutri
mechanisms. 4. Children can be a part of tional and hydration status.
the parent’s recov ery, but this is not the 2. The client does not usually have a
rationale for teaching new coping change in body image.
mechanisms. 3. ALS is a disease affecting the muscles,
not the kidneys or circulatory system.
TEST TAKING HINT: Most parents do not like
4. ALS is not painful.
did not ask for a therapeutic response but
did ask for the nurse’s best response. TEST TAKING HINT: The test taker would
The best response is to address the have to be knowledgeable about ALS to
problem. answer this question. This disease is
chronic and debilitating over time and
Process – Implementation: Client Needs – leads to wasting of the muscles.
Psychosocial Integrity: Cognitive Level – Content – Medical: Integrated Nursing
Application: Concept – Addiction. Process – Diagnosis: Client Needs –
94. 1. Telemetry and vital signs would be Physiological Adaptation: Cognitive Level
done to monitor cardiovascular – Analysis: Concept – Neurologic
compromise. Regulation.
to be corrected by their child; this could 99. 1. These signs and symptoms occur
eliminate option “2.” The correct answer during the course of ALS, but they
must address a reason for teaching new are not early symptoms.
cop ing strategies. 2. These signs and symptoms will occur
Content – Medical: Integrated Nursing as the disease progresses.
Process – Planning: Client Needs – 3. These are late signs/symptoms of ALS.
4. ALS results from the degeneration 3. Assessment is the first part of the
and demyelination of motor neurons in nursing process and is a priority, but
the spinal cord, which results in assessment will not help the client
paralysis and weakness of the muscles. breathe easier.
TEST TAKING HINT: This is an 4. This is an appropriate intervention, but
application question in which the test obtaining the pulse oximeter reading will
taker must know that ruling out of ALS not alleviate the client’s respiratory
would result in the distress.
not automatically select assessment.
Make sure that there is not another
answer being early signs/symptoms.
intervention that will directly help the
The test taker could rule out option “1”
client, especially if the client is
because of atrophy, which is a
experiencing a life-threatening
long-term occurrence; rule out option
complication.
“2” because these symptoms will occur
as the disease progresses; and rule out Content – Medical: Integrated Nursing
option “3” because these are late signs/ Process – Implementation: Client
Needs – Safe Effective Care
symptoms.
Environment, Management of Care:
Content – Medical: Integrated Nursing Cognitive
Process – Assessment: Client Needs – Level – Synthesis: Concept – Neurologic
Physiological Integrity, Physi ological Regulation.
100. 1. This is a therapeutic response, but the 102. 200 mL/hr.

client is asking for specific information. Chapter 2 Neurological Disorders 49Content – Medical:
2. About 50% of clients die within two
(2) to five (5) years from Integrated Nursing Process –
respiratory failure, aspiration
pneumonia, or another infec tious
This is a basic math question. The IV
process.
pump is calculated in mL/hr, so the
3. The nurse should allow the client to
nurse must double the rate to infuse the
talk freely about the disease process
IV solution in 30 minutes.
and should provide educational and
emotional support. TEST TAKING HINT: This is a basic
4. This is incorrect information; ALS is a calcula tion that the nurse should be
dis ease that results in death within 5 able to make even without a
years in most cases. calculator.
TEST TAKING HINT: When the client is ask Content – Medical: Integrated Nursing
ing for factual information, the nurse
Physiological Integrity, Pharmacological and
should provide accurate and truthful
Parenteral Therapies: Cognitive Level –
information. This helps foster a trusting Application: Concept – Medication.
client–nurse relationship. A therapeutic
response (option “1”) should be used 103. 1. Refusing to turn needs to be addressed
when the client needs to ventilate by the nurse, but it is not a priority
feelings and is not asking spe cific over a life threatening condition.
questions about the disease process. 2. Nausea needs to be assessed by the
Content – Medical: Integrated Nursing nurse, but it is not a priority over an
Process – Implementation: Client Needs – oxygenation problem.
Safe Effective Care Environment, Management 3. A pulse oximeter reading of less
of Care: Cognitive Level – Application: than 93% indicates that the client is
Concept – Neurologic Regulation. experiencing hypoxemia, which is a
101. 1. Elevating the head of the bed will en life-threatening emergency. This
hance lung expansion, but it is not the client should be assessed first.
first intervention. 4. The nurse must address the client’s
2. Oxygen should be given immediately com plaints, but it is not a priority over
to help alleviate the difficulty a physi ological problem.
breathing. Remember that TEST TAKING HINT: The test taker should
oxygenation is a priority. apply Maslow’s hierarchy of needs, in
which oxygenation is a priority. The tion implemented only once in every
nurse must know normal parameters shift should be eliminated as a
for diagnostic tools and laboratory possible answer when addressing
data. immobility issues.
Content – Medical: Integrated Nursing Content – Medical: Integrated Nursing
Process – Assessment: Client Needs – Safe Process – Implementation: Client Needs –
Effective Care Environ ment, Management of Physiological Integrity, Basic Care and
Care: Cognitive Level – Analysis: Concept – Comfort: Cognitive Level – Application:
Neurologic Regulation. Concept – Neurologic Regulation.
104. 1. With assistance, the client may be 106. 1. The son is not sure if he may get
able to stay at home. Therefore, ALS, so this is not an appropriate
placement in a response.
long-term care facility should not be dis 2. This is incorrect information.
cussed until the family can no longer 3. There is a genetic factor with
care for the client in the home. ALS that is linked to a
2. There is no indication that a client with chromosome 21
ALS will need a sigmoid colostomy. defect.
3. A client with ALS usually dies 4. ALS is not caused by a virus. The
within five (5) years. Therefore, the exact etiology is unknown, but
nurse studies indicate that some
should offer the client the environmental factors may lead to
opportunity to determine how he/she ALS.
wants to die. 4. ALS affects both upper TEST TAKING HINT: This question
and lower extremi ties and leads to a requires knowledge of ALS. There are
debilitating state, so the client will not be some ques tions for which test-taking
able to transfer into and operate a hints are not available.
wheelchair.
TEST TAKING HINT: The nurse should Process – Implementation: Client Needs –
always help the client prepare for death Safe Effective Care Environment,
in disease processes that are terminal Management of Care: Cognitive Level –
and should dis cuss advance directives, Application: Concept – Neurologic
which include both a durable power of Regulation.
attorney for health care and a living 107. 1. A residual (aspirated gastric
will. contents) of greater than 50 to 100 mL
Implementation: Client Needs – Physiological
indicates that the tube feeding is not being
Integrity, Physiological Adaptation: Cognitive
digested and that the feeding should be
Level – Application: Concept – Neurologic
Regulation. held.
2. A soft abdomen is normal; a distended
105. 1. Contractures can develop within a abdo men would be cause to hold the
week because extensor muscles are weaker feeding. 3. Diarrhea is a common
than flexor muscles. If the client cannot complication of tube feedings, but it is not
perform ROM exercises, then the nurse a reason to hold the feeding.
must do it for him—passive ROM. M -S S
50 ed urg uccess
2. The client should maintain a positive
nitrogen balance to promote optimal
body functioning. 4. The potassium level is low and needs
3. Adequate protein is required to inter vention, but this would not
maintain osmotic pressure and prevent indicate a need to hold the bolus tube
edema. feeding.
4. The client is usually on bedrest in the TEST TAKING HINT: Knowing normal
last stages and should be turned and assess ment data would lead the test
told to taker to elimi nate option “2” as a
cough and deep breathe more often possible correct answer. Diarrhea and
than every shift. hypokalemia would not cause the
TEST TAKING HINT: “Terminal stage” is client to not receive a feeding. Even if
the key term in the stem that should the test taker did not know what
cause the test taker to look for an “residual” means, this would be the
option addressing immobility best option.
issues—option “1.” An interven Content – Medical: Integrated Nursing
Physiological Integrity, Phar macological and
Parenteral Therapies: Cognitive
Level – Analysis: Concept – Neurologic TEST TAKING HINT: Encephalitis is
Regulation. inflam mation of the brain caused by
either a hy persensitivity reaction or
108. 1. The medication should be given a postinfectious state in which a
without food at the same time each day. virus reproduces in the
2. This medication is not affected by green, brain. Encephalitis can be a
leafy vegetables. (The anticoagulant life-threatening disease process.
warfarin [Coumadin] is a well-known History is vital in the diagnosis.
medication that is affected by eating
green, leafy vegetables.) Process – Assessment: Client Needs –
3. This medication is not affected by the Safe Effective Care Environ ment,
sun. 4. The medication can cause Management of Care: Cognitive Level –
blood dyscra sias. Therefore, the Analysis: Concept – Assessment.
client is monitored for liver function,
blood count, blood 110. 1. Bilateral facial palsies are a common
chemistries, and alkaline initial sign and symptom of encephalitis.
phosphatase. The client should 2. Fever is usually one of the first signs
report any febrile ill ness. This is and symptoms the client experiences.
the first medication devel oped to 3. A decrease in the client’s headache
treat ALS. does not indicate that the client’s
condition is becom ing worse and thus
TEST TAKING HINT: Blood dyscrasias oc
does not warrant imme diate
cur with many medications, and this
intervention.
might prompt the test taker to select
4. The absence of smell and taste
option “4” as the correct option.
indicates that the cranial nerves
Otherwise, the test taker must be
may be involved. The client’s
knowledgeable of medication
condition is becoming more
administration.
serious.
TEST TAKING HINT: This question
Physiological Integrity, requires the test taker to select an
Pharmacological and Parenteral option that in dicates the disease is
Therapies: Cognitive Level – Synthesis: progressing and the client is at risk.
Concept – Medication. Option “3” indicates that the client is
improving, and options “1” and “2” are
common early manifestations of the
Encephalitis disease. The only option that reflects
cranial nerve involvement, a sign that
109. 1. A complication of immunizations the client’s condition is becoming
for measles, mumps, and worse and requires immediate
rubella can be intervention, is option “4.”
encephalitis. Content – Medical: Integrated Nursing
2. Upper respiratory tract illnesses can Process – Assessment: Client Needs – Safe
be a precursor to encephalitis. Effective Care Environ ment, Management of
3. The herpes simplex virus, Care: Cognitive Level – Synthesis: Concept
specifically type 1, can lead to – Assessment.
encephalitis.
111. 1. A written consent is given for all
4. Fungal encephalitis is known to invasive procedures, but this would
occur in certain regions, and the
reflect care
nurse should as
before the lumbar puncture, not after.
sess for recent trips to areas where these
2. This is information that would be
fungal spores exist, but the common shared with the client about the reason
areas are the southwest United States
the proce dure would be done but not
and central California.
care after.
5. Exposure to spores does not lead to
3. The nurse should teach this
encephalitis. information to prevent the severe,
throbbing, “spinal headache”
caused by the decrease in
cerebrospinal fluid.
4. The client should lie with the head of the Content – Medical: Integrated Nursing Process
bed flat for four (4) to eight (8) hours –
after the lumbar puncture, but this Implementation: Client Needs – Physiological
position would not prevent all Integrity, Physiological Adaptation: Cognitive
hematomas. Level – Application: Concept – Nursing
Roles.
TEST TAKING HINT: When the test
taker is trying to eliminate options, 114. 1. This is an important area to assess for
any that have absolute words, such neuro logical deterioration, but it is not the first
as “all,” “never,” and “always,” are indication of increased intracranial pressure.
usually wrong and can be 2. This is the most important
eliminated quickly. Rarely is any assessment data. A change in level
activity always or never done. of consciousness
is usually the first sign of neurological
deterioration.
Content – Medical: Integrated Nursing 3. Seizures can occur with inflammation
Process – Planning: Client Needs – from encephalitis, but their occurrence
Physiological Integrity, Reduc tion of Risk does not
Potential: Cognitive Level – Synthesis: indicate that the client has increased intra
Concept – Nursing Roles. cranial pressure resulting from a
112. 1. Clients diagnosed with encephalitis have worsening condition.
neurological deficits while the 4. This is important information to assess,
inflammation is present. The but changes in vital signs are not the first
therapeutic plan is to treat the disease sign and symptom of increased intracranial
process, decrease the edema, and pressure.
return the client to an optimal level of TEST TAKING HINT: The word “first” asks
wellness. the test taker to prioritize the
2. The client may have short-term interventions. Usually all the options
memory loss from a previous are interventions
condition. that the nurse should do, but the
3. Renal function is not affected by question implies that the client may be
encepha litis. Only immobility would deteriorating. Level of consciousness
affect this is the most sensitive indicator of
system. neurological deficit.
4. There is no reason to apply Content – Medical: Integrated Nursing Process
hydrocortisone cream for encephalitis. –
Implementation: Client Needs – Safe Effective
Care
look at the option that reflects the body
sys tem that is involved with the Level – Synthesis: Concept – Neurologic
disease. Refer to medical terminology; Regulation.
encephalon means “the brain.”
115. 1. Mosquitoes breed in standing water,
Process – Diagnosis: Client Needs – even pet dishes and birdbaths. All
Physiological Integrity, Physi ological areas
Adaptation: Cognitive Level – Analysis: that collect water should be emptied,
Concept – Neurologic Regulation. removed, covered, or turned over. Rain
gutters should be cleaned.
113. 1. Clients with encephalitis should be 2. Light-colored, long-sleeved, and loose
treated for the disease process and also to 4. Immobility causes clients to be at risk
prevent complications of immobility. Turning for deep vein thrombosis. Therefore,
the client will prevent skin breakdown. clients with encephalitis should be
2. Increasing fluids helps prevent assessed for deep vein thrombosis.
urinary tract infections and 5. Immobility causes the gastrointestinal
mobilize secretions in the lungs. tract to slow, resulting in constipation.
3. The client would be maintained in a Clients can have difficulty emptying
slightly elevated position, their bladders, which can cause
semi-Fowler’s, for gravity to assist the retention and urinary tract infections
body in decreasing intracranial and stones. As sessing these systems
pressure. can identify prob lems early.
TEST TAKING HINT: Each option should be TEST TAKING HINT: Words such as “only”
read carefully. If the test taker does not (option “3”) should clue the test taker to
read each one carefully, the test taker eliminate that option. Rarely are these
could miss important words, such as ab solute terms correct.
“supine” in option “3,” resulting in an Content – Medical: Integrated Nursing
incorrect answer. Process – Planning: Client Needs – Health
fitting clothing should be worn to avoid Promotion and
mosquito bites. Maintenance: Cognitive Level – Synthesis:
3. Insect repellent may irritate the eyes, but Concept – Promoting Health.
it should be applied over clothing and on
116. 1. An alteration in body temperature in a client
all exposed areas.
with West Nile virus would not be the high
4. Mosquitoes are more prevalent at est priority.
dusk, dawn, and early evening.
Med-Surg Success Effective Care Environ ment, Management of
52
Care: Cognitive Level – Synthesis: Concept –
Nursing Roles.
2. Altered tissue perfusion would be the
118. 1. This intervention is independent, not
highest priority because it could be collaborative.
life threatening. 2. This is an independent nursing
3. A problem of fluid volume excess would intervention. 3. Assessment is an
not apply for the client with West Nile virus. independent nursing intervention.
These clients are at risk for fluid volume 4. Administering an IV fluid is collabora
def icit from nausea, vomiting, and tive because it requires an order from a
hyperthermia. 4. A problem with skin integrity health-care provider. It does, however,
could apply to the client with immobility require the nurse to assess the rate,
caused by West Nile virus, but it would not fluid, and site for complications.
be the highest priority problem.
TEST TAKING HINT: When prioritizing client
problems, oxygenation is the highest prior
TEST TAKING HINT: When reading test ques
ity problem according to Maslow, and
tions, the test taker should pay attention
tissue perfusion is oxygenation.
to adjectives. In this question, the word
Content – Medical: Integrated Nursing “col laborative” makes all the options
incorrect except option “4.”
Collaborative interven tions require an
Physiological Adaptation: Cognitive Level –
Analysis: Concept – Neurologic Regulation. order from a health-care provider, but the
nurse uses judgment and intuition within
117. 1. Clients with West Nile virus should be the scope of practice.
continuously assessed for alteration in gas Content – Medical: Integrated Nursing
exchanges or patterns. Process – Implementation: Client Needs –
2. A rash will resolve when the disease Safe Effective Care Environment, Management
causing the rash is treated. of Care: Cognitive Level – Application:
3. Hypothermia is not treated with ice Concept – Neurologic Regulation.
packs but with warming blankets.
119. 1. These vital signs are within normal
4. Lymph glands are edematous early in the
ranges. The temperature is slightly elevated and
disease process. There is no reason to
may require an antipyretic but not as an
teach the client to report this condition.
immediate need.
TEST TAKING HINT: The test taker needs to 2. This is a common complaint requiring
read words carefully. Prefixes such as medication but not immediately.
“hypo-” and “hyper-” are important in de 3. This test is used to differentiate West Nile
termining if an option is correct. Even if virus from other types of encephalitis and
the test taker did not know if the client is would not require immediate intervention.
hy pothermic or hyperthermic, “hypo-” Supportive care is given for West Nile
means “less than normal” so hypothermia virus. No definitive treatment is available.
would not be treated with ice packs. A 4. These assessment data may indicate
client with West Nile virus usually has a that the client’s condition is
fever that should be reduced. Thus, a deteriorating and require immediate
treatment for hypothermia is not needed. intervention to pre vent complications.
TEST TAKING HINT: The word “immediate”
Process – Planning: Client Needs – Safe
means that the nurse must recognize transfusion, it will take time to have the
and intervene before complications type and crossmatch completed.
occur. The test taker should eliminate TEST TAKING HINT: The nurse must re
any option that contains normal member that safety is a priority when car
assessment data. ing for clients who are incapable or unable
Content – Medical: Integrated Nursing Process to protect themselves, as in option “1.”
– Assessment: Client Needs – Safe Effective Option “3” is an appropriate assessment
Care Environ ment, Management of Care: method for a traumatic brain injury be
Cognitive Level – Synthesis: Concept – cause the first step in the nursing process
Neurologic Regulation. is assessment.
120. 1. Transmission does not occur through Content – Medical: Integrated Nursing
expo sure with sneezed or coughed Process – Intervention: Client Needs –
secretions. Physiological Integrity, Physiological
2. The most common transmission of the Adaptation: Cognitive Level – Synthesis:
West Nile virus to humans is through the Concept – Neurologic Regulation.
bite of an infected mosquito. 122. 1. This may be needed once the client is sta
3. The West Nile virus can be transmitted ble, but the first action is to get the
through breast milk, blood products, needed personnel to intervene to
and organ transplants. This is a prevent lasting damage for the client.
vector-borne disease. It is transmitted 2. A Code STROKE (for an RRT related
to mosquitoes that bite infected birds. to a stroke) has been instituted in most
The incubation period is around 15 facilities to have personnel to respond
days. so that there is no delay in initiating
4. Maculopapular rashes do not drain. interventions, thus reducing the impact
Drain ing is a characteristic of a vesicle. of a cerebrovascular accident (stroke)
TEST TAKING HINT: The test taker should on a client.
eliminate option “2” because of the
According to Reuters:
abso lute word “only.”
Content – Medical: Integrated Nursing The National Stroke Association suggests us
Process – Diagnosis: Client Needs – Safe ing the word FAST to help recognize the
Effective Care Environ ment, Management of signs of a stroke. F stands for Face: ask the
Care: Cognitive Level – Analysis: Concept – person to smile, and see whether one side
Neurologic Regulation. of the face
CONCEPTS
droops. A stands for Arms: if both arms are
121. 1. The first nursing action is to ensure that the
raised, does one drift to the side? S stands
client does not sustain further damage to the for Speech: is it slurred, or strange? And T
spinal cord. The nurse does this by plac ing stands for Time: don’t waste time before
sandbags around the client’s head or by calling 911 if someone has started to show
maintaining the client on a backboard with the any of these signs.
head securely affixed to the board. The American Stroke Association says that
2. This will not occur until a full assessment during a stroke, “Time lost is brain lost.” An
is made and brain death is imminent. estimated two million brain cells die every
3. The head of the bed has to be kept flat minute during a stroke, increasing risk of per
with the client’s head stabilized until manent brain damage, disability and death.
spinal dam age has been ruled out. (Gaitan, 2014)
4. The Glasgow Coma Scale is a 3. The first nursing intervention is to call
systematic tool used to assess a the Code STROKE, then the
client’s neurologi cal status. It gives health-care provider would be notified
health-care workers a standard next.
method to determine the prog ress of a 4. Having the client swallow could be an as
client’s condition. sessment step but not a glass of water
5. The client should have an access and with standby suction available in
to be able to administer emergency case the client is unable to swallow.
medications.
6. In an emergency the nurse must
remember that certain physiological pro
concentrate on the immediate care of the
cesses carry risks that have to be
client. If the client requires a blood
contended with. Atrial fibrillation can
cause the blood to become stagnant and 4. This is a therapeutic response and the
coat the atrial inte rior surfaces. If this client is asking for information.
coating of blood breaks loose, then the TEST TAKING HINT: The test taker should
result can be an intracranial embolus. read the stem of the question carefully
Content – Medical: Integrated Nursing and determine what the client is
Process – Intervention: Client Needs – requesting. The client is newly
Physiological Integrity, Physiological diagnosed and wants to know about the
Adaptation: Cognitive Level – Synthesis: disease. The nurse should respond to
Concept – Neurologic Regulation. the client’s question.
123. 1. Safety is always a priority intervention when Content – Medical: Integrated Nursing
working with a client whose physical func tioning is Process – Intervention: Client Needs –
impaired or when the client’s cog nitive judgment is Physiological Needs: Cognitive Level –
compromised. Analysis: Concept – Neurologic Regulation.
2. The client should receive six (6) small 125. 1. The client can be up as he/she wishes but
meals each day. The client’s swallowing the nurse should assess this and determine if
ability may be impaired and the client will the client has the functional ability to be able to
be unable to consume the meal before it accomplish this without assistance.
gets cold. The consistency should be soft 2. A client with a brain tumor would be at risk
to not require extended chewing. for increased intracranial pressure (ICP).
3. Home health may be needed but the prior Fluids should be limited to decrease the
ity intervention is safety. amount of cerebrospinal fluids
4. A skin assessment is not priority over produced by the body.
keep ing the patient safe. 3. The client can have the diet of choice.
TEST TAKING HINT: The test taker should The tumor occupies space and increases
remember that basic nursing care is ap the
propriate for client protection. Maslow’s pressure on the brain, which can cause
hierarchy of needs lists safety in the vom iting. This vomiting is not associated
second highest priority tier. with the diet; it is caused by the
Physiological needs that involve pressure.
life-threatening or life-altering 4. Clients with brain issues are at risk
complications are the only things that are for electrical misfiring of the neurons, a
more important than safety. seizure. The nurse should institute
measures to protect the client
53 during a seizure.
Med-Surg Success TEST TAKING HINT: The test taker should
54
remember that basic nursing care is ap
propriate for client protection. Maslow’s
Content – Medical: Integrated Nursing hierarchy of needs lists safety in the
Process – Intervention: Client Needs –
second highest priority tier.
Safety: Cognitive
Physiological needs that involve
Level – Analysis: Concept – Neurologic Regulation.
life-threatening or life-altering
124. 1. Sometimes a client can temporarily over
come a freezing of motion or a tremor by making
an intentional movement, but the issue is not complications are the only things that
enough of the neurotransmit ter, dopamine, in the are more important than safety.
brain. Concentration or focusing will not increase
the amount of dopamine available in the brain.
Process – I ntervention: Client Needs –
2. This is the cause of the tremors, Safety: Cognitive
cogwheel motion of movement, and Level – Analysis: Concept – Neurologic Regulation.
bradykinesia, and so forth. It is also
in layman’s terms that the client can 126. 1. This is presumably true but it is not an ap
understand and provides some propriate response to someone with a
measure of hope that something can cogni tive impairment. Rational thought
be done processes do not apply.
without giving false reassurance. 2. The client would become increasingly
3. The issue is dopamine. The acetylcholine agitated when unable to utilize the phone
effects are caused by the dopamine not and/or be unable to reach the father.
be ing available to counteract the 3. The client is focused on his father. Let
acetylcholine. ting the client talk about his father
will allow him to focus on his father
while distracting him from his intravenous, can mask signs and symp
impossible-to fulfill request. toms of deterioration of the client’s
4. This is called “passing the buck.” A nurse status.
on an Alzheimer’s unit should be able to
TEST TAKING HINT: The test taker must
assess and intervene in this type of situation.
know the actions of medications in order
TEST TAKING HINT: Arguing with a client to administer them safely. Maslow’s
with cognitive impairments only hierar
produces frustrations for the client and 2. The SLUMS scale is a measurement tool
nurse. The nurse must remember the for cognitive functioning.
disease process and respond 3. The MMSE scale is another tool to
accordingly. assess cognitive functioning.
Content – Medical: Integrated Nursing 4. There is no MDED scale and, in addition,
Process – Intervention: Client Needs – depression is not cognitive functioning.
Psychological Needs: 5. The FIMS measures how well the client
Cognitive Level – Synthesis: Concept – Cognition. can perform activities of daily living, not
127. 1. This client is 28 years old and needs to cogni tive functioning.
learn how to function in the home to be able to TEST TAKING HINT: The test taker could
manage activities of daily living. The OT works eliminate options “1,” “4,” and “5” based
with clients to help them attain the highest level of on the word “cognitive” in the stem of
functionality. the question. The test taker should
2. The PT will work with the client to de highlight any word that gives a clue as
velop upper body strength. to what the question is asking. Words
3. The RD will make sure that nutritional matter.
needs are being met. Content – Cognition: Integrated Nursing
4. The rehabilitation physician (physiatrist) Process – Implementation: Client Needs –
is a rehabilitation specialist and an expert Physiological Integrity, Management of Care:
in bone, muscle, and nerves and treats Cognitive Level – Application: Concept –
injuries or illnesses that affect how a Neurologic Regulation.
client moves.
129. 1. The priority goal is for the client to main tain
5. The SW can assist the client with finan functional ability. This improves quality
cial matters and can direct the client
and quantity of life.
to programs that will help the client to
2. Verbalizing feelings is a good goal but
re ceive training in a skill(s) that will
feel ing will not impact stabilizing the physi
assist
ological deterioration of the client.
in job placement.
3. There is no way to measure the
6. The RN represents nursing in the case client’s understanding.
con ference, not the PCT.
4. Having a home health agency does not
TEST TAKING HINT: The test taker can elimi ensure that functional ability is maintained.
nate option “6” by understanding the TEST TAKING HINT: Using Maslow’s hierar
roles of the staff members. Nurses are chy of needs, physiological needs are
with the client 24 hours a day in an
higher than psychosocial needs, so the
inpatient care facility and frequently are
test taker can eliminate option “2.” The
the coordinators of the client’s care. The
nurse cannot determine or measure
nurse must know which discipline
should be consulted. “understanding,” so option “3” can be
eliminated.
Content – Mobility: Integrated Nursing
Content – Mobility: Integrated Nursing
Process – Implementation: Client Needs – Physiological Integrity,
Physiological and Psychosocial Integrity, Management of Care: Cognitive Level –
Management of Care: Cognitive Level – Analysis: Concept – Neurologic
Synthesis, Concept – Collaboration. Regulation.
128. 1. The GDS assesses the older client for 130. 1. Dexamethasone is a steroid medication
depression, not cognitive and is the steroid of choice to reduce
functioning. cerebral edema.
Chapter 2 Neurological Disorders 55 2. An IV of NS at a keep-open rate (25 mL
per hour is a keep-open rate) would not
be ques tioned. It is needed for
emergency access. between attempts to suction.
3. A nicotine patch would be administered if Med-Surg Success
56
the client is a smoker and unable to
smoke during hospitalization.
4. A narcotic analgesic is TEST TAKING HINT: The test taker can elimi
contraindicated until it is known that nate options or decide between two of the
the client is neu rologically stable. options based on the fact that options “1”
Narcotics, especially and “4” both involve suctioning the client.
chy of needs lists safety as a high priority. Either the nurse will perform suctioning or
Many medications will only be listed on it is contraindicated. Assessment is the
the NCLEX-RN examination using only the first step of the nursing process but the
generic name. Dexamethasone’s trade test taker must decide if the nurse is
name is Decadron. assessing the correct situation. Pooled
Content – Neurologic Regulation: Integrated oral secretion is not lung sounds.
Nursing Process – Intervention: Client Needs – Content – Neurologic Regulation: Integrated
Pharmacological Therapies: Cognitive Level – Nursing Process – Implementation: Client
Synthesis: Concept – Comfort. Needs – Physiological and Psychosocial
Integrity, Management of Care: Cogni tive Level
131. 1. This complete blood count has findings that – Synthesis: Concept – Oxygenation.
are within normal limits.
2. This chemistry report has findings that are 133. 1. The lowest ranking possible on the GCS
within normal limits. is 3. The client would be considered
3. This glucose level and Hgb A 1C are within brain dead, not improving.
normal limits. 2. The lower the numbers are on the GCS, the
worse the client’s functioning; this client is
4. This client has abnormal findings which
not improving.
could result in serious issues for the
3. This GCS rating indicates the client is the
client. The nurse should first initiate
same as one (1) hour ago.
seizure precautions, then notify the
4. The GCS rating is going up, which
HCP of the results and discuss the
means the client is improving.
code status of the client.
TEST TAKING HINT: The test taker can
TEST TAKING HINT: The test taker can elimi
eliminate options “1” and “2” because
nate options “1,” “2,” and “3” based on
they both present a lower score; both
the expected results. These values are
cannot be correct in a multiple-choice
within the ranges listed. The only option
question and, here, both indicate a
with ab normal data is option “4.”
worsening of the cli ent’s condition.
Content – Medical: Integrated Nursing Likewise, option “3” is the same score as
1 hour ago, so the test taker should be
Physiological and Psychosocial Integrity,
careful to note this. Therefore, because
only one answer can show an im proving
condition, the test taker can deduce that it
132. 1. When suctioning a client on a ventilator it is is option “4.”
good to hyperventilate the client before suctioning Content – Neurologic Regulation: Integrated
because suctioning the secretions would also Nursing Process – Implementation: Client
suction the oxygen from the cli ent. However, Needs – Physiological and Psychosocial
suctioning a client who has ICP increases the ICP. Integrity, Management of Care: Cogni tive Level
The nurse should attempt to remove the – Synthesis: Concept – Neurologic Regulation.
secretions without having to suction the client.
134. In order of priority: 4, 5, 2, 3, 1. 4. The
2. The secretions pooling in the back of the
client should be turned to the side to
throat would not be assessed by
prevent the tongue from falling back
listening to lung sounds or checking for
peripheral perfusion.
3. Secretions can drain if the client is
turned to the side unless the into the throat and occluding the
secretions are too heavy. The first airway. (Padded tongue blades are
action is to at tempt to relieve the NOT forced into the mouth because
situation without increasing the ICP they can break teeth and cause
even further. aspiration of the teeth.)
4. If suctioning is absolutely needed, then 5. The client’s head should be protected
a minimum of 1 minute is needed from hitting the side rails or other
objects.
2. Clothing should be loosened to prevent Process – Implementation: Client Needs –
airway difficulties. Physiological and Psychosocial Integrity,
3. The medications to control the seizures Management of Care: Cognitive Level –
should be administered to stop the Analysis: Concept – Neurologic Regulation.
seizure. 135. 1. Elevating the head of the bed 30 degrees
1. Assessment in this instance is last be will decrease ICP by using gravity to
cause of the crisis that is occurring. drain cerebrospinal fluid.
The nurse should assess the mouth to 2. Minimizing disturbing the client and
deter mine if the client bit the tongue or allowing rest in between activities
buc cal mucosa during the seizure or if will decrease ICP.
teeth were chipped or broken. 3. Suctioning increases ICP and should not
TEST TAKING HINT: Rank order questions be performed unless absolutely necessary.
can be difficult to answer. The test taker 4. Soapsuds enemas increase
should remember safety. Which intra-abdominal pressure, which, in turn,
interven tion will keep the client safe increases ICP.
the fastest? 5. Trendelenburg position is head down,
Also important is if in stress, do not feet up. This would increase ICP.
assess: Perform an intervention.
Content – Safety: Integrated Nursing
NEUROLOGICAL DISORDERS
COMPREHENSIVE EXAMINATION
clinic nurse implement first?
1. The client is admitted with a diagnosis of 1. Prepare the client for a series of
trigeminal neuralgia. Which assessment rabies injections.
data would the nurse expect to find in this 2. Notify the local animal control shelter. 3.
client? 1. Joint pain of the neck and jaw. Administer a tetanus toxoid in the deltoid.
2. Unconscious grinding of the teeth 4. Determine if the animal has had its
during sleep. vaccinations.
3. Sudden severe unilateral facial pain. 5. The client has glossopharyngeal nerve (cranial
4. Progressive loss of calcium in the nerve IX) paralysis secondary to a stroke.
nasal septum. Which referral would be most appropriate
2. The client recently has been diagnosed for this client?
with trigeminal neuralgia. Which 1. Hospice nurse.
intervention is most important for the 2. Speech therapist.
nurse to implement with the client? 3. Physical therapist.
1. Assess the client’s sense of smell and 4. Occupational therapist.
taste. 2. Teach the client how to care for 6. Which assessment data would make the
the eyes. 3. Instruct the client to have nurse suspect that the client has
carbamazepine (Tegretol) levels amyotrophic lateral sclerosis?
monitored regularly. 1. History of a cold or gastrointestinal upset
4. Assist the client to identify factors that in the last month.
trigger an attack. 2. Complaints of double vision and
drooping eyelids.
3. The client comes to the clinic and reports a 3. Fatigue, progressive muscle weakness,
sudden drooping of the left side of the face and twitching.
and complains of pain in that area. The 4. Loss of sensation below the level of
nurse notes that the client cannot wrinkle the the umbilicus.
forehead or close the left eye. Which
condition should the nurse suspect? 7. The client is scheduled for an MRI of the brain
1. Bell’s palsy. to confirm a diagnosis of Creutzfeldt-Jakob
2. Right-sided stroke. disease. Which intervention should the nurse
3. Tetany. implement prior to the procedure?
4. Mononeuropathy. 1. Determine if the client has claustrophobia.
2. Obtain a signed informed consent form. 3.
4. The client comes to the clinic for treatment of Determine if the client is allergic to egg yolks.
a dog bite. Which intervention should the
4. Start an intravenous line in both hands. should the
nurse implement with the family? Select
8. Which should be the nurse’s first intervention
all that apply.
with the client diagnosed with Bell’s palsy? 1.
1. Refer to the Huntington’s Chorea
Explain that this disorder will resolve within
Foundation.
a month.
2. Explain the need for the client to
2. Tell the client to apply heat to the
wear football padding.
involved side of the face.
3. Discuss how to cope with the client’s
3. Encourage the client to eat a soft diet. 4.
messiness.
Teach the client to protect the affected eye
4. Provide three (3) meals a day and no
from injury.
between-meal snacks.
9. The client asks the nurse, “What causes 5. Teach the family how to perform
Creutzfeldt-Jakob disease?” Which chest percussion.
statement would be the nurse’s best
15. The nurse is discussing psychosocial
response?
implications of Huntington’s chorea with the
1. “The person must have been exposed to
adult child of a client diagnosed with the
an infected prion.”
disease. Which psychosocial intervention
2. “It is mad cow disease, and eating
should the nurse implement?
contaminated meat is the cause.”
1. Refer the child for genetic counseling as
3. “This disease is caused by a virus that is
soon as possible.
in stagnant water.”
2. Teach the child to use a warming tray
4. “A fungal spore from the lungs infects
under the food during meals.
the brain tissue.”
3. Discuss the importance of not
10. The client is diagnosed with abandoning the parent.
Creutzfeldt-Jakob disease. Which referral 4. Allow the child to talk about the fear
would be the most appropriate? of getting the disease.
1. Alzheimer’s Association.
2. Creutzfeldt-Jakob Disease
Foundation. 3. Hospice care.
16. The client is undergoing post-thrombolytic
4. A neurosurgeon. therapy for a stroke. The health-care provider
Med-Surg Success
58 has ordered heparin to be infused at
1,000 units per hour. The solution comes as
25,000 units of heparin in 500 mL of D 5W. At
11. The client is diagnosed with arboviral
what rate will the nurse set the pump?
encephalitis. Which priority intervention
___________
should the nurse implement?
1. Place the client in strict isolation. 17. Which finding is considered to be one of
2. Administer IV antibiotics. the warning signs of developing
3. Keep the client in the supine position. Alzheimer’s disease?
4. Institute seizure precautions. 1. Difficulty performing familiar tasks.
12. The client is diagnosed with a brain 2. Problems with orientation to date,
abscess. Which sign/symptom is the time, and place.
most common? 3. Having problems focusing on a task.
1. Projectile vomiting. 4. Atherosclerotic changes in the vessels.
2. Disoriented behavior. 18. Which information should be shared with the
3. Headaches, worse in the morning. client diagnosed with stage I Alzheimer’s disease
4. Petit mal seizure activity. who is prescribed donepezil (Aricept),
13. The client diagnosed with a brain abscess a cholinesterase inhibitor?
has become lethargic and difficult to arouse. 1. The client must continue taking this
Which intervention should the nurse medication forever to maintain function.
implement first? 1. Implement seizure 2. The drug may delay the progression of
precautions. the disease, but it does not cure it.
2. Assess the client’s neurological status. 3. A serum drug level must be obtained
3. Close the drapes and darken the monthly to evaluate for toxicity.
room. 4. Prepare to administer an IV 4. If the client develops any muscle aches,
steroid. the HCP should be notified.
14. The client is diagnosed with 19. The spouse of a recently retired man tells
Huntington’s chorea. Which interventions the nurse, “All my husband does is sit
around and watch television all day long. 1. Assessing the neurological status.
He is so irritable and moody. I don’t want to 2. Immobilizing the fractured leg.
be around him.” Which action should the 3. Monitoring the client’s output.
nurse implement? 1. Encourage the wife to 4. Starting an 18-gauge saline lock.
leave the client alone. 2. Tell the wife that
25. The nurse writes the nursing diagnosis
he is probably developing Alzheimer’s
“altered body temperature related to
disease.
damaged temperature regulating
3. Recommend that the client see an HCP
mechanism” for a client with a head injury.
for an antidepressant medication.
Which would be the most appropriate
4. Instruct the wife to buy him some arts
goal?
and crafts supplies.
4. “Does your father like to watch old movies
20. The nurse in a long-term care facility has on television?”
noticed a change in the behavior of one of
22. The student nurse asks the nurse, “Why
the clients. The client no longer participates
do you ask the client to identify how many
in activities and prefers to stay in his room.
fingers you have up when the client hit the
Which intervention should the nurse
front of the head, not the back?” The
implement first? 1. Insist that the client go to
nurse would base the response on which
the dining room for meals.
scientific rationale?
2. Notify the family of the change in
1. This is part of the routine
behavior. 3. Determine if the client wants
neurological examination.
another roommate.
2. This is done to determine if the client
4. Complete a Geriatric Depression Scale.
has diplopia.
3. This assesses the amount of brain
damage. 4. This is done to indicate if there is
21. A family member brings the client to the a rebound effect on the brain.
emergency department reporting that the
78-year-old father has suddenly become 1. Administer acetaminophen (Tylenol)
very confused and thinks he is living in for elevated temperature.
1942, that he has to go to war, and that 2. The client’s temperature will remain less
someone is trying to poison him. Which than 100°F.
question should the nurse ask the family 3. Maintain the hypothermia blanket at 99°F
member? for 24 hours.
1. “Has your father been diagnosed 4. The basal metabolic temperature will
with dementia?” fluctuate no more than two (2)
2. “What medication has your father degrees.
taken today?” 26. Which potential pituitary complication should
3. “What have you given him that makes the nurse assess for in the client diagnosed
him think it’s poison?” with a traumatic brain injury (TBI)?
Chapter 2 Neurological Disorders 59 1. Diabetes mellitus type 2 (DM 2).
2. Seizure activity.
24. Which intervention has the highest priority 3. Syndrome of inappropriate
for the client in the emergency department who antidiuretic hormone (SIADH).
has been in a motorcycle collision with an 4. Cushing’s disease.
automobile and has a fractured left leg?
23. The ambulance brings the client with a head injury to the emergency department. The client responds
to painful stimuli by opening the eyes, muttering, and pulling away from the nurse. How would the
nurse rate this client on the Glasgow Coma Scale?
1. 3
2. 8
3. 10
4. 15
Glasgow Coma Scale

Eye Opening (E) Verbal Response (V) Motor Response (M) 4 = Spontaneous 5 = Normal
conversation 6 = Normal
3 = To voice 4 = Disoriented conversation 5 = Localizes to pain 2 = To pain 3 = Words, but not coherent
4 = Withdraws to pain 1 = None 2 = No words ... only sounds 3 = Decorticate posture 1 = None 2 =
Decerebrate
1 = None
Total = E+V+M
From Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81–84. Reprinted with
permission.
Med-Surg Success anticoagulant. 3. Monitor intake and
60
output strictly.
4. Apply warm compresses to the eyes.
27. The nurse is discussing seizure prevention 5. Perform passive range-of-motion exercises.
with a female client who was just diagnosed
with epilepsy. Which statement indicates the 32. Which client should the nurse assess first
after receiving the shift report?
client needs more teaching?
1. The client diagnosed with a stroke who
1. “I will take calcium supplements daily
has right-sided paralysis.
and drink milk.”
2. “I will see my HCP to have my blood
levels drawn regularly.”
3. “I should not drink any type of alcohol while 2. The client diagnosed with meningitis
taking the medication.” who complains of photosensitivity.
4. “I am glad that my periods will not affect my 3. The client with a brain tumor who
epilepsy.” has projectile vomiting.
4. The client with epilepsy who complains
28. The unlicensed assistive personnel (UAP)
of tender gums.
is caring for a client who is having a seizure.
Which action by the UAP would warrant 33. The client is reporting neck pain, fever, and a
immediate intervention by the nurse? headache. The nurse elicits a positive
1. The assistant attempts to insert an Kernig’s sign. Which diagnostic test
oral airway. procedure should the nurse anticipate the
2. The assistant turns the client on the HCP ordering to confirm a diagnosis?
right side. 1. A computed tomography (CT).
3. The assistant has all the side rails padded 2. Blood cultures times two (2).
and up. 3. Electromyogram (EMG).
4. The assistant does not leave the 4. Lumbar puncture (LP).
client’s bedside.
34. Which behavior is a risk factor for
29. The nurse is preparing the male client for an developing and spreading bacterial meningitis?
electroencephalogram (EEG). Which 1. An upper respiratory infection (URI).
intervention should the nurse implement? 1. 2. Unprotected sexual intercourse.
Explain that this procedure is not painful. 2. 3. Chronic alcohol consumption.
Premedicate the client with a benzodiazepine 4. Use of tobacco products.
drug.
35. Which assessment data should the nurse
3. Instruct the client to shave all facial
expect to observe for the client diagnosed
hair. 4. Tell the client it will cause him to
with Parkinson’s disease?
see “floaters.”
1. Ascending paralysis and pain.
30. Which assessment data indicate that the client 2. Masklike facies and pill rolling.
with a traumatic brain injury (TBI) exhibiting 3. Diplopia and ptosis.
decorticate posturing on admission is 4. Dysphagia and dysarthria.
responding effectively to treatment?
36. The client diagnosed with Parkinson’s disease
1. The client has flaccid paralysis.
is prescribed carbidopa/levodopa (Sinemet).
2. The client has purposeful movement.
Which intervention should the nurse implement
3. The client has decerebrate posturing
prior to administering the medication?
with painful stimuli.
1. Discuss how to prevent orthostatic
4. The client does not move the extremities.
hypotension.
31. The intensive care nurse is caring for the 2. Take the client’s apical pulse for one (1)
client who has had intracranial surgery. full minute.
Which interventions should the nurse 3. Inform the client that this medication is for
implement? Select all that apply. short-term use.
1. Assess for deep vein thrombosis. 4. Tell the client to take the medication on
2. Administer intravenous an empty stomach.
nurse suspect that the client with a C7
37. The client diagnosed with amyotrophic lateral
spinal cord injury is experiencing
sclerosis (Lou Gehrig’s disease) is
autonomic dysreflexia? 1. Abnormal
prescribed medications that require
diaphoresis.
intravenous access. The HCP has ordered a
2. A severe throbbing headache.
primary
3. Sudden loss of motor function.
intravenous line at a keep-vein-open (KVO)
4. Spastic skeletal muscle movement.
rate at 25 mL/hr. The drop factor is
10 gtts/mL. At what rate should the nurse 45. The nurse stops at the scene of a
set the IV tubing? ___________ motor-vehicle accident and provides
emergency first aid at the scene. Which law
38. Which intervention should the nurse take with
protects the nurse as a first responder?
the client recently diagnosed with
1. The First Aid Law.
amyotrophic lateral sclerosis (Lou Gehrig’s
2. Ombudsman Act.
disease)?
3. Good Samaritan Act.
1. Discuss a percutaneous gastrostomy
4. First Responder Law.
tube. 2. Explain how a fistula is accessed.
3. Provide an advance directive. 46. The nurse writes the problem “high risk for
4. Refer to a physical therapist for leg braces. impaired skin integrity” for the client with an
L5-6 spinal cord injury. Which intervention
should the nurse include in the plan of care? 1.
39. The public health nurse is discussing St. Perform active range-of-motion exercise.
Louis encephalitis with a group in the 2. Massage the legs and trochanters every
community. Which instruction should the shift. 3. Arrange for a Roho cushion in the
nurse provide to help prevent an outbreak? wheelchair. 4. Apply petroleum-based lotion to
1. Yearly vaccinations for the disease. the
2. Advise that the city should spray for extremities.
mosquitoes. 47. The nurse is preparing to administer
3. The use of gloves when gardening. acetaminophen (Tylenol) to a client diagnosed
4. Not going out at night. with a stroke who is complaining of a
40. The husband of a client who is an alcoholic headache. Which intervention should the
tells the nurse, “I don’t know what to do. I nurse implement first?
don’t know how to deal with my wife’s 1. Administer the medication in pudding.
problem.” Which response would be most 2. Check the client’s armband.
appropriate by the nurse? 3. Crush the tablet and dissolve in juice.
1. “It must be difficult. Maybe you should think 4. Have the client sip some water.
about leaving.” 48. The nurse is caring for clients on a medical
2. “I think you should attend Alcoholics comes to the clinic and reports that a migraine
Anonymous.” is coming because the client is experiencing
3. “I think that Alanon might be very helpful for bright spots before the eyes. Which phase of
you.” migraine headaches is the client experiencing?
4. “You should not enable your wife’s 1. Prodrome phase.
alcoholism.” 2. Aura phase.
41. The client is brought to the emergency 3. Headache phase.
department by the police for public 4. Recovery phase.
disorderliness. The client reports feeling 43. The client with a history of migraine
no pain and is unconcerned that the headaches comes to the emergency
police have arrested him. The nurse notes department complaining of a migraine
the client has headache. Which collaborative treatment
epistaxis and nasal congestion. Which should the nurse anticipate?
substance should the nurse suspect the 1. Administer an injection of sumatriptan
client has abused? 1. Marijuana. (Imitrex), a triptan.
2. Heroin. 2. Prepare for a computed tomography (CT) of
3. Ecstasy. the head.
4. Cocaine. 3. Place the client in a quiet room with the
42. The client with a history of migraine headaches lights off.
Chapter 2 Neurological Disorders 61 4. Administer propranolol (Inderal), a beta
blocker.
44. Which assessment data would make the unit. Which client would be most at risk for
experiencing a stroke?
1. A 92-year-old client who is an alcoholic. 2.
A 54-year-old client diagnosed with hepatitis.
3. A 60-year-old client who has a Greenfield
filter.
4. A 68-year-old client with chronic atrial
fibrillation.
49. The charge nurse is making client
assignments for a neuro-medical floor.
Which client should be assigned to the most
experienced nurse? 1. The elderly client who
is experiencing a stroke in evolution.
2. The client diagnosed with a transient
ischemic attack 48 hours ago.
3. The client diagnosed with Guillain-Barré
syndrome who complains of leg pain.
4. The client with Alzheimer’s disease who
is wandering in the halls.

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Med-Surg Success

A Q&A Review Applying Critical

Study smarter with Davis Edge NCLEX-RN.®

Davis Edge is an incredible asset that is

Comprehensive, helpful, and a total life saver.

SAVE START STUDYING

20% Use Promo

Kathryn Cadenhead Colgrove, RN, MSN, CNS

Copyright © 2017 by F.A. Davis Company

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Terri Wood Allen

Library of Congress Cataloging-in-Publication Data

Names: Colgrove, Kathryn Cadenhead, author.

I would like to dedicate this book to the memory of my mother, Mary

This book is dedicated to the memory of my husband, Bill, and my

Stephanie D. Huff, RN, DNP, FNP-BC

Mary Jo Konkloski, MSN, RN, ANP Susan M. Perry, MS, RN

Karen Kulhanek, BSN, MEd, MSN

1 Test Taking ........................................................................................................................................ 1

2 Neurological Disorders ............................................................................................................ 9

3 Cardiac Disorders ...................................................................................................................... 71

4 Peripheral Vascular Disorders ...................................................................................... 111

5 Hematological Disorders ................................................................................................... 149

Anemia ........................................................................................................................................... 164

6 Respiratory Disorders .......................................................................................................... 189

7 Gastrointestinal Disorders ............................................................................................... 249

Diverticulosis/Diverticulitis ........................................................................................................ 275

8 Endocrine Disorders ............................................................................................................. 313

9 Genitourinary Disorders ..................................................................................................... 355

10 Reproductive Disorders ..................................................................................................... 397

11 Musculoskeletal Disorders .............................................................................................. 439

12 Integumentary Disorders .................................................................................................. 475

Burns .............................................................................................................................................. 486

13 Immune System Disorders .............................................................................................. 513

14 Sensory Deficits ....................................................................................................................... 557

15 Emergency Nursing .............................................................................................................. 577

CONCEPTS ......................................................................................................................................... 585

16 Perioperative Care .................................................................................................................. 615

18 End-of-Life Issues .................................................................................................................. 667

CONCEPTS ANSWERS AND RATIONALES ................................................................................ 690

19 Pharmacology ............................................................................................................................ 701

20 Comprehensive Final Examination ........................................................................... 733

Glossary of English Words Commonly Encountered

GUIDELINES FOR USING THIS BOOK

Table 1-1 Client Needs Categories and Percentage of Items

SAFE AND EFFECTIVE CARE ENVIRONMENT

PREPARING FOR LECTURE

Sample Study Guide

Medical Diagnosis: Definition:

PROCEDURES AND NURSING

PREPARING FOR AN EXAMINATION

Understanding What the Test Taker Does Not Know

The Night Before the Exam

TAKING THE EXAM

Test-Taking Hints for the Computerized NCLEX-RN Examination

Understanding the Types of Nursing Questions

Components of a Multiple-Choice Question

a. Have the client sit down. Correct answer

d. Apply oxygen via nasal cannula.

Cognitive Levels of Nursing Questions

THE RACE MODEL: THE APPLICATION OF CRITICAL

3. Determine if the client is incontinent of urine diagnosed with a brain

55. The client diagnosed with a brain tumor was