1.

A patient has Alzheimer's disease and keeps the nurse in the room for extended periods of time while reminiscing about the past. Which of the following interventions by the nurse would be MOST therapeutic? a. Keep the patient focused on the present and future only b. Take the patient to group therapy with others in a similar age group c. Set aside time in planning care in which you can let the patient reminisce about the past d. Offer diversionary activities that will free you to do your work, and reduce patient's talking about past

 Rationale:

Patients with Alzheimer's Disease often focus a great deal on the past. It is important for the nurse to allow the patient to do this in order to maintain self-esteem and self-concept. The nurse should set aside a certain amount of time in providing daily care in which the patient is allowed to reminisce about the past.

2. A patient is admitted to the Surgical Intensive Care Unit following a motorcycle accident in which severe head trauma was obtained. Which of the following signs would be indicative of increased intracranial pressure? a. Increased pulse, increased respirations, increased BP b. Increased pulse, decreased respirations, increased BP c. Decreased pulse, decreased respirations, increased BP d. Decreased pulse, decreased respirations, decreased BP

Answer: C Rationale: Signs and symptoms that may indicate an increase in Intracranial Pressure may include headaches, visual changes, seizures, vomiting, stiff neck etc. VS are also an important indicator, as indicated by Choice C, the triad of decreased pulse and respirations, and a rising BP, also called Cushing's Triad are very important indicators of increased intracranial pressure (ICP) and MUST be monitored carefully by the nurse.
2.

3. The nurse reading the physician's report of an elderly patients physical examination knows a notation that the patient demonstrates xanthelasma refers to: a. bright red moles. b. dark discoloration of the skin. c. yellowish waxy deposits on upper eyelids. d. liver spots

Answer: C Rationale: Xanthelasma is the yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia
3.

4. Which type of glaucoma presents an ocular emergency? a. Chronic open-angle glaucoma b. Acute angle-closureglaucoma c. Ocular hypertension d. Normal tension glaucoma

Answer: B Rationale: Acute angle-closure glaucoma results in rapid progressive visual impairment.Ocular hypertension and normal tension glaucoma is treated with topical medication. Chronic open-angle glaucoma is treated initially with topical medications, with oral medications added at a later time.
4.

5. Which of the following terms refers to surgical repair of the tympanic membrane? a. Ossiculoplasty b. Myringotomy c. Tympanoplasty d. Tympanotomy

Answer: C Rationale: Tympanoplasty may be necessary to repair a scarred eardrum. Myringotomy is an incision into the tympanic membrane. Tympanotomy is an incision into the tympanic membrane. Ossiculoplasty is a surgical reconstruction of the middle ear bones to restore hearing.
5.

6. When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a. sees an object from 200 feet away that a person with normal vision sees from 200 feet away. b. sees an object from 20 feet away that a person with normal vision sees from 20 feet away. c. sees an object from 200 feet away that a person with normal vision sees from 20 feet away. d. sees an object from 20 feet away that a person with normal vision sees from 200 feet away.

Answer: D Rationale: The standard of normal vision, 20/20 means that the patient can read the 20/20 line from a distance of 20 feet.
6.

7. The cranial nerve that is responsible for salivation, tearing, taste, and sensation in the ear is the ________nerve. a. trigeminal b. facial c. vestibulocochlear d. oculomotor

Answer: C Rationale: The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The facial (VII) nerve controls facial expression and muscle movement. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation.
7.

8. A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized? a. Prevent an increase intraocular pressure b. Alleviate pain c. Maintain darkened room d. Promote low-sodium diet

Answer: A Rationale: After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.
8.

9. Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this disorder is present? a. Transparent tympanic membrane b. Thick and immobile tympanic membrane c. Pearly colored tympanic membrane d. Mobile tympanic membrane

Answer: B Rationale: Otoscopicexamnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or without perforation.
9.

10. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotic is for: a. Constricting pupil b. Relaxing ciliary muscle c. Constricting intraocular vessel d. Paralyzing ciliary muscle

 10.

Answer: A Rationale: Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of aqueous humor.

11. Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure? a. Intermittent tachycardia b. Polydipsia c. Tachypnea d. Increased restlessness

 11.

Answer: D Rationale: Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.

12. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal? a. Red blood cells b. White blood cells c. Insulin d. Protein

 12.

Answer: A Rationale: The adult with normal cerebrospinal fluid has no red blood cells.

13. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion? a. Administer diuretics b. Administer anlgesics c. Provide hygiene. d.Hyperoxygenate before and after suctioning

 13.

Answer: D Rationale: It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.

14. A client receiving chemotherapy has developed sores in his mouth. He asks the nurse why this happened. What is the nurses best response? a.It is a sign that the medication is working. b. You need to have better oral hygiene. c. The cells in the mouth are sensitive to the chemotherapy. d. This always happens with chemotherapy.

 14.

Answer: C Rationale: The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover.

15. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA? a. Pupil size and papillary response b. cholesterol level c. Echocardiogram d. Bowel sounds

 15.

Answer: A Rationale: It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.

16. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? a. "I have constant blurred vision." b. "I can't see on my left side." c. "I have to turn my head to see my room." d. "I have specks floating in my eyes

 16.

Answer: C Rationale: Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye.

17. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? a. Place the child in the nearest bed b. Administer IV medication to slow down the seizure c. Place a padded tongue blade in the child's mouth d. Remove the child's toys from the immediate area

 17.

Answer: D Rationale: Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child''s mouth and they should not be moved. Of the choices given, first priority would be for safety.

18. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed: a. Reactive pupils b. A depressed fontanel c. Bleeding from ears d. An elevated temperature

 18.

Answer: C Rationale: Bleeding from ears. The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation

19. Your patient Allen, a carnival performer dubbed as The Human Cannonball has been in the neurology ICU because of brain herniation almost immediately after a severe head injury during a stunt that had gone bad. The following are corrct nursing interventions associated with taking car of this patient EXCEPT: a. Log roll client b. Avoid extreme flexion or extension of the neck c. Administer lubricating eyedrops d. Keep client in a quiet environment and in a supine position.

 19.

Answer: D Rationale: the herniated tissue exerts pressure on the brain which interferes with the blood supply in that area. Cessation of cerebral blood flow results in cerebral ischemia, infarction and brain death. The nurse in charge to care for the client should elevate the head of bed to 30 degrees to promote venous drainage of the brain and avoid extreme flexion and extension of the neck to avoid increase intracranial pressure.

20. You have been assigned to a 25-year old woman with GBS. Which of the following is your priority nursing diagnosis for the client with Gullain-Barre Syndrome? a. Impaired physical mobility b. Impaired breathing pattern c. Acute Pain d. Imbalanced nutrition

Answer: b Rationale: GBS typically begins with muscle weakness and diminished that progress upwards. The compromised respiratory function would eventually lead to respiratory failure. Impaired breathing pattern is the priority nursing diagnosis because respiratory involvement makes GBS a medical emergency that often needs assistive ventilation.
20.

21. Sensation is one of the many areas of the body which the nervous system regulates. You have a client with an injury to the thalamus. In providing care for this client, you should plan to: a. Insert an NGT to feed the client b. Keep patches on the clients eyes to prevent corneal abrasion c. Monitor the temperature of the bathwater d. Give higher doses of pain medication.

21. Answer: c Rationale: the thalamus acts as a relay station for all senses except smell. All memory, sensation and pain impulses also pas through this section of the brain. It plays a role in the conscious awareness of pain and the recognition of variation in temperature and touch. Damage to the thalamus will prevent the patient from recognizing extreme heat or cold predisposing him to injury. A thalamus injury would cause a decreased sensation of pain, eliminating or reducing the need for pain medications.

22. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure a. Pulling the auricle backward and upward b. Warming the solution to room temperature c. Pacing the tip of the dropper on the edge of ear canal d. Placing client in side lying position

Answer: C Rationale: The dropper should not touch any object or any part of the clients ear.
22.

23. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure? a. Tonic seizure b. Absence seizure c. Myoclonic seizure d. Clonic seizure

Answer: C Rationale: Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle groups.
23.

24. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be: a. Hold the clients arms and leg firmly b. Place the client immediately to soft surface c. Protects the clients head from injury d. Attempt to insert a tongue depressor between the clients teeth

Answer: C Rationale: Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.
24.

25. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration? a. Position the client on the side with head flexed forward b. Elevate the head c. Use tongue depressor between teeth d. Loosen restrictive clothing

Answer: A Rationale: Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.
25.

26. What is the EARLIEST SIGN of increased ICP? a. Headache b. Widening pulse pressure c. Tachycardia d. Agitation

Answer: D Rationale: A change in the level of consciousness is the earliest sign of increased ICP. Options a and b are both late signs. Option c is incorrect; increased ICP causes bradycardia, not tachycardia.
26.

27. What is the action of Baclofen [Liorisal]? a. induces sleep b. stimulates appetite c. muscle relaxant d. reduce bacterial urine count

Answer: C Rationale: Baclofen is a muscle relaxant used to treat spastic movement in multiple sclerosis, spinal cord injury, amyotrophic lateral sclerosis (Lou Gehrig's disease) and trigeminal neuralgia.
27.

28. What type of environment is appropriate for a client with Alzheimers? a. familiar b. variable c. challenging d. non-stimulating

Answer: A Rationale: To promote the patients safety and security, the patient needs to be in a familiar environment.
28.

29. A patient has increased ICP due to stroke. What is the immediate nursing action? a. Administer Mannitol as ordered b. Elevate the head of the bed 30 - 45 c. Restrict fluids d. Avoid the use of restraints

Answer: A Rationale: Mannitol will produce the fastest response in decreasing the patients intracranial pressure. Option B, while correct, will not produce a fast response. Option C is incorrect; a patient with increased ICP should have fluids limited, not restricted. Option D is a nursing intervention for a patient at risk for developing increased ICP, but it will not help if the ICP is already elevated.
29.

30. Which nursing intervention is appropriate for a client with intracranial pressure of 20 mmHg? a. Give the client a warming blanket b. Administer low-dose barbiturates c. Encourage client to hyperventilate d. Restrict the patients fluids

Answer: C Rationale: Increased ICP produces bradypnea, so hyperventilating will help maintain the clients oxygenation. Option A is incorrect; increased ICP produces hyperthermia, so a warming blanket will aggravate the clients temperature. Option B is incorrect; barbiturates are CNS depressants that will further decrease the clients respiratory rate. Option D is incorrect; a patient with increased ICP should have fluids limited, not restricted.
30.

31. A patient is at risk for increased ICP. What would be the priority for the nurse to monitor? a. Unequal pupil size b. Decreased systolic BP c. Tachycardia d. Decreased body temp

Answer: A Rationale: Increased ICP causes anisocoria due to pressure on the oculomotor nerve. Options B, C and D are incorrect; increased ICP produces increased BP, bradycardia and hyperthermia
31.

32. A client who is regaining consciousness after a craniotomy attempts to pull out his IV line. Which action protects the client without increasing ICP? a. Jacket restraints b. Wrap hands in a soft mitten restraint c. Tuck arms and hands under the draw sheet d. Apply wrist restraints to each arm.

Answer: B Rationale: Mittens will protect the client while still allowing freedom of movement. Options A, C and D will limit the patients movement, which will increase the patients anxiety and consequently increase the patients ICP.
32.

33. Which is the characteristic of Alzheimers disease? a. transient ischemic attacks b. remissions and exacerbations c. rapid deterioration of mental functioning because of arteriosclerosis d. slowly progressive deficits in the intellect, which may not be noted for a long time.

33. Answer: D Rationale: Option A is a characteristic of stroke. Option B is a characteristic of Myasthenia Gravis or Multiple Sclerosis. Option C is a characteristic of Dementia

34. When performing a sensory assessment on a client with a head injury, the nurse would include which assessment intervention? a. Having the client grasp the examiner's hands b. Having the client state how he is feeling c. Touching sharp and dull objects to both extremities d. Using a reflex hammer to assess deep tendon reflexes

34. Answer: C Rationale: Using sharp and dull objects touched to both extremities is one aspect of the sensory assessment that aids in determining the client's ability to discriminate between different sensations.

35. Which functions would the nurse expect to be affected in a client who sustains a concussion to the temporal lobe of the brain? a. Abstract thinking and judgment b. Interpretation and auditory association c. Sensory recognition and position sense d. Speech and visual functioning

35. Answer: B Rationale: The temporal lobe of the brain contains the auditory receptive areas, a vital area called the interpretive area that provides integration and somatization, and the visual and auditory areas.

36. The client with a closed head injury is obtunded with a Glasgow Coma Score of 3. His pupils are fixed and dilated, his blood pressure has gone from 140/94 mm Hg to 170/62 mm Hg, and his heart rate has gone from 84 to 42 beats per minute. The client is exhibiting which condition? a.Cerebral edema b. Curling's syndrome c. Cushing's triad d. Impaired cerebral perfusion

36. Answer: C Rationale: Cushing's triad is characterized by increasing systolic blood pressure, decreasing diastolic blood pressure, and bradycardia; it is indicative of brain stem involvement and impending herniation.

37. Following a stroke, a client exhibits ptosis and a decreased corneal reflex in the right eye. Which nursing intervention would be most appropriate for this client? a. Instituting eye exercises to strengthen the client's weak eye b. Keeping the client's eye open to help with visualization c. Patching the client's eye and instilling drops d. Placing objects within the client's central field of vision

Answer: C Rationale: Because of the client's ptosis and decreased corneal reflex, the client is at risk for eye trauma. Patching the eye and applying eyedrops for lubrication would help prevent corneal abrasions for a client. Placing objects within the central field of vision is appropriate for a client with unilateral neglect or visual field deficits.
37.

38. Which nursing intervention would the nurse institute immediately for a newly admitted client diagnosed with a seizure disorder? a. Placing a padded tongue blade at the head of the bed b. Keeping the bed in a high position with side rails down c. Padding the head and foot of the bed d. Placing the client on seizure precautions

Answer: D Rationale: Seizure precautions, such as padding side rails, keeping an oral airway at bedside, maintaining the bed in a low position with side rails up, and making sure all staff are aware of the seizure disorder, should be instituted for any client with a seizure disorder to minimize the risk of injury should a seizure occur.
38.

39. For which diagnostic procedure would the nurse expect to prepare a client diagnosed with meningitis? a. Computed tomography (CT) scan b. Electroencephalography (EEG) c. Lumbar puncture d. Myelogram

39. Answer: C Rationale: A lumbar puncture, which allows for evaluation of cerebrospinal fluid (CSF), is used in the diagnosis of meningitis; a sample of CSF can be obtained and cultured to identify the causative organism.

40. The nurse would expect to assess which clinical manifestation in a client diagnosed with multiple sclerosis (MS)? a. Ascending paralysis of the lower extremities and paresthesias b. Muscle weakness, diplopia, and nystagmus c. Resting tremors, muscle rigidity, and masklike facial expressions d. Muscle weakness after activity, drooping facial muscles, and ptosis

40. Answer: B Rationale: MS is a progressive demyelinating disease affecting nerve fibers of the brain and spinal cord, resulting in visual problems, motor problems, fatigue, and mental changes. Ascending paralysis of the lower extremities and paresthesias are clinical manifestations of Guillain-Barr syndrome. Resting tremors, muscle rigidity, and masklike facial expressions are clinical manifestations of Parkinson's disease. Muscle weakness after activity, drooping facial muscles, and ptosis are clinical manifestations of myasthenia gravis.

41. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information? a. "I usually avoid driving at night since lights sometimes seem to make things blur." b. "I take half of the usual dose for my sinuses to maintain my blood pressure." c. "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem." d. "I take extra fiber and drink lots of water to avoid getting constipated.

41. Answer: D Rationale: Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure

42. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory? a."Name the year." "What season is this?" (pause for answer after each question) b."Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." c."I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." d."What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

42. Answer: C Rationale: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, and pen."

43. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? a. Confusion b. Loss of half of visual field c. Shallow respirations d. Tonic-clonic seizures

Answer: C Rationale: A.L.S. is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective
43.

44. Chemical burn of the eye are treated with a. local anesthetics and antibacterial drops for 24 to 36 hours. b. hot compresses applied at 15-minute intervals c. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water d. cleansing the conjunctiva with a small cotton-tipped applicator

44. Answer: C Rationale: Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done.

45. A client with head injury is confused, drowsy and has unequal pupils. Which of the following nursing diagnosis is most important at this time? a. altered level of cognitive function b. high risk for injury c. altered cerebral tissue perfusion d. sensory perceptual alteration

45. Answer: C Rationale: The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage.

46. What would be the MOST therapeutic nursing action when a clients expressive aphasia is severe? a. Anticipate the client wishes so she will not need to talk b. Communicate by means of questions that can be answered by the client shaking the head c. Keep us a steady flow rank to minimize silence d. Encourage the client to speak at every possible opportunity.

Answer: D Rationale: Expressive or motor aphasia is a result of damage in the Brocas area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively.
46.

47. The client has clear drainage from the nose and ears after a head injury. How can the nurse determine if the drainage is CSF? a. Measure the ph of the fluid b. Measure the specific gravity of the fluid c. Test for glucose d. Test for chlorides

Answer: C Rationale: The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicates CSF leakage.
47.

48. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation? a. A rapid pulse and increased RR b. Decreased physiologic functioning c. Rigid posture and altered perceptual focus d. Increased awareness and attention

Answer: A Rationale: A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival.
48.

49. Which of the following indicates poor practice in communicating with a hearingimpaired client? a. Use appropriate hand motions b. Keep hands and other objects away from your mouth when talking to the client c. Speak clearly in a loud voice or shout to be heard d. Converse in a quiet room with minimal distractions.

49. Answer: C Rationale: Speak clearly in a loud voice or shout to be heard. Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly.

50. The nurse is performing an eye examination on an elderly client. The client states My vision is blurred, and I dont easily see clearly when I get into a dark room. The nurse best response is: a. You should be grateful you are not blind. b. As one ages, visual changes are noted as part of degenerative changes. This is normal. c. You should rest your eyes frequently. d. You may be able to improve you vision if you move slowly.

50. Answer: B Rationale: Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision.

51. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: a. Brief exaggeration of symptoms b. Prolonged symptomatic improvement c. Rapid but brief symptomatic improvement d. Symptomatic improvement of just the ptosis

51. Answer: C Rationale: Rapid but brief symptomatic improvement. Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.

52. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurses priority intervention is to: a. Administer the medication exactly on time b. Administer the medication with food or mild c. Evaluate the clients muscle strength hourly after medication d. Evaluate the clients emotional side effects between doses

52. Answer: C Rationale: Evaluate the clients muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels

53. The most significant initial nursing observations that need to be made about a client with myasthenia include: a. Ability to chew and speak distinctly b. Degree of anxiety about her diagnosis c. Ability to smile and to close her eyelids d. Respiratory exchange and ability to swallow

53. Answer: D Rationale: Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

54. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to: a. Develop a teaching plan b. Facilitate psychologic adjustment c. Maintain the present muscle strength d. Prepare for the appearance of myasthenic crisis

54. Answer: C Rationale: Maintain the present muscle strength. Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

55. Lumbar Tap is a test to evaluate the fluid surrounding the brain and spinal cord. This is also used to diagnose infections, bleeding, inflammatory conditions and other illnesses. When the doctor obtains a cerebrospinal fluid specimen during a lumbar puncture, its important that the nurse: a. combine all fluid into one sterile container then label it with the clients name and diagnosis b. Dispose the first specimen drawn then collect the remaining specimens then send it to the laboratory. c. Number all of the specimens in the order that they were drawn. d. Do not send the last specimen drawn to the laboratory.

55. Answer: C Rationale: In a lumbar tap, the physician carefully inserts a needle into the spinal canal. CSF specimens are collected in a series of sterile test tubes, each tube should be numbered in the order obtained to provide the most accurate fluid analysis results. It is immediately taken to the laboratory for analysis to maintain the cell count. No specimens should be discarded or combined in order to get the accurate result.

56. After teaching the client regarding the proper care of conjuctivitis while at home which of the following statements made by the client indicates that a further explanation is needed? a. If evver I have eye discomfort I can use an opthalmic analgesic ointment. b. If a purulent discharge is present I can first apply a saline eye irrigation before I instill the antibiotic drops into my affected eye. c. If a purulent dishcarge is present I can apply warm compress before I put antibiotic drops. d. if there is purulent discharge, I will discontinue the medication until the discharge is gone.

56. Answer: D Rationale: Conjunctivitis is highly contagious. Antibiotic medication, usually eye drops is usually administered four times a day for bacterial conjuctivitis. When purulent dishcarge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication.

57. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Menieres disease except: a. Antiemetics b. Diuretics c. Antihistamines d. Glucocorticoids

57. Answer: D Rationale: Glucocorticoids play no significant role in disease treatment.

58. The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position? a. Widening pulse pressure and bounding pulse. b. Diplopia and decreased visual acuity. c. Bradykinesia and scanning speech. d. Hemiparesis and personality changes

58. Answer: D Rationale: Hemiparesis would localize a tumor to a motor area of the brain, and personality changes localize a tumor to the frontal lobe.

59. The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? a. Assess the clients neurological status every hour. b. Monitor the clients heart rhythm via telemetry. c. Administer an anticonvulsant medication intravenous push. d. Prepare to administer a glucocorticosteroid orally.

59. Answer: C Rationale: Administering an anticonvulsant medication intravenous push requires the nurse to have an order or confer with another member of the health-care team.

60. The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? a. Ensure that helmets are worn in appropriate areas. b. Implement daily exercise programs for the staff. c. Provide healthy foods in the cafeteria. d. Encourage employees to wear safety glasses

60. Answer: A Rationale: Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway safety programs.

61. The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? a. Discuss how to remove insertion pins correctly. b. Instruct the client to report reddened or irritated skin areas. c. Inform the client that the vest liner cannot be changed. d. Encourage the client to remain in the recliner as much as possible.

61. Answer: B Rationale: Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period

62. The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained 3 hours later would indicate the client is improving? a. Purposeless movement in response to painful stimuli. b. Flaccid paralysis in all four extremities. c. Decerebrate posturing when painful stimuli are applied. d. Pupils that are 6 mm in size and nonreactive on painful stimuli.

62. Answer: A Rationale: Purposeless movement indicates that the clients cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

63. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? a. Administer a stool softener BID. b. Encourage the client to cough hourly. c. Monitor neurological status every shift. d. Maintain the dopamine drip to keep BP at 160/90.

63. Answer: A Rationale: The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore stool softeners would be appropriate.

64. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? a. Potential for injury. b. Powerlessness. c. Disturbed thought processes. d. Sexual dysfunction.

64. Answer: B Rationale: Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

65. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? a. Observing the client swallowing for possible aspiration. b. Positioning the client in a semi-Fowlers position when sleeping. c. Placing a suction set-up at the clients bedside during meals. d. Referring the client to an occupational therapist for evaluation.

65. Answer: D Rationale: A collaborative intervention is an intervention in which another health-care disciplinein this case, occupational therapy is used in the care of the client.

66. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? a. An oral anticoagulant medication. b. A beta-blocker medication. c. An anti-hyperuricemic medication. d. A thrombolytic medication

66. Answer: A Rationale: The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

67. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is brain dead. Which data support that the client is brain dead? a. When the clients head is turned to the right, the eyes turn to the right. b. The electroencephalogram (EEG) has identifiable waveforms. c. There is no eye activity when the cold caloric test is performed. d. The client assumes decorticate posturing when painful stimuli are applied.

67. Answer: C Rationale: The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the clients eyes moved, that would indicate that the brain stem is intact.

68. The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? a. Notify the health-care provider immediately. b. Prepare to administer an antihistamine. c. Test the drainage for presence of glucose. d. Place 2x2 gauze under the nose to collect drainage.

68. Answer: C Rationale: The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid and the HCP should be notified immediately once this is determined.

69. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? a. Assess neurological status. b. Monitor pulse, respiration, and blood pressure. c. Initiate an intravenous access. d. Maintain an adequate airway.

69. Answer: D Rationale: The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.

70. The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care? a. Administer antibiotics. b. Obtain a sputum culture. c. Monitor the pulse oximeter. d. Assess intake and output.

70. Answer: A Rationale: A nurse administering antibiotics is a collaborative intervention because the HCP must write an order for the intervention; nurses cannot prescribe medications unless they have additional education and licensure and are NPs with prescriptive authority.

71. The nurse is planning the care for a client diagnosed with Parkinsons disease. Which would be a therapeutic goal of treatment for the disease process? a. The client will experience periods of akinesia throughout the day. b. The client will take the prescribed medications correctly. c. The client will be able to enjoy a family outing with the spouse. d. The client will be able to carry out activities of daily living.

71. Answer: D Rationale: The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing routine daily tasks.

72. The nurse educator is presenting an inservice on seizures. Which disease process is the leading cause of seizures in the elderly? a. Alzheimers disease. b. Parkinsons disease. c. Cerebral vascular accident (stroke). d. Brain atrophy due to aging.

72. Answer: C Rationale: A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures.

73. The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? a. Do you have trouble hearing? b. Are you allergic to any type of dairy products? c. Have you had anything to eat in the last eight (8) hours? d. Are you uncomfortable in closed spaces?

73. Answer: D Rationale: MRIs are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI, which is available if needed.

74. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/symptoms would warrant transferring the resident to the emergency department? a. A 4-cm area of bright red drainage on the dressing. b. A weak pulse, shallow respirations, and cool pale skin. c. Pupils that are equal, react to light, and accommodate. d. Complaints of a headache that resolves with medication.

74. Answer: B Rationale: These signs/symptomsweak pulse, shallow respirations, cool pale skinindicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

75. The client has been diagnosed with a cerebrovascular accident (stroke). The clients wife is concerned about her husbands generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? a. Obtain a rubber mat to place under the dinner plate. b. Purchase a long-handled bath sponge for showering. c. Purchase clothes with Velcro closure devices. d. Obtain a raised toilet seat for the clients bathroom.

75. Answer: D Rationale: Raising the toilet seat is modifying the home and addresses the clients weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

76. The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority? a. Assess lung sounds. b. Assess the six cardinal fields of gaze. c. Assess apical pulse. d. Assess level of consciousness

76. Answer: D Rationale: Meningitis directly affects the clients brain. Therefore, assessing the neurological status would have priority for this client.

77. The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering? a. Thiamine (vitamin B6) and librium, a benzodiazepine. b. Dilantin, an anticonvulsant, and Feosol, an iron preparation. c. Methadone, a synthetic narcotic, and Depakote, a mood stabilizer. d. Mannitol, an osmotic diuretic, and Ritalin, a stimulant.

77. Answer: A Rationale: Thiamine is given in high doses to decrease the rebound effect on the nervous system as it adjusts to the absence of alcohol, and a benzodiazepine is given in high doses and titrated down over several days for the tranquilizing effect to prevent delirium tremens

78. The nurse is caring for clients on a medical surgical floor. Which client should be assessed first? a. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a 2 on a 110 scale. b. The 24-year-old client diagnosed with a T-10 spinal cord injury that cannot move his toes. c. The 58-year-old client diagnosed with Parkinsons disease who is crying and worried about her facial appearance. d. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.

78. Answer: C Rationale: Body image is a concern for clients diagnosed with PD. This client is the one client that is not experiencing expected sequelae of the disease.

79. The client diagnosed with Parkinsons disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain this assessment data? a. Masklike facies and shuffling gait. b. Difficulty swallowing and immobility. c. Pill rolling of fingers and flat affect. d. Lack of arm swing and bradykinesia.

79. Answer: B Rationale: Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications.

80. The nurse and the unlicensed nursing assistant are caring for clients on a medical-surgical unit. Which task should not be assigned to the assistant? a. Feed the 69-year-old client diagnosed with Parkinsons disease who is having difficulty swallowing. b. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinsons disease. c. Assist the 54-year-old client diagnosed with Parkinsons disease with toilet-training activities. d. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinsons disease.

80. Answer: A Rationale: The nurse should not delegate feeding a client that is at risk for complications during feeding. This requires judgment that the assistant is not expected to possess.

81. The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report? a. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. b. The 36-year-old female client admitted with complaints of left-sided weakness that is scheduled for a magnetic resonance imaging (MRI) scan. c. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. d. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

81. Answer: C Rationale: The Glasgow Coma Scale is used to determine a clients response to stimuli (eye opening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse.

82. The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? a. Tell the client to take any routine anti-seizure medication prior to the EEG. b. Tell the client not to eat anything for eight (8) hours prior to the procedure. c. Instruct the client to stay awake 24 hours prior to the EEG. d. Explain to the client that there will be some discomfort during the procedure.

82. Answer: C Rationale: The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure

83. The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? a. Note the first thing the client does in the seizure. b. Assess the size of the clients pupils. c. Determine if the client is incontinent of urine or stool. d. Provide the client with privacy during the seizure.

83. Answer: A Rationale: Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether

84. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? a. It is all right for me to drink coffee for breakfast. b. My menstrual cycle will not affect my seizure disorder. c. I am going to take a class in stress management. d. I should wear dark glasses when I am out in the sun.

84. Answer: C Rationale: Tension states, such as anxiety and frustration, induce seizures in some clients so stress management may be helpful in preventing seizures.

85. The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidalhypophysectomy. Which pre-op instruction is important for the nurse to teach? a. There will be a large turban dressing around the skull after surgery. b. The client will not be able to eat for four or five days post-op. c. The client should not blow the nose for two weeks after surgery. d. The client will have to lie flat for 24 hours following the surgery.

85. Answer: C Rationale: Blowing the nose creates increased intracranial pressure and could result in a cerebrospinal fluid leak.