PHINMA – CAGAYAN DE ORO COLLEGE A.
The client will have wires attached to the scalp and lights will
COLLEGE OF NURSING
NUR 040
COMPETENCY APPRAISAL 2
Name:
Date:
IMMUNE SYSTEM AND INFLAMMATORY DISORDERS
Score: Percentage:
NEUROLOGIC DISORDERS
Score: Percentage:
INTEGUMENTARY DISORDERS
Score: Percentage:
WRITE THE CAPITAL LETTER OF YOUR FINAL ANSWER BESIDE
EACH NUMBER.
IMMUNE SYSTEM AND INFLAMMATORY DISORDERS
Multiple Sclerosis
1.The nurse is assessing a 48-year-old client diagnosed with multiple
sclerosis. Which clinical manifestation warrants immediate
intervention?
A. The client has scanning speech and diplopia.
B. The client has dysarthria and scotomas.
C. The client has muscle weakness and spasticity.
D. The client has a congested cough and dysphagia.
2.The client newly diagnosed with multiple sclerosis (MS) states, “I
don’t understand how I got multiple sclerosis. Is it genetic?” On which
statement should the nurse base the response?
A. Genetics may play a role in susceptibility to MS, but the
disease may be caused by a virus.
B. There is no evidence suggesting there is any chromosomal
involvement in developing MS.
C. Multiple sclerosis is caused by a recessive gene, so both
parents had to have the gene for the client to get MS.
D. Multiple sclerosis is caused by an autosomal dominant
gene on the Y chromosome, so only fathers can pass it on.
3.The 30-year-old female client is admitted with complaints of
numbness, tingling, a crawling sensation affecting the extremities,
and double vision which has occurred two (2) times in the month.
Which question is most important for the nurse to ask the client?
A. “Have you experienced any difficulty with your menstrual
cycle?”
B. “Have you noticed a rash across the bridge of your nose?”
C. “Do you get tired easily and sometimes have problems
swallowing?”
D. “Are you taking birth control pills to prevent conception?”
4.The nurse enters the room of a client diagnosed with acute
exacerbation of multiple sclerosis and finds the client crying. Which
statement is the most therapeutic response for the nurse to make?
A. “Why are you crying?The medication will help the disease.”
B. “You seem upset. I will sit down and we can talk for
awhile.”
C. “Multiple sclerosis is a disease that has good times and
bad times.”
D. “I will have the chaplain come and stay with you for a
while.”
5.The client diagnosed with multiple sclerosis is scheduled for a
magnetic resonance imaging (MRI) scan of the head. Which
information should the nurse teach the client about the test?
flash off and on.
B. The machine will be loud and the client must not move the
head during the test.
C. The client will drink a contrast medium 30 minutes to one (1)
hour before the test.
D. The test will be repeated at intervals during a five (5)- to six
(6)-hour period.
Guillain-Barré Syndrome
6.Which assessment data should the nurse assess in the client
diagnosed with Guillain-Barré syndrome?
A. An exaggerated startle reflex and memory changes.
B. Cogwheel rigidity and inability to initiate voluntary movement.
C. Sudden severe unilateral facial pain and inability to chew.
D. Progressive ascending paralysis of the lower extremities and
numbness.
7.Which statement by the client supports the diagnosis of Guillain-
Barré syndrome?
A. “I just returned from a short trip to Japan.”
B. “I had a really bad cold just a few weeks ago.”
C. “I think one of the people I work with had this.”
D. “I have been taking some herbs for more than a year.”
8.Which assessment intervention should the nurse implement
specifically for the diagnosis of Guillain-Barré syndrome?
A. Assess deep tendon reflexes.
B. Complete a Glasgow Coma Scale.
C. Check for Babinski’s reflex.
D. Take the client’s vital signs.
9.The health-care provider scheduled a lumbar puncture for a client
admitted with rule-out Guillain-Barré syndrome. Which preprocedure
intervention has priority?
A. Keep the client NPO.
B. Instruct the client to void.
C. Place in the lithotomy position.
D. Assess the client’s pedal pulse.
10.Which priority client problem should be included in the care plan
for the client diagnosed with Guillain-Barré syndrome?
A. High risk for injury.
B. Fear and anxiety.
C. Altered nutrition.
D. Ineffective breathing pattern.
Myasthenia Gravis
11.Which ocular or facial signs/symptoms should the nurse expect to
assess for the client diagnosed with myasthenia gravis?
A. Weakness and fatigue.
B. Ptosis and diplopia.
C. Breathlessness and dyspnea.
D. Weight loss and dehydration.
12.The client is being evaluated to rule out myasthenia gravis and
being administered the Tensilon (edrophonium chloride) test. Which
response to the test indicates the client has myasthenia gravis?
A. The client has no apparent change in the assessment data.
B. There is increased amplitude of electrical stimulation in the
muscle.
C. The circulating acetylcholine receptor antibodies are
decreased.
D. The client shows a marked improvement of muscle strength.
13.Which surgical procedure should the nurse anticipate the client
with myasthenia gravis undergoing to help prevent the
signs/symptoms of the disease process?
A. There is no surgical option.
B. A transsphenoidal hypophysectomy.
C. A thymectomy.
D. An adrenalectomy.
Nurse Joseph Bahian Abang
14.The client diagnosed with myasthenia gravis is being discharged
home. Which intervention has priority when teaching the client’s
significant others?
A. Discuss ways to help prevent choking episodes.
B. Explain how to care for a client on a ventilator.
C. Teach how to perform passive range-of-motion exercises.
D. Demonstrate how to care for the client’s feeding tube.
15.Which collaborative health-care team member should the nurse
refer the client to in the late stages of myasthenia gravis?
A. Occupational therapist.
B. Recreational therapist.
C. Vocational therapist.
D. Speech therapist.
Systemic Lupus Erythematosus
16.The 26-year-old female client is complaining of a low-grade fever,
arthralgias, fatigue, and a facial rash. Which laboratory tests should
the nurse expect the HCP to order if SLE is suspected?
A. Complete metabolic panel and liver function tests.
B. Complete blood count and antinuclear antibody tests.
C. Cholesterol and lipid profile tests.
D. Blood urea nitrogen and glomerular filtration tests.
17.The client diagnosed with SLE is being discharged from the
medical unit. Which discharge instructions are most important for the
nurse to include? Select all that apply.
A. Use a sunscreen of SPF 30 or greater when in the sunlight.
B. Notify the HCP immediately when developing a low-grade
fever.
C. Some dyspnea is expected and does not need immediate
attention.
D. The hands and feet may change color if exposed to cold or
heat.
E. Explain the client can be cured with continued therapy.
18.The nurse is developing a care plan for a client diagnosed with
SLE. Which goal is priority for this client?
A. The client will maintain reproductive ability.
B. The client will verbalize feelings of body-image changes.
C. The client will have no deterioration of organ function.
D. The client’s skin will remain intact and have no irritation.
19.The nurse is admitting a client diagnosed with R/O SLE. Which
assessment data observed by the nurse support the diagnosis of
SLE?
A. Pericardial friction rub and crackles in the lungs.
B. Muscle spasticity and bradykinesia.
C. Hirsutism and clubbing of the fingers.
D. Somnolence and weight gain.
20.The client diagnosed with an acute exacerbation of SLE is
prescribed high-dose steroids. Which statement best explains the
scientific rationale for using high-dose steroids in treating SLE?
A. The steroids will increase the body’s ability to fight the
infection.
B. The steroids will decrease the chance of the SLE
spreading to other organs.
C. The steroids will suppress tissue inflammation, which
reduces damage to organs.
D. The steroids will prevent scarring of skin tissues associated
with SLE.
Acquired Immunodeficiency Syndrome
21.The school nurse is preparing to teach a health class to ninth
graders regarding sexually transmitted diseases. Which information
regarding acquired immunodeficiency syndrome (AIDS) should be
included?
A. Females taking birth control pills are protected from becoming
infected with HIV.
B. Protected sex is no longer an issue because there is a
vaccine for the HIV virus.
C. Adolescents with a normal immune system are not at risk for
developing AIDS.
D. Abstinence is the only guarantee of not becoming infected
with sexually transmitted HIV.
22.The nurse is admitting a client diagnosed with protein-calorie
malnutrition secondary to AIDS. Which intervention should be the
nurse’s first intervention?
A. Assess the client’s body weight and ask what the client has
been able to eat.
B. Place in contact isolation and don a mask and gown before
entering the room.
C. Check the HCP’s orders and determine what laboratory tests
will be done.
D. Teach the client about total parenteral nutrition and monitor
the subclavian IV site.
23.The client diagnosed with AIDS is complaining of a sore mouth
and tongue. When the nurse assesses the buccal mucosa, the nurse
notes white, patchy lesions covering the hard and soft palates and
the right inner cheek. Which interventions should the nurse
implement?
A. Teach the client to brush the teeth and patchy area with a
soft-bristle toothbrush.
B. Notify the HCP for an order for an antifungal swish-and-
swallow medication.
C. Have the client gargle with an antiseptic-based mouthwash
several times a day.
D. Determine what types of food the client has been eating for
the last 24 hours.
24.Which type of isolation technique is designed to decrease the risk
of transmission of recognized and unrecognized sources of
infections?
A. Contact Precautions.
B. Airborne Precautions
C. Droplet Precautions.
D. Standard Precautions.
25.The nurse is describing the HIV virus infection to a client who has
been told he is HIV positive. Which information regarding the virus is
important to teach?
A. The HIV virus is a retrovirus, which means it never dies as
long as it has a host to live in.
B. The HIV virus can be eradicated from the host body with the
correct medical regimen.
C. It is difficult for the HIV virus to replicate in humans because it
is a monkey virus.
D. The HIV virus uses the client’s own red blood cells to
reproduce the virus in the body.
Rheumatoid Arthritis (RA)
26.The client diagnosed with RA is being seen in the outpatient clinic.
Which preventive care should the nurse include in the regularly
scheduled clinic visits?
A. Perform joint x-rays to determine progression of the disease.
B. Send blood to the lab for an erythrocyte sedimentation rate.
C. Recommend the flu and pneumonia vaccines.
D. Assess the client for increasing joint involvement.
27.The client with RA has nontender, movable nodules in the
subcutaneous tissue over the elbows and shoulders. Which
statement is the scientific rationale for the nodules?
A. The nodules indicate a rapidly progressive destruction of the
affected tissue.
B. The nodules are small amounts of synovial fluid that have
become crystallized.
C. The nodules are lymph nodes which have proliferated to try to
fight the disease.
D. The nodules present a favorable prognosis and mean the
client is better.
28.The nurse is assessing a client diagnosed with RA. Which
assessment findings warrant immediate intervention?
A. The client complains of joint stiffness and the knees feel
warm to the touch.
Nurse Joseph Bahian Abang
 B. The client has experienced one (1)-kg weight loss and is
very tired.
C. The client requires a heating pad applied to the hips and
back to sleep.
D. The client is crying, has a flat facial affect, and refuses to
speak to the nurse.
29.The client diagnosed with RA who has been prescribed
etanercept, a tumor necrosis factor alpha inhibitor, shows marked
improvement. Which instruction regarding the use of this medication
should the nurse teach?
A. Explain the medication loses its efficacy after a few
months.
B. Continue to have checkups and lab work while taking the
medication.
C. Have yearly magnetic resonance imaging to follow the
progress.
D. Discuss the drug is taken for three (3) weeks and then
stopped for a week.
30.The client diagnosed with RA has developed swan-neck fingers.
Which referral is most appropriate for the client?
A. Physical therapy.
B. Occupational therapy.
C. Psychiatric counselor.
D. Home health nurse.
NEUROLOGIC DISORDERS
Cerebrovascular Accident (Stroke)
1. A 78-year-old client is admitted to the emergency department with
numbness and weakness of the left arm and slurred speech. Which
nursing intervention is priority?
A. Prepare to administer recombinant tissue plasminogen
activator (rt-PA).
B. Discuss the precipitating factors that caused the
symptoms.
C. Schedule for a STAT computed tomography (CT) scan of
the head.
D. Notify the speech pathologist for an emergency consult.
2. The nurse is assessing a client experiencing motor loss as a result
of a left-sided cerebrovascular accident (CVA). Which clinical
manifestations would the nurse document?
A. Hemiparesis of the client’s left arm and apraxia.
B. Paralysis of the right side of the body and ataxia.
C. Homonymous hemianopsia and diplopia.
D. Impulsive behavior and hostility toward family.
3. Which client would the nurse identify as being most at risk for
experiencing a CVA?
A. A 55-year-old African American male.
B. An 84-year-old Japanese female.
C. A 67-year-old Caucasian male.
D. A 39-year-old pregnant female.
Head Injury
4.The client diagnosed with a mild concussion is being discharged
from the emergency department. Which discharge instruction should
the nurse teach the client’s significant other?
A. Awaken the client every two (2) hours.
B. Monitor for increased intracranial pressure.
C. Observe frequently for hypervigilance.
D. Offer the client food every three (3) to four (4) hours.
5.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.
6.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 who 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.
Spinal Cord Injury (SCI)
7. The nurse arrives at the site of a one-car motor-vehicle accident
and stops to render aid. The driver of the car is unconscious. After
stabilizing the client’s cervical spine, which action should the nurse
take next?
A. Carefully remove the driver from the car.
B. Assess the client’s pupils for reaction.
C. Assess the client’s airway.
D. Attempt to wake the client up by shaking him.
8 .In assessing a client with a T12 SCI, which clinical manifestations
would the nurse expect to find to support the diagnosis of spinal
shock?
A. No reflex activity below the waist.
B. Inability to move upper extremities.
C. Complaints of a pounding headache.
D. Hypotension and bradycardia.
9.The rehabilitation nurse caring for the client with an L1 SCI is
developing the nursing care plan. Which intervention should the
nurse implement?
A. Keep oxygen via nasal cannula on at all times.
B. Administer low-dose subcutaneous anticoagulants.
C. Perform active lower extremity ROM exercises.
D. Refer to a speech therapist for ventilator-assisted speech.
Seizures
10.The male client is sitting in the chair and his entire body is rigid
with his arms and legs contracting and relaxing. The client is not
aware of what is going on and is making guttural sounds. Which
action should the nurse implement first?
A. Push aside any furniture.
B. Place the client on his side.
C. Assess the client’s vital signs.
D. Ease the client to the floor.
11.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.
12.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 antiseizure 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 for 24 hours prior to the
EEG.
D. Explain to the client that there will be some discomfort
during the procedure.
Brain Tumors
13.The client is being admitted to rule out a brain tumor. Which
classic triad of symptoms supports a diagnosis of brain tumor?
A. Nervousness, metastasis to the lungs, and seizures.
Nurse Joseph Bahian Abang
 B. Headache, vomiting, and papilledema.
C. Hypotension, tachycardia, and tachypnea.
D. Abrupt loss of motor function, diarrhea, and changes in
taste.
14.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.
15.The male client diagnosed with a brain tumor is scheduled for a
magnetic resonance imaging (MRI) scan in the morning. The client
tells the nurse that he is scared. Which response by the nurse
indicates an appropriate therapeutic response?
A. “MRIs are loud but there will not be any invasive procedure
done.”
B. “You’re scared. Tell me about what is scaring you.”
C. “This is the least thing to be scared about—there will be
worse.”
D. “I can call the MRI tech to come and talk to you about the
scan.”
Meningitis
16.The wife of the client diagnosed with septic meningitis asks the
nurse, “I am so scared. What is meningitis?” Which statement would
be the most appropriate response by the nurse?
A. “There is bleeding into his brain causing irritation of the
meninges.”
B. “A virus has infected the brain and meninges, causing
inflammation.”
C. “This is a bacterial infection of the tissues that cover the
brain and spinal cord.”
D. “This is an inflammation of the brain parenchyma caused
by a mosquito bite.”
17.The public health nurse is giving a lecture on potential outbreaks
of infectious meningitis. Which population is most at risk for an
outbreak?
A. Clients recently discharged from the hospital.
B. Residents of a college dormitory.
C. Individuals who visit a third world country.
D. Employees in a high-rise office building.
18.The nurse is assessing the client diagnosed with bacterial
meningitis. Which clinical manifestations would support the diagnosis
of bacterial meningitis?
A. Positive Babinski’s sign and peripheral paresthesia.
B. Negative Chvostek’s sign and facial tingling.
C. Positive Kernig’s sign and nuchal rigidity.
D. Negative Trousseau’s sign and nystagmus.
Parkinson’s Disease
19.The client diagnosed with Parkinson’s 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 these 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.
20.The client diagnosed with PD is being discharged on
carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which
statement is the scientific rationale for combining these medications?
A. There will be fewer side effects with this combination than
with carbidopa alone.
B. Dopamine D requires the presence of both of these
medications to work.
C. Carbidopa makes more levodopa available to the brain.
D. Carbidopa crosses the blood–brain barrier to treat
Parkinson’s disease.
21.The nurse caring for a client diagnosed with Parkinson’s disease
writes a problem of “impaired nutrition.” Which nursing intervention
would be included in the plan of care?
A. Consult the occupational therapist for adaptive appliances
for eating.
B. Request a low-fat, low-sodium diet from the dietary
department.
C. Provide three (3) meals per day that include nuts and
whole-grain breads.
D. Offer six (6) meals per day with a soft consistency.
Substance Abuse
22.The friend of an 18-year-old male client brings the client to the
emergency department (ED). The client is unconscious and his
breathing is slow and shallow. Which action should the nurse
implement first?
A. Ask the friend what drugs the client has been taking.
B. Initiate an IV infusion at a keep-open rate.
C. Call for a ventilator to be brought to the ED.
D. Apply oxygen at 100% via nasal cannula.
23.The chief executive officer (CEO) of a large manufacturing plant
presents to the occupational health clinic with chronic rhinitis and
requesting medication. On inspection, the nurse notices holes in the
septum that separates the nasal passages. The nurse also notes
dilated pupils and tachycardia. The facility has a “No Drug” policy.
Which intervention should the nurse implement?
A. Prepare to complete a drug screen urine test.
B. Discuss the client’s use of illegal drugs.
C. Notify the client’s supervisor about the situation.
D. Give the client an antihistamine and say nothing.
24.The nurse is working with clients in a substance abuse clinic.
Client A tells the nurse that another client, Client B, has “started
using again.” Which action should the nurse implement?
A. Tell Client A the nurse cannot discuss Client B with him.
B. Find out how Client A got this information.
C. Inform the HCP that Client B is using again.
D. Get in touch with Client B and have the client come to the
clinic.
Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease)
25. Which diagnostic test is used to confirm the diagnosis of ALS?
A. Electromyogram (EMG).
B. Muscle biopsy.
C. Serum creatine kinase (CK).
D. Pulmonary function test.
26. The client is diagnosed with ALS. Which client problem would be
most appropriate for this client?
A. Disuse syndrome.
B. Altered body image.
C. Fluid and electrolyte imbalance.
D. Alteration in pain.
27. The client is being evaluated to rule out ALS. Which
signs/symptoms would the nurse note to confirm the diagnosis?
A. Muscle atrophy and flaccidity.
B. Fatigue and malnutrition.
C. Slurred speech and dysphagia.
D. Weakness and paralysis
Encephalitis
28.The nurse is assessing the client admitted with encephalitis.
Which data require immediate nursing intervention? The client:
A. Has bilateral facial palsies.
B. Has a recurrent temperature of 100.6˚F.
C. Has a decreased complaint of headache.
D. Comments that the meal has no taste.
29.The client admitted to the hospital to rule out encephalitis is being
prepared for a lumbar puncture. Which instructions should the nurse
teach the client regarding care postprocedure?
Nurse Joseph Bahian Abang
 A. Instruct that all invasive procedures require a written
permission.
B. Explain that this allows analysis of a sample of the
cerebrospinal fluid.
C. Tell the client to increase fluid intake to 300 mL for the next
48 hours.
D. Discuss that lying supine with the head flat will prevent all
hematomas.
30. Which is an expected outcome for a client diagnosed with
encephalitis?
A. The client will regain as much neurological function as
possible.
B. The client will have no short-term memory loss.
C. The client will have improved renal function.
D. The client will apply hydrocortisone cream daily.
INTEGUMENTARY DISORDERS
Burns
1.The client comes into the emergency room in severe pain and
reports that a pot of boiling hot water accidentally spilled on his lower
legs. The assessment reveals blistered, mottled red skin, and both
feet are edematous. Which depth of burn should the nurse
document?
A. Superficial partial thickness.
B. Deep partial thickness.
C. Full thickness.
D. First degree.
2. The client with full-thickness burns to 40% of the body, including
both legs, is being transferred from a community hospital to a burn
center. Which measure should be instituted before the transfer?
A. A 22-gauge intravenous line with normal saline infusing.
B. Wounds covered with moist sterile dressings.
C. No intravenous pain medication.
D. Adequate peripheral circulation to both feet ensured.
3. The client has full-thickness burns to 65% of the body, including
the chest area. After establishing a patent airway, which collaborative
intervention is priority for the client?
A. Replace fluids and electrolytes.
B. Prevent contractures of extremities.
C. Monitor urine output hourly.
D. Prepare to assist with an escharotomy.
4. The nurse is applying mafenide acetate (Sulfamylon), a sulfa
antibiotic cream, to a client’s lower extremity burn. Which
assessment data would require immediate attention by the nurse?
A. The client complains of pain when the medication is
administered.
B. The client’s potassium level is 3.9 mEq/L and sodium level
is 137 mEq/L.
C. The client’s ABGs are pH 7.34, PaO2 98, PaCO238, and
HCO320.
D. The client is able to perform active range-of-motion
exercises.
5.The client is scheduled to have a xenograft to a left lower-leg burn.
The client asks the nurse, “What is a xenograft?” Which statement by
the nurse would be the best response?
A. “The doctor will graft skin from your back to your leg.”
B. “The skin from a donor will be used to cover your burn.”
C. “The graft will come from an animal, probably a pig.”
D. “I think you should ask your doctor about the graft.”
Pressure Ulcers
6. The nurse in a long-term care facility is teaching a group of new
unlicensed assistive personnel. Which information regarding skin
care should the nurse emphasize?
A. Keep the skin moist by leaving the skin damp after the
bath.
B. Do not rub any lotion into the skin.
C. Turn clients who are immobile at least every two (2) hours.
D. Only the licensed nursing staff may care for the client’s
skin.
7. The nurse is caring for a client who has developed stage IV
pressure ulcers on the left trochanter and coccyx. Which
collaborative problem has the highest priority?
A. Impaired cognition.
B. Altered nutrition.
C. Self-care deficit.
D. Altered coping.
8. The nurse is caring for clients in a long-term care facility. Which is
a modifiable risk factor for the development of pressure ulcers?
A. Constant perineal moisture.
B. Ability of the clients to reposition themselves.
C. Decreased elasticity of the skin.
D. Impaired cardiovascular perfusion of the periphery.
9. What is the scientific rationale for placing lift pads under an
immobile client?
A. The pads will absorb any urinary incontinence and contain
stool.
B. The pads will prevent the client from being diaphoretic.
C. The pads will keep the staff from workplace injuries such
as a pulled muscle.
D. The pads will help prevent friction shearing when
repositioning the client.
10.The paraplegic client is being admitted to a medical unit from
home with a stage IV pressure ulcer over the right ischium. Which
assessment tool should be completed on admission to the hospital?
A. Complete the Braden Scale.
B. Monitor the client on a Glasgow Coma Scale.
C. Assess for Babinski’s sign.
D. Initiate a Brudzinski flow sheet.
Skin Cancer
11. The school nurse is preparing to teach a health promotion class
to high school seniors. Which information regarding self-care should
be included in the teaching?
A. Wear a sunscreen with a protection factor of 10 or less
when in the sun.
B. Try to stay out of the sun between 0300 and 0500 daily.
C. Perform a thorough skin check monthly.
D. Remember caps and long sleeves do not help prevent skin
cancer.
12.The female client admitted for an unrelated diagnosis asks the
nurse to check her back because “it itches all the time in that one
spot.” When the nurse assesses the client’s back, the nurse notes an
irregular-shaped lesion with some scabbed-over areas surrounding
the lesion. Which action should the nurse implement first?
A. Notify the HCP to check the lesion on rounds.
B. Measure the lesion and note the color.
C. Apply lotion to the lesion.
D. Instruct the client to make sure the HCP checks the lesion.
13. The nurse is caring for clients in an outpatient surgery clinic.
Which client should be assessed first?
A. The client scheduled for a skin biopsy who is crying.
B. The client who had surgery three (3) hours ago and is
sleeping.
C. The client who needs to void prior to discharge.
D. The client who has received discharge instructions and is
ready to go home.
14.Which client is at the greatest risk for the development of skin
cancer?
A. The African American male who lives in the northeast.
B. The elderly Hispanic female who moved from Mexico as a
child.
C. The client who has a family history of basal cell carcinoma.
D. The client with fair complexion who cannot get a tan.
Nurse Joseph Bahian Abang
15.The middle-aged client has had two (2) lesions diagnosed as
basal cell carcinoma removed. Which discharge instruction should
the nurse include?
A. Teach the client that there is no more risk for cancer.
B. Refer the client to a prosthesis specialist for prosthesis.
C. Instruct the client how to apply sunscreen to the area.
D. Demonstrate care of the surgical site.
Bacterial Skin Infection
16.The client comes to the emergency department complaining of
pain in the left
lower leg following a puncture wound from a nail in a board. The left
lower leg is reddened with streaks, edematous, and hot to the touch,
and the client has a temperature of 100.8˚F. Which condition would
the nurse suspect the client is experiencing?
A. Cellulitis.
B. Lyme disease.
C. Impetigo.
D. Deep vein thrombosis.
17. The client comes to the clinic complaining of sudden onset of
high fever, chills, and a headache. The nurse assesses a patchy
macular rash on the trunk and a circular type of rash that looks like
an insect bite. Which question would be most appropriate for the
nurse to ask during the interview?
A. “Do you own dogs that stay in the yard?”
B. “Have you been working in your garden lately?”
C. “Have you been deer hunting in the last week?”
D. “Do you use sunscreen when you are outside?”
18.The school nurse is discussing impetigo with the teachers in an
elementary school. One of the teachers asks the nurse, “How can I
prevent getting impetigo?” Which statement would be the most
appropriate response?
A. “Wash your hands after using the bathroom.”
B. “Do not touch any affected areas without gloves.”
C. “Apply a topical antibiotic to your hands.”
D. “Keep the child with impetigo isolated in the room.”
19. The client is admitted to the medical floor diagnosed with cellulitis
of the left arm. Which assessment data would warrant immediate
intervention by the nurse?
A. The client has bilaterally weak radial pulses.
B. The client is able to move the left fingers.
C. The client has a CRT less than 3 seconds.
D. The client is unable to remove the wedding ring.
20.The nurse writes the client problem of “acute pain and itching
secondary to bacterial skin lesions.” Which interventions should be
included in the care plan?Select all that apply.
A. Keep humidity at less than 20%.
B. Maintain a cool environment.
C. Use a mild soap for sensitive skin.
D. Keep lesions covered at all times.
E. Apply skin lotion after bathing.
Viral Skin Infection
21.The nurse is discussing the prevention of herpes simplex 2.
Which intervention should the nurse discuss with the client?
A. Encourage the client to get the chickenpox immunization.
B. Do not engage in oral sex if you have a cold sore on the
mouth.
C. Wear nonsterile gloves when cleaning the genital area.
D. Do not share any type of towel or washcloth with another
person.
22.The client is complaining of burning, lancinating, stabbing pain
that radiates around the left rib cage area. The nurse cannot find any
type of skin abnormality. Which action should the nurse implement?
A. Transfer the client to the ED for a cardiac work-up.
B. Inform the client that the nurse can’t see anything.
C. Administer a nonnarcotic analgesic to the client.
D. Ask the client if he or she has ever had chickenpox.
23.The client is diagnosed with herpes simplex 2 and prescribed the
antiviral medication valacyclovir (Valtrex). Which instructions should
the nurse teach?
A. This medication will prevent pregnancy and treat the virus.
B. This medication must be tapered when discontinuing the
medication.
C. This medication will suppress symptoms but does not cure
the disease.
D. This medication may cause the client’s urine to turn
orange.
24.The nurse administered morphine sulfate, a narcotic analgesic,
IVP 45 minutes ago to a client diagnosed with herpes zoster. On
reassessment, the client complains the pain is at a “5” on a 1-to-10
scale. Which intervention should the nurse implement?
A. Turn on soft music and shut the blinds.
B. Apply warm, moist heat to the lesions.
C. Notify the HCP for more pain medication.
D. Encourage the client to ambulate with assistance.
25.The client is diagnosed with disseminated herpes zoster
secondary to AIDS. Which interventions should the nurse
implement?Select all that apply.
A. Place the client in contact isolation.
B. Administer a corticosteroid IVP.
C. Assess the client’s pain on a 1-to-10 scale.
D. Request that the client not have any visitors.
E. Ensure that only nurses who have had chickenpox care for
this client.
Fungal/Parasitic Skin Infection
26.The school nurse is assessing a teacher who has pediculosis.
Which statement by the teacher makes the nurse suspect that the
teacher did not comply with the instructions that were discussed in
the classroom with the children?
A. “I used the comb to remove all the nits.”
B. “I washed my hair with Kwell shampoo.”
C. “I removed all the sheets from my bed.”
D. “I had to fix my daughter’s hair with my brush.”
27. The school nurse is discussing how to prevent tinea cruris with
the football players. Which intervention should the nurse implement?
A. Instruct the football players to wear tight, snug-fitting jock
straps.
B. Explain the importance of wearing white socks.
C. Teach the football players to not share brushes or combs.
D. Discuss the need to dry the groin area thoroughly after
bathing.
28. The elderly client is admitted from the long-term care facility
diagnosed with congestive heart failure. The client complains of
severe itching on both hands and the nurse notes wavy, brown,
threadlike lesions between the client’s fingers. Which comorbid
condition would the nurse suspect the client of having based on
these assessment data?
A. Tinea capitis.
B. Herpes simplex 2.
C. Scabies.
D. Psoriasis.
29.The HCP prescribed Kwell lotion to be applied to the entire body.
Which instructions should the nurse teach the client concerning this
medication?
A. Leave the lotion on for two (2) hours after applying it to the
body.
B. Make sure that the skin is completely dry before applying
the lotion.
C. Repeat total body lotion application daily for at least one (1)
week.
D. Put the lotion in the bathwater and soak for at least 20
minutes.
Nurse Joseph Bahian Abang
30. The nurse in the long-term care facility must delegate a nursing
task to an unlicensed assistive personnel. Which nursing task would
be most appropriate to delegate?
A. Comb the nits out of the client’s hair.
B. Massage the reddened area on the hip.
C. Scrape the burrows to remove the scabies mite.
D. Apply antifungal lotion to the groin area.

Nurse Joseph Bahian Abang