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ST.

DOMINIC COLLEGE OF ASIA


NCM 104 SECTION A (SUMMATIVE TEST PRELIM)
1. A 65-year-old right-handed man presents to the emergency department (ED) for evaluation of a possible transient ischemic attack. He reports right arm weakness and unsteady walking. The patient also states that he had difficulty speaking for 10 minutes on the previous day. A computed tomography (CT) angiogram reveals 60% and 80% stenosis of the right internal carotid artery and left middle cerebral artery, respectively. He takes no medications. In addition to assessing relevant risk factors, which intervention is most appropriate at this time? A. Initiate aspirin B. Initiate aspirin-dipyridamole and refer for carotid endarterectomy (CEA) C. Initiate clopidogrel and refer for intracranial angioplasty and stenting D. Initiate warfarin E. Refer for intracranial angioplasty and stenting 2. A 75-year-old woman presents to the ED with abrupt onset of left-sided weakness that began 1 hour ago. Assuming all imaging tests are immediately available and there are no contraindications to the following imaging modalities, which test should initially be performed in routine clinical care? A. CT angiogram of the head and neck B. CT scan of the head without contrast C. Magnetic resonance image (MRI) of the brain D. MRI of the brain and magnetic resonance angiogram (MRA) of the head and neck 3. A 57-year-old woman presents to the ED 45 minutes after the onset of severe expressive aphasia, right hemiparesis, and hemisensory loss. Her National Institutes of Health Stroke Scale (NIHSS) score is 16. Past medical history is significant for coronary artery disease, coronary angioplasty and stent placement 4 years ago, and surgery on her left foot 5 days ago. On initial presentation, the patients blood pressure was 190/100 mm Hg and is now 170/90 mm Hg. The patient reports taking aspirin and clopidogrel for coronary artery disease. Emergent laboratory studies, electrocardiogram, and CT scan of the head performed over the next half hour are normal. After the initial evaluation and testing, the patients symptoms improve to a NIHSS score of 3. Which of the following is a contraindication to this patient receiving intravenous (IV) recombinant tissue plasminogen activator (rt-PA)? A. Current use of aspirin and clopidogrel B. Fluctuating blood pressure readings between 190/110 and 170/90 mm Hg C. NIHSS score of 3 D. Rapidly resolving symptoms E. Recent minor surgery Situation: Questions for 4 and 5. A 50-year-old woman with no past history of venous or arterial thrombosis presents to the ED with acute-onset left hemiparesis. The patient takes lisinopril for hypertension and a daily multivitamin. Brain MRI confirms an infarct in the right frontal lobe. MRA of the head and neck is normal. Cardiac rhythm on Holter monitor is also normal. Hypercoagulability studies are unremarkable. The patient is scheduled for echocardiography. 4. For an accurate diagnosis, which of the following stroke-associated cardiac conditions requires transesophageal echocardiography (TEE) rather than transthoracic echocardiography (TTE)? A. Dilated cardiomyopathy B. Interatrial shunt C. Left atrial thrombus D. Left ventricular thrombus E. Valvular vegetation 5. A small patent foramen ovale (PFO) is discovered on echocardiography. Minimal right to left shunting is seen only on Valsalva maneuver. Which of the following is the most appropriate treatment for this patient?

A. Initiate aspirin 325 mg/day B. Initiate warfarin with a target international normalized ratio (INR) of 1.5 to 2.5 C. Initiate warfarin with a target INR of 1.5 to 2.5 and aspirin 81 mg/day D. Initiate warfarin with a target INR of 1.5 to 2.5 and refer for PFO closure E. Initiate warfarin with a target INR of 2 to 3 6. A 66-year-old man with a history of atrial fibrillation presents to the ED with acute onset of right-sided weakness and sensory loss that occurred 25 minutes prior to presentation. He is alert and swallows normally. Blood pressure is 195/120 mm Hg, and heart rate is irregular at approximately 90 bpm. Serum glucose level is 358 mg/dL. Prothrombin time is elevated beyond therapeutic range. The patient currently takes warfarin. Emergent noncontrast CT scan of the head is performed (Figure). All of the following are indicated in the management of this patient EXCEPT A. Fresh frozen plasma B. Insulin C. IV labetalol D. IV vitamin K E. Phenytoin Situation: A 28-year-old woman is brought to the emergency department (ED) by ambulance after she developed a generalized convulsive seizure at home. She has had neck stiffness and fever for the past several days and has been somewhat confused and not acting like herself. The patient is still convulsing when she arrives in the ED 20 minutes later. 7. Which anticonvulsant should be used to treat this patient? A. Lorazepam 0.1 mg/kg intravenously (IV) B. Phenobarbital 20 mg/kg IV C. Phenytoin 7 mg/kg IV D. Phenytoin 20 mg/kg IV 8. The patient stops seizing with institution of anticonvulsant therapy. A lumbar puncture is emergently performed, and analysis of the cerebrospinal fluid (CSF) reveals 9 white blood cells with a lymphocytic predominance, 32 red blood cells, a protein level of 63 mg/dL, and a glucose level of 65 mg/dL. An electroencephalogram (EEG) shows sharp wave discharges in the temporal lobes but no electrographic seizures. These EEG findings are most likely to result from infection by what organism? A. Cryptococcus neoformans B. Cytomegalovirus C. Herpes simplex virus (HSV) D. Streptococcus pneumoniae 9. A 21-year-old woman presents to the ED after experiencing a first-time convulsive seizure. A friend observed the patient suddenly falling at home and convulsing for 45 seconds. Afterwards, the patient was lethargic for 15 minutes but then recovered completely without residual neurologic deficit. She sustained a tongue bite during the seizure and was incontinent of urine. What is the most appropriate next step in the management of this patient? A. Initiate an antiepileptic drug B. Obtain an EEG and a neuroimaging study C. Obtain a serum neuron-specific enolase level D. Perform a lumbar puncture for CSF analysis Situation: A 25-year-old man presents to the neurologist for follow-up evaluation of epilepsy that started in his teens. The patient averages approximately 3 to 4 seizures per month. His seizures are preceded by a warning of dj vu and a rising abdominal sensation, followed by lip smacking and speech arrest for 1 to 2 minutes and then postictal disorientation and amnesia. 10. What is this patients most likely diagnosis? A. Atypical absence seizures B. Myoclonic absence seizures C. Partial seizures originating in the frontal lobe D. Partial seizures originating in the temporal lobe

11. Previous medications have included carbamazepine, valproate sodium, and topiramate, alone and in combination, but the patient continues to have frequent seizures. Two years prior, magnetic resonance imaging (MRI) of the brain showed a discrete lesion that was compatible with mesial temporal sclerosis (Figure). What is the most appropriate next step in this patients treatment? A. Administer a different antiepileptic B. Insert a vagal nerve stimulator C. Obtain an EEG D. Refer to an epilepsy surgery center Situation: A 23-year-old woman with a history of epilepsy is in a new relationship and seeks advice about birth control. Her first seizure was a generalized tonic-clonic seizure that occurred on awakening from sleep 2 years ago. Two EEGs and an MRI of the brain were unremarkable. A second seizure occurred 6 months later. She was started on valproate sodium and has since been seizure-free. She has considered many available options and conveys that her preferred method of birth control is a combined oral contraceptive pill. 12. Which of the following is an appropriate recommendation regarding birth control in this patient? A. Discontinue valproate sodium and monitor for seizure recurrence B. Take a birth control formulation containing at least 50 g of ethinyl estradiol C. Take a progesterone-only pill instead D. There is no interaction between valproate sodium and oral contraceptive pills 13. Three years later, the patient states that she wants to stop birth control and start a family. She has not had any seizures and remains on valproate sodium. What is the most appropriate next step in this patients care? A. Add a second antiepileptic drug since pregnancy may affect seizure control B. Continue valproate sodium and begin folic acid supplementation C. Discontinue valproate sodium and monitor for seizure recurrence D. Obtain a repeat EEG and MRI to help guide decisions on continued use of valproate sodium prior to pregnancy Situation: A 62-year-old man presents to the emergency department (ED) for evaluation of leg weakness that started 4 hours prior to arrival. The patient states that his right leg suddenly became weak while walking and he had great difficulty being helped to a chair. He delayed seeking medical help, hoping that symptoms would improve, but they have not. Past medical history is significant for a heart attack 3 years ago, hypertension, hyperlipidemia, type 2 diabetes mellitus, and chronic neck and low back pain for the past 5 years. He has not taken any medications for the past month due to financial hardship. On examination, the patient is profoundly weak with all movements of the right leg, has mild weakness in the right arm, and has sensory loss over the entire right leg. Coordination and gait seem to be limited by his weakness. An electrocardiogram shows normal sinus rhythm. 14. What is this patients most likely diagnosis? A. Acute C6-C7 disk herniation B. Acute compression fracture of the L2 vertebral body C. Acute left anterior cerebral artery (ACA) stroke D. Acute left middle cerebral artery stroke 15. Noncontrast computed tomography (CT) of the head performed within 30 minutes of arrival in the ED reveals no acute findings. Assuming that the patients reported medical history is complete and accurate, what is the most appropriate treatment? A. Aspirin 325 mg B. Intravenous (IV) ketorolac 30 mg

C. IV alteplase 0.9 mg/kg as 10% dose bolus then infusion D. IV heparin drip with weight-based dosing to the therapeutic partial thromboplastin time goal

16. A 43-year-old woman presents to the ED for evaluation of weakness in both legs. She has an 18-year history of multiple sclerosis (MS), and she has had several clinical relapses. Glatiramer is her only medication. A relapse 2 years ago caused profound weakness in her legs, but after months of physical therapy, she was able to ambulate steadily with a walker. She now describes worsening weakness in her legs over the last 24 hours similar to that experienced during the relapse 2 years ago. She has new urinary incontinence, describes feeling feverish overnight, and is preoccupied with an intense ache in her left flank that has been present for the last 2 days. Magnetic resonance imaging (MRI) of the spine with and without contrast is performed (Figure). How should this patient be treated? A. Antibiotics for treatment of a urinary tract infection (UTI) B. Antibiotics for treatment of a UTI and concurrent IV methylprednisolone 250 mg every 6 hours for 3 days C. Change from glatiramer to high-dose interferon beta-1a D. IV methylprednisolone 250 mg every 6 hours for 3 days Situation: A 62-year-old man presents to the ED for evaluation of a 1-day history of leg weakness. He reports weakness in both legs while walking, and he now needs help standing up from a seated position. Past medical history is significant for a heart attack 3 years ago, hypertension, hyperlipidemia, type 2 diabetes mellitus, and lung cancer. An evaluation 3 months ago revealed no evidence of metastatic disease. He reports chronic neck and low back pain for the past 5 years. The patient also describes increasing pain in his mid-back over the past few weeks, which is not relieved by pain medication. On examination, the patient is profoundly weak with all movements of both legs but has no weakness in his arms. He has diminished sensation from the level of the umbilicus down. Reflexes are brisk in the legs and Babinskis sign is present in both feet. Coordination and gait seem to be limited by his weakness. 17. What is this patients most likely diagnosis? A. Acute C6-C7 disk herniation B. L2 vertebral body metastatic lesion causing epidural cauda equina compression C. Transverse myelitis at the T9 level of the spinal cord D. T10 vertebral body metastatic lesion causing epidural spinal cord compression 18. What is the most appropriate next step in this patients management? A. CT of the spine with and without contrast B. IV dexamethasone 24 mg C. MRI of the spine with and without contrast D. Neurosurgical consultation for immediate surgical management 19. A 62-year-old man presents to the ED for evaluation of right leg weakness. Two hours prior to arrival, the patient fell asleep in a chair with his legs crossed while watching television. When the patient awoke, he realized that his right leg had become weak. He tried walking, but it was difficult, and he had to be helped back to his chair by his wife. After 15 minutes, symptoms had not improved. He denies any pain accompanying these symptoms. Past medical history is significant for a heart attack 3 years ago, hypertension, hyperlipidemia, type 2 diabetes mellitus, low back pain for the past 5 years due to degenerative disk disease, and sciatica in the right lower extremity. He has not taken any medications for the past month due to financial hardship. On examination, he has complete inability to dorsiflex or evert the right foot but normal strength elsewhere. He has slight sensory loss over the dorsum

of the right foot. Gait is affected by a right foot drop. What is the patients most likely diagnosis? A. Flare of right lower extremity sciatica B. L5 vertebral body compression fracture C. Lacunar infarct in the left internal capsule D. Pressure palsy (neurapraxia) of the right peroneal nerve Situation: A 56-year-old man with a history of hypertension presents to the clinic with complaints of progressive hand tremor. The patient is left-handed. He first noticed the tremor 9 months ago, mostly when he is at rest. On examination, the patient has resting tremor with rigidity that is worse on the left side and decreased facial expressions. Rapid alternating movements are slow on the left side. Sporadic Parkinsons disease is suspected. 20. All of the following may help to identify this patients diagnosis EXCEPT A. HIV history B. Laboratory tests, including complete blood count C. Manganese exposure D. Trauma history 21. All of the following are cardinal features of Parkinsons disease EXCEPT A. Dementia B. Postural instability C. Rigidity D. Tremor 22. All of the following are appropriate treatment options for this patient EXCEPT A. Amantadine B. Duloxetine C. Pramipexole D. Selegiline 23. A 72-year-old man presents to the emergency department after a fall. He states that he has fallen frequently over the past 8 months. On examination, he has no tremor, but he has generalized rigidity (mostly axial), bradykinesia, increased gag reflex, and difficulty with vertical gaze. What is this patients most likely diagnosis? A. Corticobasal degeneration B. Multiple system atrophy C. Parkinsonism-dementia-amyotrophic lateral sclerosis D. Progressive supranuclear palsy 24. Alien limb phenomenon is typically seen in which of the following disorders? A. Corticobasal degeneration B. Huntingtons disease C. Multiple system atrophy D. Parkinsons disease 25. All of the following statements regarding essential tremor are correct EXCEPT A. Essential tremor is the most common adult-onset movement disorder B. Essential tremor is secondary to decreased dopaminergic neurotransmission in the basal ganglia C. Symptoms may improve with alcohol intake D. Tremor is typically postural and kinetic 26. Which of the following movement disorders persists during sleep? A. Dementia with Lewy bodies B. Huntingtons disease C. Palatal tremor D. Parkinsons disease 27. A 37-year-old man presents to the clinic with clumsiness and infrequent jerking of all limbs. He has a recent history of admission to the psychiatry unit for paranoia. Family history is significant for dementia at young age and suicide. Magnetic resonance imaging (MRI) reveals atrophy of the caudate nucleus. What is this patients most likely diagnosis? A. Essential tremor B. Huntingtons disease C. Paranoid schizophrenia

D. Tardive dyskinesia Situation: A 72-year-old woman is admitted to the psychiatry unit with agitation and visual hallucinations. The patients symptoms started 1 year ago, and 6 months later, the patient started to have fluctuating cognitive impairments. Physical examination reveals tremor and rigidity. 28. Which of the following is this patients most likely diagnosis? A. Alzheimers disease B. Corticobasal degeneration C. Dementia with Lewy bodies D. Multi-infarct dementia 29. Which of the following medications is the most appropriate for the long-term management of the patients visual hallucinations and agitation? A. Chlorpromazine B. Haloperidol C. Quetiapine D. Thioridazine 30. Wilsons disease is most accurately diagnosed with which of the following? A. Biopsy of the liver B. Computed tomography C. MRI D. Urinary copper excretion 31. A 6-year-old boy awakens in his normal state, but by noon becomes so unsteady that he cannot walk. On examination, he looks scared but is well-spoken and cooperative. He has mild nystagmus on lateral gaze bilaterally, past-pointing on finger-nose-finger test, and normal reflexes. Strength is intact, but he cannot balance while standing, and his gait is wildly lurching. He developed chicken pox 10 days ago, but he is otherwise healthy. Developmental milestones are normal. What is this childs most likely diagnosis? A. Acute postinfectious cerebellitis B. Medulloblastoma C. Miller Fisher syndrome D. Multiple sclerosis 32. A 2-year-old girl has sudden attacks of falling multiple times a day. During these attacks, she walks like shes drunk, looks scared, and turns pale, but there is no loss of consciousness. Her parents have noticed that sometimes with an attack, her eyes will appear to wobble. She will grab at the walls, and, when on the floor, grab at the floor. If she falls asleep after onset of an attack, she wakes up normal. Vomiting also helps relieve symptoms transiently. She has these episodes about once every few weeks to few months, in between which she is normal. Physical examination is normal. What is this childs most likely diagnosis? A. Benign paroxysmal positional vertigo B. Benign paroxysmal vertigo (BPV) of childhood C. Ependymoma D. Frontal lobe epilepsy 33. An 11-year-old boy still cannot ride a bike and has become increasingly clumsy over the past 4 to 5 years. A distant uncle was also clumsy and died in young adulthood of heart disease. Physical examination shows dysarthric speech, head thrusts with visual tracking, past-pointing on finger-nose-finger test, disorganization on rapid pronation-supination of the hand, jerky and illegible handwriting, and lurching gait. Deep tendon reflexes are not elicitable. What test is most likely to be diagnostic in this child? A. Magnetic resonance imaging (MRI) of the brain and lumbar puncture B. Lipid panel, apolipoproteins A and B C. Test for trinucleotide repeat of FRDA gene D. Plasma amino acids and urine organic acids 34. A 4-year-old girl presents for involuntary writhing movements in her arms with small, random, superimposed twitches. She has a history of asthma and frequent pneumonia and sinusitis. Physical examination shows hypometric saccades, forced

blinking to initiate saccades, truncal ataxia, and choreoathetosis. Skin examination shows telangiectasias on the bulbar conjunctivae, on the tops of the ears, along the malar prominences of the face, and within the flexor creases of the elbows and knees. What test is most likely to be diagnostic? A. Alpha-fetoprotein (AFP) and carcinoembryonal antigen (CEA) B. Chest radiograph C. MRI of the brain and lumbar puncture D. Urine for catecholamines Situation:A 76-year-old retired English professor is brought to the clinic by her daughter, who reports that over the past 2 years her mother has had slowly progressing forgetfulness of recent conversations and events, peoples names, and the location of personal items. She also appears more withdrawn and less interested in longstanding social activities, but she enjoys her grandchildren, lives alone, drives locally, and manages her own finances. The patient denies being depressed or forgetful but admits to occasional senior moments. Her past medical history is significant for hypertension, and she takes a diuretic. Review of systems is negative. She has been widowed for 3 years and is a nonsmoker. She has had 1 or 2 mixed drinks in the evening for 30 years, but denies history of alcoholism. Her family history is significant for senility (mother) and stroke (brother). On examination, she is easily engaged, has sharp social wit, and has normal affect and mood. Mini-Mental State Exam (MMSE) score is 27/30 (-2 item recall, -1 date), and she has mildly diminished light touch, pinprick, cold, and vibration sensation in the feet. Otherwise, results of a general and elementary neurologic examination are unremarkable for her age. Results of laboratory tests are within normal limits except for a borderline (lownormal) vitamin B12 level. 35. What is the most likely primary cause of this patients presentation? A. Normal aging B. Pseudodementia C. Chronic excessive alcohol intake D. A mild form of a primary neurodegenerative cognitive disorder E. Vitamin B12 deficiency 36. Suppose that a detailed assessment of the above patient shows normal basic and complex activities of daily living (ADL), neuropsychological (NP) testing reveals deficits only in learning and recall of new information, and magnetic resonance imaging (MRI) of the brain shows mild age-appropriate general cerebral atrophy and mild leukoaraiosis. Which of the following diagnoses would be consistent with this presentation? A. Alzheimers disease (AD) B. Mild cognitive impairment (MCI)-amnestic type C. Vitamin B12 deficiency D. Normal pressure hydrocephalus (NPH) 37. Instead, suppose that the patient has had difficulty with planning large family meals and long trips, balancing her checkbook, and doing her taxes. NP testing shows not only deficits in new learning and remembering but also mild deficits in executive function, visuospatial function, and confrontational naming. Which of the following diagnoses would be consistent with this presentation? A. MCI-multiple domains type B. AD C. NPH D. Combination of vitamin B12 deficiency and chronic excessive alcohol intake 38. A 67-year-old man with no significant past medical history, family history, or history of toxic exposure presents with a 1-year history of gradually increasing wellformed visual hallucinations, periods of confusion lasting minutes to hours, and increasing slowness of movement and imbalance. NP testing and examination show preserved memory function but moderate executive and visuospatial dysfunction, slowness of thought and general movements, and mildly diminished finger dexterity and postural reflexes. Results of laboratory tests and brain MRI are unremarkable. Electroencephalogram (EEG) shows mild bilateral posterior slowing but no spikes. A

trial of carbidopa-levadopa did not improve his motor symptoms. What is this patients most likely diagnosis? A. Idiopathic Parkinsons disease with dementia B. Frontotemporal dementia C. Complex partial epilepsy D. Dementia with Lewy bodies 39. The primary neurochemical disturbance in idiopathic Parkinsons disease involves which of the following neurotransmitters? A. Gamma-aminobutyric acid B. Dopamine C. Glutamate D. Serotonin 40. Which of the following pathologic abnormalities are characteristically found in patients with Parkinsons disease? A. Corpora amylacea B. Lewy bodies C. Neurofibrillary tangles D. Pick bodies 41. Parkinsons disease is characterized by each of the following clinical symptoms EXCEPT: A. Action tremor B. Bradykinesia C. Postural instability D. Resting tremor 42. Which of the following symptoms or symptom complexes must be present to diagnose Tourettes syndrome? A. Coprolalia B. Multiple motor tics present for 6 months C. Multiple motor and phonic tics present for 12 months D. Vocal tics present for 3 months 43. What is the genetic inheritance pattern of Huntingtons disease? A. Autosomal dominant B. Autosomal recessive C. Maternal D. X-linked 44. What is the gene mutation present in Huntingtons disease? A. Frameshift mutation B. Mitochondrial DNA deletion C. Nuclear point mutation D. Trinucleotide repeat expansion 45. Which of the following is the most common tardive, drug-induced movement disorder? A. Chorea B. Myoclonus C. Orolingual dyskinesia D. Tremor 46. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma 47. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room c. increase the dose of muscle relaxants. d. avoid naps during the day 48. A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed.

b. Restrain the clients arms and legs. c. Place a tongue blade in the clients mouth. d. Take measures to prevent injury. 49. A female client with Guillain-Barr syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. You may have difficulty believing this, but the paralysis caused by this disease is temporary. b. Youll have to accept the fact that youre permanently paralyzed. However, you wont have any sensory loss. c. It must be hard to accept the permanency of your paralysis. d. Youll first regain use of your legs and then your arms. 50. The nurse is working on a surgical floor. The nurse must logroll a male client following a: a. laminectomy. b. thoracotomy. c. hemorrhoidectomy. d. cystectomy.

51. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the clients head. d. Administer a sedative as ordered. 52. During a routine physical examination to assess a male clients deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. C. tap the tendon slowly and softly d. hold the reflex hammer tightly. 53. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this clients plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury 54. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, Sometimes I feel so frustrated. I cant do anything without help! This comment best supports which nursing diagnosis? a. Anxiety b. Powerlessness c. Ineffective denial d. Risk for disuse syndrome 55. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. prevent respiratory alkalosis. b. lower arterial pH. c. promote carbon dioxide elimination. d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg 56. Nurse Maureen witnesses a neighbors husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? a. Flexed position b. Head tilt-chin lift c. Jaw thrust maneuver d. Modified head tilt-chin lift

57. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the clients peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle 58. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the clients history of: a. Hypertension b. Heart failure c. Prosthetic valve replacement d. Chronic obstructive pulmonary disorder 59. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburgs position d. Side-lying, with the legs pulled up and head bent down onto chest.

60. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees 61. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and test positive of glucose 62. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours 63. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the clients limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward 64. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to move the right arm but is able to walk independently.

65. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing 66. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self 67. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech 68. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods 69. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. Eating large, well-balanced meals b. Doing muscle-strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications on time to maintain therapeutic blood levels 70. A male client with Bells palsy asks the nurse what has caused this problem. The nurses response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia c. Primary genetic in origin, triggered by exposure to meningitis d. Primarily genetic in origin, triggered by exposure to neurotoxins 71. The nurse has given the male client with Bells palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. Exposure to cold and drafts b. Massage the face with a gentle upward motion c. Perform facial exercises d. Wrinkle the forehead, blow out the cheeks, and whistle 72. Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of: a. Seizures or trauma to the brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the previous month. 73. A female client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion

c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors 74. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety? a. Speak loudly to the client b. Test the temperature of the shower water c. Check the temperature of the food on the delivery tray. d. Provide a clear path for ambulation without obstacles 75. A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the clients behavior. a. Is disoriented to person, place, and time b. Affect is flat, with periods of emotional lability c. Cannot recall what was eaten for breakfast today d. Demonstrate inability to add and subtract; does not know who is president 76. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. body temperature control. b. balance and equilibrium. c. visual acuity. d. thinking and reasoning. 77. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? a. phenytoin (Dilantin) b. mannitol (Osmitrol) c. lidocaine (Xylocaine) d. furosemide (Lasix) 78. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. Hes unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? a. Give him a barbiturate. b. Place him on mechanical ventilation. c. Perform a lumbar puncture. d. Elevate the head of his bed. 79. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: a. light flashes and floaters in front of the eye. b. a recent driving accident while changing lanes. c. headaches, nausea, and redness of the eyes. d. frequent episodes of double vision. 80. Which nursing diagnosis takes highest priority for a client with Parkinsons crisis? a. Imbalanced nutrition: Less than body requirements b. Ineffective airway clearance c. Impaired urinary elimination d. Risk for injury 81. To encourage adequate nutritional intake for a female client with Alzheimers disease, the nurse should: a. stay with the client and encourage him to eat. b. help the client fill out his menu. c. give the client privacy during meals. d. fill out the menu for the client. 82. The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following?

a. Cerebellar function b. Intellectual function c. Cerebral function d. Sensory function 83. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? a. In 30 to 45 seconds b. In 10 to 15 minutes c. In 30 to 45 minutes d. In 1 to 2 hours 84. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil a condition resulting from acute iris inflammation (iritis). As part of the clients therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? a. Parasympathomimetic agent b. Sympatholytic agent c. Adrenergic blocker d. Cholinergic blocker

85. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and hes comatose. We intubated him and hes maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manualresuscitation bag. Which intervention by the nurse has the highest priority? a. Assessing the left leg b. Assessing the pupils c. Placing the client in Trendelenburgs position d. Assessing level of consciousness 86. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: a. increasing the exudative reaction of ocular tissue. b. decreasing leukocyte infiltration at the site of ocular inflammation. c. inhibiting the action of carbonic anhydrase. d. producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris. 87. Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal? a. More back pain than the first postoperative day b. Paresthesia in the dermatomes near the wounds

c. Urine retention or incontinence d. Temperature of 99.2 F (37.3 C) 88. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: a. instilling one drop of pilocarpine 0.25% into both eyes daily. b. instilling one drop of pilocarpine 0.25% into both eyes four times daily. c. instilling one drop of pilocarpine 0.25% into the right eye daily. d. instilling one drop of pilocarpine 0.25% into the left eye four times daily. 89. A female client whos paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? a. The client leaves the side rails down. b. The client uses a mirror to inspect the skin. c. The client repositions only after being reminded to do so. d. The client hangs the left arm over the side of the wheelchair. 90. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the clients feet make a half circle. To document the clients gait, the nurse should use which term? a. Ataxic b. Dystrophic c. Helicopod d. Steppage 91. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? a. A private room down the hall from the nurses station b. An isolation room three doors from the nurses station c. A semiprivate room with a 32-year-old client who has viral meningitis d. A two-bed room with a client who previously had bacterial meningitis 92. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the clients history. Which preexisting condition would contraindicate the use of pyridostigmine? a. Ulcerative colitis b. Blood dyscrasia c. Intestinal obstruction d. Spinal cord injury 93. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Mnires disease. When assessing this client, the nurse expects to note: a. vertigo, tinnitus, and hearing loss. b. vertigo, vomiting, and nystagmus c. vertigo, pain, and hearing impairment. d. vertigo, blurred vision, and fever. 94. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? a. Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours. b. Try to ambulate independently after about 24 hours. c. Shampoo your hair every day for 10 days to help prevent ear infection.

d. Dont fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days. 95. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? a. Excessive tearing b. Urine retention c. Muscle weakness d. Slurred speech 96. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? a. Tachycardia b. Increased salivation c. Hypotension d. Apnea 97. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this clients care, the nurse should assign highest priority to which nursing diagnosis? a. Impaired physical mobility b. Ineffective breathing pattern c. Disturbed sensory perception (tactile) d. Self-care deficient: Dressing/grooming 98. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for: a. long-term treatment of epilepsy. b. postoperative pain management of laminectomy clients. c. postoperative pain management of diskectomy clients d. treatment of spasticity associated with spinal cord lesions.

99. A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the clients oculocephalic (dolls eye) response by: a. introducing ice water into the external auditory canal. b. touching the cornea with a wisp of cotton. c. turning the clients head suddenly while holding the eyelids open. d. shining a bright light into the pupil. 100. While reviewing a clients chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? a. The client may be less sensitive to the effects of a neuromuscular blocking agent. b. Succinylcholine shouldnt be used; pancuronium may be used in a lower dosage. c. Pancuronium shouldnt be used; succinylcholine may be used in a lower dosage. d. Pancuronium and succinylcholine both require cautious administration.