I 1. A home care nurse is preparing to visit a client with a diagnosis of Meniere’s disease. The nurse review’s the physician’s orders and expects to note that which of the following dietary measures will be prescribed? A. low fiber diet with decreased fluids B. low sodium diet and fluid restriction C. low carbohydrate diet and elimination of red meats D. low fat with restriction of citrus fruits 2. A nurse is assigned to care for a client who has just undergone eye surgery. The nurse plans to instruct the client that which of the following activities is permitted in the postoperative period? A. reading B. watching television C. bending over D. lifting objects 3. A nurse is instilling an otic solution into an adult client’s left ear. The nurse avoids doing which of the following as part of this procedure? A. warming the solution to room temperature B. placing the client in a side lying position with the ear facing up C. pulling the auricle backward and upward D. placing the tip of the dropper on the edge of the ear canal 4. A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the clients? A. wound healing usually takes 12 weeks B. expected the vision will be permanently impaired C. a shield or eye patch should be worn to protect the eye D. the sutures are removed after 1 week 5. Which assessment findings provide the best evidence that a client with acute angle-closure glaucoma is responding to drug therapy? A. swelling of the eyelids decreases B. redness of the sclera is reduced C. eye pain is reduced or eliminated D. peripheral vision is diminished 6. At the time of retinal detachment, a client most likely describes which symptoms? A. a seeing flashes of light B. being unable to see light C. feeling discomfort in light D. seeing poorly in daylight 7. The most important health teaching the nurse can provide to the client with conjunctivitis is to: A. eat a well balanced, nutritious diet B. wear sunglasses in bright light C. cease sharing towels and washcloths D. avoid products containing aspirin 8. When the nurse prepares the client or the myringotomy, the best explanation as to the purpose for the procedures is that it will: A. prevent permanent hearing loss B. provide a pathway for drainage C. aid in administering medications D. maintain motion of the ear bones 9. A nurse is reviewing the record of the client with a disorder involving the inner ear. Which of the following would the nurse expect to see documented as an assessment finding in this client? A. severe hearing loss B. complaints of severe pain in the affected ear C. complaints of burning in the ear D. complaints of tinnitus 10. A client with a conduction hearing loss asks the nurse how a hearing aid improves hearing. The nurse most accurately informs the client that a hearing aid: A. amplifies sound heard B. makes sounds sharper and clearer
C. produces more distinct, crisp, speech D. eliminates garbled background sounds 11. Which nursing action is best for controlling the client’s nosebleed? A. have the client lay down slowly and swallow frequently B. have the client lay down and breathe through his mouth C. have the client lean forward and apply direct pressure D. have the client lean forward and clench his teeth Situation: Benjie 59 years old male was admitted to the hospital complaining of nausea, vomiting, weight loss of 20 lbs, constipation and diarrhea. A diagnosis of carcinoma of the colon was made. 12. A sigmoidoscopy was performed as a diagnostic measures. What position Benjie should assume for hi examination? A. knee-chest B. Sim’s C. Fowler’s D. Trendelenburg 13. As part of the preparation of the client for sigmoidoscopy the nurse should: A. explain to Benjie that he will swallow a chalk-like substance B. administer a cathartic the night before C. withhold fluids and foods on the day of examination D. administer cleansing enema in the morning of the examination 14. The doctor performed a colostomy, post operative nursing care include: A. keeping the skin around the opening clean and dry B. limiting visitors C. withholding D. limiting fluid intake 15. During the irrigation of the colostomy, Benjie complains complains of abdominal cramps, the nurse should: A. discontinue the irrigation B. clamp the catheter for a few minutes C. advance the catheter about one inch D. add color water 16. If colostomy irrigation is done, the height of the irrigator can must be how many inches above the stoma? A. 14-18 inches B. 18-20 inches C. 20-24 inches D. 10-14 inches 17. Which of the following gastrointestinal condition is known to predispose to Cancer of the colon? A. hemorrhoids B. intussusception C. islated colonic polyps D. pyloric stenosis Situation: Mr. J was brought to the ER complaining of p ain located in the upper abdomen hematemesis and melena. Diagnosis is peptic ulcer. 18. A frequent discomfort experience by Mr. J due to his peptic ulcer is: A. diarrhea B. vomiting C. eructation D. nausea 19. Which of this diagnostic measure is not indicated for Mr. J? A. x-ray of the abdomen B. patient’s history C. gastrointestinal series D. gastric analysis 20. The purpose of dietary treatment of Mr. J is to: A. neutralize the free HCL in the stomach B. delay gastric emptying C. prevent constipation
D. delay surgery 21. Antacids are administered administered to Mr. J to: A. tranquilize the intestine B. decrease gastric motility C. lower the acidity of gastric secretion D. aid in digestion 22. It is thought that emotional stress contribute contribute to ulcer formation through: A. excessive stimulation of the parasympathetic parasympathetic nervous system B. increased activity of the sympathetic nervous system C. disturbance o cerebral cortex appetite control D. decrease of pituitary function 23. The tissue change most characteristics characteristics of p eptic ulcer is: A. a soft mass of the necrotic tissue with bleeding B. an erosion of the mucosa covered with thick exudates C. a sharp excavation of tissue membrane with a clean base D. an elevated fibrous tissue membrane with soft margins 24. The stool Guiac test was ordered to detect detect the presence of: A. hydrochloric acid B. occult blood C. inflammatory cells D. undigested food 25. In addition to its antacids effects, aluminum hydroxide gel is locally: A. analgesic B. astringent C. irritating D. depressant 26. Intervention that would help control his bleeding: A. gastric lavage using iced cold normal saline solution B. gastric using warm normal saline solution C. application of tourniquet D. insertion of NGT 27. Since she has NGT the appropriate nursing action is: A. render sponge bath B. provide laxative at bedtime C. administer enema once a day D. provide oral hygiene 3x a day 28. He underwent total gastrectomy, dumping syndrome may occur and the least symptoms he may experience would be: A. feeling of soreness B. weakness C. feeling of fullness D. diaphoresis 29. To prevent dumping syndrome the the following includes your nursing care except: A. serve dry meals B. allow him to walk for a while after eating C. instruct him to lie down after eating D. giving of fluids after meals must be avoided 30. Your operative nursing assessment after surgery: A. note and report excessive bleeding only B. assess for excessive secretions secretions from the operative site C. ensure that the NG tube is detached from suction apparatus D. check the drainage from the NG tube everyday 31. What is the involvement of her total gastrectomy? A. removal of the stomach only B. removal of the stomach with anastomosis of the esophagus to the jejunum C. removal of the ovary and fallopian tube D. removal of the stomach with anastomosis of the duodenal to jejunum 32. A nurse is giving instructions to the client with peptic ulcer disease about symptom management. The nurse tells the client to: A. eat slowly and chew food thoroughly B. eat large meals to absorb gastric acid C. limit the intake of water D. use acetylsalicylic acid (aspirin) to relieve gastric pain
33. A client has been given a prescription for Propantheline (Probanthine) as adjunctive treatment for peptic ulcer disease. The nurse tells the client to take this medication: A. with antacids B. 30 minutes before meals C. with meals D. just after meals Situation: Kim was known to be alcoholic for 15 yrs. He was admitted in the hospital after having vomited a large quantity of bright red blood with some coffee gr ound appearance. 34. The most probable cause of Kim’s cirrhosis is: A. malnutrition B. bacterial inflammation of liver cells C. alcoholism D. obstruction of major bile ducts 35. Which of the following vitamins are stored by the normal liver? A. vit. A, vit. B and vit. C B. vit. A, vit. B, vit. C, and vit. D C. vit A and vit B D. vit. A and vit. C 36. The nurse should know how that pathophysiology predispose him to: A. varicose veins B. splenic rupture C. inguinal hernia D. umbilical hernia 37. Kim’s portal hypertension is the result of: A. contraction of vascular muscles response to psychological stress B. compression of the liver substance due to emotional stress C. acceleration of portal blood flow secondary to severe anemia D. twisting and constriction of intralobular and interlobular blood vessels 38. Kim is scheduled for a liver biopsy. What instructions regarding respiration is essential for the nurse to give him prior to the biopsy: A. exhale forcefully and to hold his breath for a few seconds B. hold his breath when the needle has reached the liver site C. take several deep breaths and to hold his breath while needle is being introduced D. flat with one pillow under his head 39. Which position in bed would be best for Kim immediately after he has the needle biopsy of the liver? A. on his right side, with a small pillow under the costal margin B. anyway that he is comfortable C. semi-Fowler’s with his knees flexed D. flat with one pillow under his head 40. A Blakemore-Sengstaken tube is inserted to prevent bleeding from esophageal varices. The nurse responsibility in this instance would be to: A. alternate inflate and deflate the esophageal balloon B. make certain that the desired degree of pressure is constantly maintained C. deflate both balloons periodically D. encourage Kim to swallow frequently while tube is I place 41. A physician orders the deflation of the esophageal balloon of a Sengstaken-Balkemore tube in a client. The nurse prepares for the procedure knowing that the deflation of the esophageal balloon places. The client is at risk for: A. increased ascites B. esophageal necrosis C. recurrent hemorrhage from the esophageal varices D. gastritis 42. Foods usually omitted from diet of Kim with cirrhosis of liver are: A. whole grain cereals B. milk products C. cereal products D. rich gravies and sauces 43. Clay colored stool are caused by: A. improper utilization of vitamin K by the body
B. the absence of bile salt in the feces C. the absence of bile pigments in the urine D. rich gravies and sauces 44. Kim develop ascites, this is caused by: A. pulmonary failure B. portal obstruction C. capillary obstruction D. arterial obstruction 45. Symptoms indicating progression into hepatic coma include: 1. flapping tremor 2. nystagmus 3. fruity odor breath 4. fetid breath A. 2 and 4 C. 2 and 3 B. 1 and 4 D. 1 and 3 46. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and has difficulty breathing. A nurse performs which intervention as a priority measure to assist the client with breathing? A. auscultates the lung fields every 4 hours B. repositions side to side every 2 hours C. encourages deep breathing exercises every 2 hours D. elevates the head of the bed 60 degrees Situation: Karla is confine with a diagnosis of chronic cholecystitis. 47. After thorough examination your findings would be: A. high red blood cell counts and fever B. leukocyte count is low and high fever C. leukocyte count high and pyrexia D. leukocytosis and abdominal pain that radiates to the groin 48. The surgical intervention indicated for Karla is: A. choledochostomy B. cholecystostomy C. cholecystotomy D. cholecystectomy 49. Following exploration of the common duct is a T-tube inserted. The rationale for this is to: A. facilitate healing of the operative site B. offer a route to p ost operative cholecystectomy cholecystectomy C. provide sufficient drainage to promote healing D. ensure adequate bile drainage during duct healing 50. Upon admission her doctor ordered for cholecystoghram in AM. The preparations of this procedure begins: A. in early am B. with evening meal C. at bedtime D. upon admission 51. The ingestion of fatty food usually precipitates rubies episodes of the upper abdominal pain because; A. fat in the stomach increases the rate of peristaltic movements B. fat in the duodenal contents initiate the reaction that cause gallbladder contraction C. fatty foods are likely to generate gas D. fatty foods contain higher amount of cholesterol than do proteins 52. Karla is having pruritus of the extremities. Which of the following nursing measures might be most helpful in relieving her discomfort. A. rubbing the skin with potassium permanganate 10:1000 solution B. bathing in weak sodium bicarbonate solution C. dusting with liberal amount of talcum powder D. rubbing the skin with alcohol 53. Karla is experiencing severe biliary colic. The drug of choice during attack is: A. ponstan B. Demerol C. atropine sulfate D. morphine sulfate 54. A T-tube was inserted into the common bile d uct. Her nursing care of the T-tube is: A. empty and measure the bile drainage every 4 hours B. report STAT for any bile seen in the drainage system
C. secure it very well D. irrigate the T-tube with sterile normal saline every 4 hours 55. A client with diverticulitis has just been advanced from a liquid diet to solids. The nurse encourages the client to eat foods that are: A. low residue B. high residue C. moderate in fat D. high roughage 56. A client has just undergone an upper gastrointestinal (GI) series. The nurse provides which of the fo llowing upon the client’s return to the unit as an important part of routine post procedure care? A. increased fluids B. bland diet C. NPO status D. laxative 57. A nurse is administering continuous tube feedings to the client. The nurse takes which of the following actions as party of routine care for this client? A. checks the residual every 4hours B. changes the feeding bag and tubing every 12 hours C. pours additional feeding into bag when 25 ml are left D. holds the feeding if greater than 200 ml are aspirated 58. A nurse is monitoring dr ainage from a nasogastric (NG) tube in a client who had a gastric resection. No drainage has been noted during the past 4 hours and the client complains of severe nausea. The most appropriate nursing action would be to: A. reposition the tube B. irrigate the tube C. notify the physician D. medicate for nausea 59. A nurse is performing a health history on a client with chronic pancreatitis. The nurse expects to most likely note which of the following when obtaining information regarding the client’s health history? A. abdominal pain relieved with food or antacids B. exposure to o ccupational chemicals chemicals C. weight gain D. use of alcohol 60. A home care nurse visits a client with bowel cancer who recently received a course of chemotherapy. The client has developed stomatitis. The nurse avoids telling the client to: A. drink foods and liquids that are cold B. eat foods without spices C. maintain a diet of soft foods D. drink juices that are not citrus 61. A nurse is caring for a client with is receiving total parenteral nutrition (TPN). The nurse plans which nursing intervention to prevent infection? A. using strict aseptic technique for intravenous site dressing changes B. monitoring serum blood urea nitrogen (BUN) daily C. weighing the client daily D. encouraging increased fluid intake 62. A nurse is caring for a client with possible cholelithiasis who is being prepared for a cholangiogram. The nurse teaches the client about the procedure. Which client statement indicates that the client understands the purpose of this procedure? A. “they are going to look at my gallbladder gallbladder and ducts.” B. “this procedure will drain my gallbladder” C. “my gallbladder will be irritated” D. “they will put medication in my gallbladder” 63. A client who has a history o f chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which of the following factors is most likely responsible for the anemia? A. decrease intake of dietary iron B. intestinal malabsorption C. blood loss D. intestinal hookworm
64. A client’s nasogastric (NG) feeding tube has become clogged. The nurse’s first action is to: A. flush the tube with warm water B. aspirate the tube C. flush the carbonated liquids, such as cola D. Replace the tube 65. When the client ask the nurse why he must take the neomycin sulfate (Mycifradin), the most accurate explanation in this case is that the drug is given to: A. treat any current infection he may have B. suppress the growth of intestinal bacteria C. prevent the onset of postoperative diarrhea D. reduce the number of bacteria near the incision 66. If the client is typical of others with appendicitis the nurse can expect that when the client’s abdomen is palpated midway between the umbilicus and right iliac crest, the client will: A. experienced more pain when pressure is released B. lack any sensation of pain or pressure o n palpation C. have extreme discomfort with the slightest pressure D. will feel referred pain in the opposite quadrant 67. Which factor most probably contributed to the development of the client’s hemorrhoids? A. the client takes a daily stool softener B. the client has a history of ulcerative colitis C. the client is frequently constipated D. the client works as a computer programmer 68. When the client describes her discomfort to the nurse she is most likely to indicate that the pain she experiences becomes worse: A. shortly after eating B. especially on an empty stomach C. following periods of activities D. before rising in the morning 69. When the nurse empties the drainage in the Jackson Pratt bulb reservoir. Which nursing action is essential for reestablishing the negative pressure within this drainage device? A. the nurse compresses the bulb reservoir and closes the drainage valve B. the nurse opens the drainage valve, allowing the bulb to fill with air C. the nurse fill the bulb reservoir with sterile normal saline D. the nurse secures the bulb reservoir to the skin near the wound 70. When the client asks the nurse how she acquired hepatitis A, the best answer is that a common route of hepatitis. A transmission is from: A. fecal contamination B. insect carries C. infected blood D. wound drainage 71. It is essential that the nurse inform the client with hepatitis B that for the remainder of his lifetime he must avoid: A. sexual activity B. donating blood C. excessive caffeine D. foreign travel 72. Which nursing action is appropriate prior to assisting with the paracentesis? A. the nurse asks the client to void B. the nurse withholds food and water C. the nurse cleanses the client’s abdomen with Betadine D. the nurse obtains a suction machine from storage room 73. Which statements provides the best evidence that a client with colostomy is adjusting to the change in body image? A. the client wears loose-fitting garments B. the client takes a shower each day C. the client empties the appliance D. the client avoids foods that form gas 74. A previously health client comes to the emergency department complaining of severe nausea and vomiting hours after eating in a
restaurant. Which assessment question best determines if a food borne pathogen is the cause of the client’s syndrome? A. “what food did did you eat?” B. “did you take something for you nausea?” C. “did your food look spoiled?” D. “have you ever had food poisoning?” 75. A nurse is caring for a client with peptic ulcer. In assessing the client for gastrointestinal perforation (GI), the nurse monitors for: A. increase bowel sounds B. sudden, severe abdominal pain C. positive Guaiac test D. slow, strong pulse 76. Which assessment is most important for the nurse to make before advancing a client from liquid to solid food? A. increase bowel sounds B. appetite C. presence of bowel sounds D. chewing ability 77. What method would a nurse u se to most accurately assess the effectiveness of a weight loss diet for an obese client? A. daily weights B. serum protein levels C. daily caloric counts D. daily intake and output 78. A pregnant client has been diagnosed with a v aginal infection from the organism Candida albicans. Which findings would the nurse expect to note on assessment of the client? A. absence of any and symptoms B. pain, itching and vaginal discharge C. proteinuria, hematuria, edema and hypertension D. costovertebral angle pain 79. A nurse is caring for a client who is hospitalized with acute systemic lupus erythematosus (SLE). The nurse monitors the client knowing that which of the following clinical manifestation is not associated with this disease? A. fever B. muscular aches and pains Associated with SLE s/sx C. butterfly rash on the face D. bradycardia 80. A male being seen in the ambulatory care clinic has a history of being treated for syphilis infection. The nurse interprets that the client has been reinfected if which of the following characteristics is noted in a penile lesion? A. multiple vesicles, with some that have ruptured B. popular areas and erythema C. cauliflower-like appearance D. induration and absence of pain 81. A nurse is pr eparing a poster for a booth at a health care to promote primary prevention of cervical cancer. The nurse includes which of the following recommendations on the poster? A. perform monthly breast self-examination (BSE) B. use oral contraceptives as a preferred method of birth control C. use a commercial douches on a daily basis D. seek treatment promptly for infections of the cervix 82. A nurse is caring for a client who has just had a mastectomy. The nurse assists the client in doing which of the f ollowing exercises during the first 24 hours following surgery? A. elbow flexion and extension B. shoulder abduction and external rotation C. pendulum arm swing D. hand wall climbing 83. Tretinoin (Retin-A) is prescribed for a client with acne. The client calls the clinic nurse and says that the skin has become very red and is beginning to pee. Which of the following nursing statements to the client would be most appropriate? A. “come to the clinic immediately” immediately” B. “discontinue the medication” C. “notify the physician”
D. this is a normal occurrence with the use of medication” Situation: Luz 19 years old single is scheduled for mastectomy of the right breast 84. Based on the health history and other assessment data, Luz’s nursing diagnosis includes the following except: A. potential sexual dysfunction B. body image disturbance C. pain related to anesthesia D. self-care deficit related to immobility of arm on the operative side 85. The following are her possible post op erative complication complication except: A. hematoma B. lymphedema C. neurovascular deficits D. infection 86. Luz complains of pain 2 hour s after receiving her medication of Meperidine HCL 50 mg IM ordered every 4 hours for the first 24 hours only. You should: A. tell Luz to wait for 2 hours more B. give the medicine STAT C. give fractional dose of Meperidine HCL D. use nursing measure to relieve pain 87. You informed her that the most common breast tumor occurring in young women is: A. fibrocystic B. papilloma C. gynecomastia D. fibroadenoma 88. Which of these work-up is not related to her surgery? A. CBC B. Urinalysis C. B.T. D. C.T. 89. Rationale for moderately elevating post operative affected arm is to: A. prevent lymphedema B. reduce pain C. B.T. D. C.T. 90. Which of these maybe used to her post operatively? A. pleural drainage B. hemovac C. prevent infection D. improve coping ability 91. Which of the following is not a post operative complication A. bronchopneumonia B. pneumonia C. atelectasis D. decubitus ulcer 92. Allowing her to do deep breathing exercise every 2 hours would prevent: A. bronchopneumonia B. atelectasis C. bronchitis D. pneumonia 93. A client has a left mastectomy with axillary lymph node dissection. The nurse determines that client understands post operative restrictions and arm care if the client states to: A. use a straight razor to shave under the arms B. allow blood pressures to be taken only on the left arm C. carry a handbag and heavy objects on the left arm D. use gloves when working in the garden 94. A nurse has pro vided instructions to a client who is receiving external radiation therapy. Which of the following if started by the client would indicate a need for further instructions regarding selfcare related to the radiation therapy? A. “I need to avoid exposure to sunlight?” B. “I need to wash my skin with a mild soap and pat dry”
C. “I need to apply pressure pressure to the irritated area to prevent prevent bleeding” D. “I need to eat a high-protein diet” 95. A nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places highest priority on discussing which of the following risk factors with this client? A. personal history of ulcerative colitis or gastrointestinal (GI) polyps B. distant relative with colorectal cancer C. age over 30 years D. high-fat, low fiber diet Situation: Fe, a 21-year-old fourth year physical therapy student has been diagnosed with peptic ulcer. The personal and family history shows that she has difficulty coping with the demands of the course and her mother is being treated for peptic u lcer to: 96. A relevant diagnosis the nurse identifies is one of the following: A. defensive coping B. self-esteem disturbance C. sensory-perceptual alteration D. ineffective individual coping 97. Typical personality traits of a person with peptic ulcer: A. submissive and dependent B. competitive and aggressive C. self-sacrificing and dependent D. perfectionist and assertive 98. One of the nu rsing intervention is to teach Fe: A. relaxation technique B. behavior modification C. stress management technique D. desensitization technique 99. The following are psycho-physiological reactions except: A. migraine B. constipation C. bronchial asthma D. peptic ulcer 100. The defense mechanism usually used by patient with peptic ulcer is: A. denial B. reaction formation C. projection D. sublimation
II 1. The home health nurse is visiting the client who has had a prosthetic valve replacement for severe mitral valve stenosis. Which statement by the client reflects an understanding of specific postoperative care for this surgery? A. “I threw away my straight razor and brought an electric razor.” B. “I have to go to the bathroom several times at night” C. “I count my pulse everyday” D. “I still do my deep breathing exercise” 2. A client has been diagnosed with thromboangitis obliterans. The nurse is considering measures to help the client cope up with lifestyle changes needed to control the disease process. The nurse plans to refer the client to a: A. medical social worker B. dietician C. smoking cessation program D. pain management clinic 3. The nurse is implementing a plan of care for a client with deep pain thrombosis of the right leg. Which of the following interventions does the nurse avoid when delivering care to this client? A. elevation of the right leg B. ambulation in the hall twice per shift
C. application of moist heat to the right leg D. administration of acetaminophen (Tylenol) 4. The client was hospitalized hospitalized 5 days ago have developed left calf tenderness and have a positive Homan’s sign. sign. The nurse assigned to this client, assesses the client for: A. coolness and pallor of the affected limb B. diminished distal peripheral pulses C. increased calf circumference D. bilateral edema 5. The nurse is monitoring a client with leukemia who is receiving Doxorubicin (Adriamycin) by IV infusion. Which of the fo llowing assessment findings indicate toxicity of the medication? A. Elevated BUN B. elevated creatinine C. ECG changes D. a red coloration of the urine * one of the adverse rxn, but transient 6. A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is requesting for some water. The nurse must: A. keep the client NPO until n order is written B. check the vital signs first C. check the gag and swallowing reflex D. encourage coughing and deep breathing 7. A 45-year-old client is receiving heparin sodium for a p ulmonary embolus. The nurse evaluates which of the following laboratory reports of partial thromboplastin time as indicative of effective heparin therapy. A. within normal range B. one to 1.5 times the control value C. two to 2.5 times the control value D. three times the control value 8. A client is taking Wafarin (coumadin) following the placement of an artificial mitral valve. The nurse instructs this client to avoid taking the following commonly used drug: A. Maalox plus B. sudafed C. Tylenol cold and flu medication D. aspirin 9. A client with insulin dependent diabetes mellitus (IDDM) is being discharged. The nurse knows that the client has understood essential teaching when the following statement is heard: A. “I need to cut my nails straight across” B. “I can’t make any substitutions in my diet” C. “my insulin should be given into my arms” D. “I should eat less before exercising” 10. A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the following laboratory test daily: A. complete blood count B. electrolyte studies C. prothrombin time – for – for bleeding time D. BUN and creatinine 11. A client has developed depression of the bone marrow from antineoplastic drugs. The nurse states the nursing diagnosis of highest priority as: A. fluid fluid volume deficit C. ineffective thermoregulation B. High risk for aspiration D. high risk for infection 12. Radioactive iodine is being used to treat a client with cancer of the thyroid gland. The nurse knows that the client has understood teaching about the treatment when the following statement is heard: A. “only my thyroid gland will be radioactive” B. “I need not be concerned about radioactivity” C. “my whole body will be radioactive” D. “my body fluids will be radioactive for a short time” 13. A client’s TPN is 6 hou rs behind schedule. The nurse would: A. run the fluid at r ate to make up the lost time. B. report the situation to the physician C. run the IV at the prescribed site D. check the blood glucose level
14. A 45-year-old client is in acute congestive heart failure. The nurse and client establish a goal of highest priority as: A. rest mentally as well as physically B. learn stress management C. train for a less demanding job D. prevent complications of immobility 15. A client diagnosed with IDDM becomes irritable and confused; the skin is cool and clammy and the pulse rate is 110. The first action of the nurse would be to: A. give a half-cup of orange juice B. check the serum glucose C. administer regular insulin D. call the physician 16. A client with IDDM is recovering from DKA. Information of the serum level of the following substance will be very important to the nurse: A. sodium C. potassium B. calcium D. magnesium 17. A 17-year-old client’s mother has been recently diagnosed with pulmonary tuberculosis. The nurse would expect the doctor to order which of the following tests initially? A. the mantoux C. a sputum culture B. an X-ray D. gram stain of the sputum 18. The nurse injects 0.1 ml. of purified protein derivative (PPD) intradermally into the inner aspect of the forearm of a client. This nurse will interpret the reaction to this test as positive when the following is seen: A. redness greater than 5mm. B. swelling greater than 7mm. C. induration greater than 10mm. D. exudates covering more than 12mm 19. A 29-year-old has been taking Prednisolone 60 mg. daily for an inflammatory condition for the past 6 months. The physician just wrote an order to discontinue the medication. The nurse should: A. stop the medication as ordered B. continue the medication until physician is available C. call the physician and question the order D. hold the medication until the physician is available 20. A 55 year old has a chest tube connected to a Pleur Evac system to remove blood from the pleural cavity. While turning the client the nurse remembers to: A. keep the Pleur Evac below the level of the wound B. Remove the suction from the Pleur vac C. Clamp the tubing connected to the Pleur Evac D. drain the sterile water from the Pleur Evac 21. A client on anti-neoplastic therapy has a platelet count of 20,000/cu.mm (N wbc 5,000 to 10,000). 10,000). An appropriate intervention for the nurse to use would be: A. administering Vit. K IM B. massaging injection sites to avoid absorption C. encouraging the use of firm toothbrushes and vigorous flossing D. avoiding rectal temperatures and other rectal procedures 22. A nurse assumes responsibility for the care of the client at 7 A.M. NPH insulin is ordered for 7:30 A.M. Before giving the insulin, the nurse checks to see if the client will eat that day and for the: A. signs and symptoms of hypoglycemia B. previous sites of injection C. serum glucagons level D. serum glucose level 23. A nurse is teaching a client to observe for signs of hypoxia. The nurse explains that cyanosis is not reliable indicator of the amount that tissues are receiving because the blue color is caused by: A. reduced hemoglobin B. a low partial pressure of oxygen in the blood C. inability of oxygen to enter the cell D. increased pH of the blood 24. A client has ARDS. The lowest fraction of inspired ox ygen possible for optimizing gas exchange is used. The nurse explains to the family that the reason for this precaution is to:
A. avoid respiratory depression B. prevent oxygen toxicity C. increase lung compliance D. promote production of surfactant 25. A client who is recovering from a myocardial infarction demonstrates that touching has been effective with the statements: A. “if my chest pain lasts for more than 5 minutes, I should get myself to the emergency room” B. “I just need to avoid salty foods and not add salt to my food ” C. “I need to avoid constipation constipation and all activities activities that have caused me chest pain in the past” D. “I need to get to the drugstore to get some medicine for my cold” 26. A client is admitted to the hospital complaining of nervousness, heat intolerance and muscle weakness. Her pulse rate is 118 and she has exopthalmos. An essential part of her assessment will be: A. palpation of the thyroid gland B. evaluation of fluid and electrolyte balance C. evaluation of deep tendon reflexes D. use of the Glasgow Coma Scale 27. A client is scheduled for thyroidectomy. The nurse explains that PTU or an iodine preparation is given prior to surgery in order to: A. increase the size of the thyroid gland B. render the parathyroid glands visible C. induce a euthyroid state in the body D. Separate the thyroid from the laryngeal nerve 28. A client is being evaluated for the possibility of Grave’s disease. The nurse teaches that the best laboratory test for evaluating whether a client has hypothyroidism or hyperthyroidism is the serum level of: A. thyroxine (T4) C. TSH B. triiodothyroinine (T3) D. epinephrine 29. A client is taking Levothyroxine (synthroid) for hypothyroidism. The nurse teaches the client to: A. monitor the pulse regularly B. restrict sodium in the diet C. take the drug with meals D. measure urinary output 30. A client with NIDDM is admitted to the hospital. The client is confused and has dry mucus membranes and poor skin turgor. The serum sodium is 149; the blood pressure 90/60 mmHg; the pulse is 118; and the serum glucose 465 mg/dl. The nurse anticipates that insulin and the following will be needed: A. a potassium drip C. intravenous fluids B. sodium bicarbonate D. calcium gluconate 31. A nurse is teaching a diabetic client how to attain the optimal level of health. When assessing for other risk factors stroke and heart attack, this nurse looks for: A. hypervolemia C. proteinuria B. hypokalemia D. hypertension 32. A nurse stops at the sight of a motor vehicle accident to find a young woman slumped over the wheel. She is b reathing with a regular rhythm at a rate of 22; ventilation efforts normal. Her pulse rate is 110. The nurse’s next action would be: A. check the level of consciousness B. immobilize the spine C. call the rescue squad D. check for bleeding 33. A 57-year-old client is being prepared for discharge following a myocardial infarction. The nurse knows that her teaching has been understood when she hears: A. “I guess my sex life is over” B. “depression is bad for me. I must stay happy and optimistic” C. “ the best way to know the amount of exercise I should should take is to watch my pulse” D. “the injured area will be replaced with a new heart tissue” 34. A client with IDDM has just been admitted to the ER after hitting a telephone pole with her car. Bystanders said she acted as if she has been drinking. Her temperature is 37.4 degrees Celsius, pulse 80, resp. 44 and deep. She complained of headache and acted
confused. A fruity odor was noted on her breath. Her ABG report read= pH= 7.32, pCO2= 36, and bicarbonate= 18. The nurse prepared for the treatment of: A. metabolic acidosis C. respiratory acidosis B. metabolic alkalosis D. respiratory alkalosis 35. A client with peptic ulcer is taking Maalox, Amoxicillin and Famotidine. The nurse teaches the client to take the Maalox: A. 1-2 hours before meals meals C. ½ hour before meals meals B. with meals D. 1-2 hours after meals 36. A client with varicose veins tells the nurse, “I am afraid they will burst while I am walking.” Which response by the nurse would be the BEST? A. “the only way to prevent rupture is to have surgery” B. “you must find another job, one that requires less walking” C. “if that happens, you could bleed to death” D. “rupture of varicose veins rarely occur” 37. A client asks why is it important to check the pupils. The nurse replies that changes in the pupils are a reflection of how well the following area of the nervous system is functioning: A. spinal cord C. midbrain B. brain stem D. cerebellum 38. A 32-year-old client is being evaluated in the clinic today for possible Addison’s disease. The nurse knows that the most common cause of the disease is attributed to: A. autoimmune response C. disseminated tuberculosis B. blastomycosis D. diabetes mellitus 39. The nurse knows that the recommended diet for a client with Addison’s disease includes: A. 1 mg. Na C. low fat, low cholesterol B. 3 gms. Na D. high potassium, high cholesterol 40. A 36-year-old client with a history of Cushing’s disease is being seen in the ER for complaints of anorexia, vomiting, weakness and muscle cramps for the past 24 hours. The nurse recognizes that these clinical findings are a result of: A. hypernatremia C. hyperglycemia B. hypoglycemia D. hypokalemia 41. When teaching a patient about home care related to outpatient corticosteroid therapy, the nurse emphasizes that side effects of corticosteroid therapy include: A. hyperglycemia and weight loss B. hyponatremia and hypotension C. hypoglycemia and gastric ulcers D. hyperglycemia and weight gain 42. Additional teaming to a newly diagnosed diabetic client related to the effects of regular insulin is necessary when the client asks, “if I take my regular insulin at 8 A.M., when might I experience signs of low blood sugar reaction? A. 8:30 am B. 11 am C. 1:30 pm D. 4 pm 43. The nurse recognizes which of the following as signs of early hypoxia? A. bradycardia, hypotension, facial flushing B. confusion, bradycardia, headache C. hypotension, tachypnea, lethargy D. restlessness, yawning, tachycardia 44. A 68-year-old client has a new colostomy and is being treated today at the clinic for diarrhea. When discussing diet with the client, the nurse explains to him that the one fo od that caused this problem was: A. cabbage C. tapioca D. fried chicken B. eggs 45. The nurse is caring for a client with folic acid deficiency. The nurse recalls that one of the most frequent causes of folic acid deficiency is: A. poor nutritional intake due to alcoholism B. lack of absorption of the intrinsic factor C. a diet that consists of vegetables only and no meat
D. a complicated pregnancy during the second trimester 46. When planning care for a patient who is pancytopenic, the major goal should be: A. prevent hemorrhage and infection B. administering an oral iron preparation C. preventing fatigue and fluid overload D. encouraging consumption of a neutropenic diet 47. when explaining different effects of chemotherapy to students, the nurse correctly identifies which group of chemotherapy drugs that does not affect DNA synthesis to kill tumor cells? A. hormones C. antimetabolites B. vinca alkalosis D. alkylating agents 48. The nurse evaluates the client’s ability to self-monitor blood glucose level at home. What information BEST indicates the average degree of diabetes control during the past 2 to 4 months? A. serum glycosylated hemoglobin B. postprandial blood glucose level C. a written record of daily blood glucose levels D. a written record of daily double voided urine glucose levels 49. Which of the findings would the nurse most likely note during an Addisonian crisis? A. serum potassium of 3 mEq/L, BP=158/72 mmHg B. serum potassium of 5.8 mEq/L, BP=62/48 mmHg C. serum sodium of 150 mEq/L, BP= 158/72 D. serum sodium of 135 mEq/L, BP=62/48 50. Propanolol (Inderal) is commonly prescribed for clients with hyperthyroidism to: A. block formation of the thyroid hormone B. decrease the vascularity of the thyroid gland C. inhibit peripheral conversion of T4 and T3 D. decrease CNS stimulation 51. The client with cancer is is receiving chemotherapy and develops thrombocytopenia. Which goal should be given the highest priority in the NCP? A. ambulation tree times a day B. monitoring temperature C. monitoring hemoglobin and hematocrit D. monitoring for pathologic fractures 52. The nurse assesses the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse determines that this occurrence: A. is common B. is characteristic of thrush infection C. indicates that oral hygiene need to be improved D. suggests that the client is anemic 53. The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the WBC count is normal if which of the following results is present? A. 3,000 to 8,000/cu.mm. B. 4,000 to 9,000/cu.mm. C. 7,000 to 15,000/cu.mm. D. 2,000 to 5,000/cu. Mm. 54. The client suspected of having an abdominal tumor is scheduled for a CT scan with dye injection. Which of the following is an accurate description of the scan? A. the test maybe painful B. the dye injected may cause a warm, flushing, sensation C. fluids will be restricted following the test D. the test takes approximately 2 hours 55. The client is diagnosed as having a bowel tumor. Several diagnostic test are prescribed. Which of the following test will confirm the diagnosis of the malignancy? A. MRI C. abdominal ultrasound B. CT scan D. biopsy of the tumor 56. The oncology nurse is preparing to administer chemotherapy to the client with Hodgkin’s disease. A multiagent medication regimen known as MOPP is prescribed. The medications included in the therapy are: A. belomycin, oncovin, vincristine, prednisone
B. adrimycin, vincristine, oncovin, prednisone C. adriamycin, cytoxan, prednisone, oncovin D. procarbazine, mechlorethemine, oncovin, prednisone 57. The nurse is analyzing the laboratory results of a client with leukemia who received a regimen of chemotherapy. Which of the following laboratory values does the nurse note specifically as a result of massive cell destruction that occurred from chemotherapy? A. anemia C. decrease platelets B. decreased WBC D. increased uric acid level 58. The client is receiving external radiation to the neck for cancer of the larynx. The MOST likely side effect to be expected is: A. constipation C. sore throat B. dyspnea D. diarrhea 59. The nurse is providing instructions to the client receiving external radiation therapy. Which of the following is NOT a component of the instructions? A. avoid exposure to sunlight B. wash the skin with a mild soap and pat dry C. apply pressure on the irritated area to prevent bleeding D. eat a high protein diet 60. The nurse teaches skin care to the client receiving external radiation therapy. Which of the following statements, if made by the client indicates the need for fur ther instruction? A. “I will handle the area gently” B. “I will avoid the use of deodorants” C. “I will limit sun exposure exposure to 1 hour daily” D. “I will wear loose fitting clothing” 61. The nurse is reviewing the laboratory results of a client receiving chemotherapy. The platelet count is 10,000/cu.mm. Based on this laboratory value, the priority nursing assessment is which of the following? A. assess level of consciousness B. assess temperature C. assess bowel sounds D. assess skin turgor 62. The client is admitted to the hospital with a diagnosis of suspected Hodgkin’s disease. Which of the following assessment signs would the nurse MOST likely to note in the client? A. weakness C. weight gain B. fatigue D. enlarged lymph nodes 63. The client with leukemia is receiving receiving Busulfan (myleran). Allopurinol (Zyloprim) is prescribed for the client. The purpose of Allopurinol (Zyloprim) is to: A. prevent gouty arthritis C. prevent hyperuricemia hyperuricemia B. prevent stomatitis D. prevent diarrhea 64. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the NGT. Which of the ff. is the MOST appropriate nursing intervention? A. notify the physician C. continue to monitor the drainage B. measure abdominal girth D. irrigate the NGT 65. The nurse is reviewing the history of a client with bladder cancer. The MOST common symptom of this type of cancer is which of the following? A. frequency of urination C. hematuria B. urgency of urination urination D. dysuria
66. The nurse is assessing the stoma of a client following a
ureterostomy. Which of the following does the nurse expect to note? A. a pale stoma C. a red and moist stoma B. a dry stoma D. a dark-colored stoma 67. The nurse is caring for a client following a radical mastectomy. Which of the following nursing interventions would assist in preventing lymphedema of the affected arm? A. placing cool compress on the affected arm B. elevating the affected arm on pillow below the heart level C. maintaining an IV site below the antecubital area of the affected side D. avoiding arm exercises in the immediate post-operative period 68. The nurse is teaching BSE to a client who had a hysterectomy. The MOST appropriate instruction regarding BSE should be performed is: A. 7 to 10 days after menstruation B. just before menses begin C. at ovulation time D. at a specific day of the month and on the same day every month thereafter 69. The nurse is instructing the client, Ben how to perform testicular self-examination. Which instruction is correct? A. examine testicles when lying down B. the best time for the examination is after a shower C. gently feel the testicle with one finger to feel for a growth D. testicular examination should be done at least every 6 months 70. The nurse is instructing a group of female about BSE. The nurse instructs the clients to perform the examination: A. at the onset of menstruation B. one week after menstruation begins C. every month during ovulation D. weekly at the same time of the day
71. The client has undergone esophagogastroduodenoscopy (EGD).
The nurse places highest priority on which of the following items as apart of the client’s care plan? A. assessing for the return of the gag reflex B. giving warm gargle for sore throat C. monitoring temperature D. monitoring complaints of heartburn 72. The client being seen in a physician’s office has just been schedule for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test? A. removal all metal and jewelry before the test B. eat regular supper and breakfast C. continue to take all oral medication as scheduled D. monitor own bowel movement pattern for constipation 73. The client is diagnosed with bleed and the bleeding has b een controlled antacid are prescribed to be administered every hour. The nurse should plan on maintaining an approximately gastric pH of: A. 3 B. 9 C. 6 D. 15 74. The nurse is caring for a client following a Billroth II Procedure. On review of the post-operative orders, which of the following, if prescribed, does the nurse question and verify? A. irrigating the NG tube B. coughing and deep breathing exercises C. leg exercises D. early ambulation 75. A client who has a peptic ulcer is schedule for a vagotomy. The client asks about the purpose of this procedure. The BEST nursing response is which of the following? A. “decreases food absorption in the stomach” B. “heal the gastric mucosa” C. “halts stress reaction” D. “reduces the stimulus to acid acid secretion” 76. The nurse ins monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following syndrome indicate this occurrence? A. abdominal cramping and pain B. bradycardia and indigestion C. sweating and pallor D. double vision and chest pain
77. The nurse is caring for a hospitalized patient with a diagnosis of
ulcerative colitis (inflammation). When assessing the client, which finding, if noted, would the nurse report to the physician? A. bloody diarrhea C. hemoglobin level of 12 mg/dl B. hypotension D. rebound tenderness 78. The nurse is providing discharge instruction to a client following gastrectomy, which of the following measures will the nurse instruct the client to the following assist in preventing dumping syndrome? A. eat high carbonated food B. limit the fluid taking with food C. ambulate following a meal D. sit in a high-fowler’s position during meals 79. The nurse is caring for a client post-operatively following the creation of a colostomy. Which of the ff. nursing diagnosis does the nurse include in the plan of care? A. altered nutrition; more than body requirements B. body image disturbance C. fear related to poor diagnosis D. sexual dysnfunction 80. The nurse is reviewing the record of the client with Crohn’s disease (inflammation). Which of the fo llowing stool characteristic does the nurse expect to note in this client? A. bloody stool B. diarrhea C. constipation alternating with diarrhea D. stool constantly oozing from the rectum 81. The client with cirrhosis has ascites and a fluid volume excess. Which measure will the nurse include in the plan of care for this client? A. increase the amount of sodium in diet B. restrict the amount of f luids consumed C. encourage ambulation frequently D. administer magnesium antacids 82. The client with ascites is schedule for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure? A. supine C. right side lying B. left side lying D. upright 83. An ultrasound of the gallbladder is schedule for the client client with a suspect diagnosis of cholecystitis. The nurse explain to the client that this test: A. requires the client to lie still for short intervals B. requires that the client be NPO C. requires the administration of oral tables D. is uncomfortable 84. The nurse is providing pr eoperative teaching to a client scheduled for a cholecystectomy. Which of the following interventions is of highest priority in the preoperative teaching p lan? A. teaching coughing and deep breathing exercises B. teaching leg exercises C. instructions regarding fluid restrictions D. frequent need to work overtime on short notice
85. A client with peptic ulcer states states that stress frequently causes causes exacerbation (aggrevate;increase) of the disease. The nurse interprets that which of the following items mentioned by the client is most likely responsible for the exacerbations? A. sleeping 8 hours a night B. eating 5 to 6 small meals per day C. ability to work at home periodically D. frequent need to work overtime on short notice 86. The client with peptic ulcer disease needs dietary modification to reduce episode of epigastric pain. The nurse plans to teach the client that which of the following items, which the client enjoys, does not need to be limited or eliminated with this disease? A. wine C. coffee B. baked chicken D. fresh fruit 87. The medication history of a client with peptic ulcer disease reveals intermittent use of the following medications. The nurse teaches the client to avoid which of these medications altogether because of the irritating effects on the lining of the GI tract? A. (Prilosec) B. ibuprofen (Motrin) C. sucralfate (Carafate) D. Nizatidine (Axid) 88. The nurse instructs the ileostomy client to do which of the following as part of essential care of the stoma? A. cleanse the peristomal skin meticulously B. take in high-fiber foods such as n uts C. massage the area below the stoma D. limit fluid intake to prevent diarrhea 89. The client who has undergone creation of a colostomy has a nursing diagnosis of Body Image disturbance. The nurse evaluates that the client is making the most significant progress toward identified goals if the client: A. watches the nurse empty the ostomy bag B. looks at the ostomy site C. reads the ostomy produ ct literature D. practices cutting the ostomy appliance 90. The client with a new colostomy is concerned about odor from stool in the ostomy drainage bag. The nurse should teach the client to include which of the following foods in the diet to reduce odor? A. yogurt C. cucumbers B. broccoli D. eggs 91. The nurse is giving dietary instruction for the client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the f irst 4 to 6 weeks postoperatively? A. high protein C. low calorie B. high carbohydrates D. low residue 92. The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse evaluates that the client did not fully understand the instructions if the client stated that eating which of the following foods makes the stool less watery? A. pasta C. bran B. boiled rice D. low-fat cheese 93. The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperatively period for which of the following most frequent complications of this type of surgery? A. intestinal obstruction B. fluid and electrolyte imbalance imbalance C. malabsorption of fat D. folate deficiency 94. The client with acute pancreatitis is experiencing severe pain from the disorder. The nurse teaches the client to avoid which of the following positions that could aggravate the pain? A. sitting up C. leaning forward B. lying flat D. flexing the left leg 95. The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse evaluates that the client understands the instructions given if the client stated that which of the following food items is acceptable in the diet?
A. baked scrod C. fried chicken B. sauces sauces and gravies D. fresh whipped cream cream 96. The nurse assesses the client experiencing an acute episode of cholecystitis cholecystitis for pain that is located in the right: A. upper quadrant and radiates to the left scapula and shoulder B. upper quadrant and radiates to the right scapula and shoulder C. lower quadrant and radiates to the umbilicus D. lower quadrant and radiates to the back 97. The client is beginning to show signs of hepatic encephalopathy. The nurse plans a dietary consult to limit the amount of which of the following ingredients in the client’s diet? A. fat B. carbohydrates C. protein D. minerals 98. The client with Crohn’s disease has an order to begin taking antispasmodic medication. The nurse should time the medication so that each dose is taken: A. 30 minutes before meals B. during meals C. 60 minutes after meals D. upon arising and at bedtime 99. The client with ulcerative ulcerative colitis is diagnosed with mild case case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets? A. high-fat with milk B. high-protein without milk C. low-roughage without milk D. low-roughage with milk 100. It has been determined that the client with hepatitis has contracted the infection from contaminated food. What type of hepatitis is this client most likely experiencing? A. hepatitis A B. hepatitis B C. hepatitis C D. hepatitis D
III Situation: The head nurse of an eye and ear clinic is ordering nursing students. 1. Normal visual acuity as measured with a Snellen eye chart is 20/20. What does a visual acuity of 20/30 indicate? A at 20 feet, an individual can only read letters large enough to be read at 30 feet B. at 30 feet, an individual can read letters large enough to be read at 20 feet C. an individual can read 20 out of 30 total letters on the chart D. an individual can read 30 out o f 50 total letters on the chart at 20 feet 2. Damage to the visual area of the occipital lobe of cerebrum, on the left side, would produce what type of visual loss? A. left eye only B. right eye only C. medial half of the right eye and lateral half of the left eye D. medial half of the left eye and lateral half of the right eye 3. An anterior chamber of the eye refers to all the space in what area? A. anterior to the retina B. between the iris and the cornea C. between the lens and the cornea D. between the lens and the iris 4. What condition results when rays of light are focused in front of the retina? A. myopia (near sightedness) B. hyperopia (farsightedness) C. presbyopia (kind of farsightedness) D. emmetropia (normal)
5. As the person grows older, the lens losses its elasticity, causing which kind of farsightedness? A. emmetropia B. presbyopia C. diplopia (double vision) D. myopia 6. If a person has a foreign object of unknown material that is not readily seen in one eye, what would the first action be? A. irrigate the eye with a boric acid solution B. examine the lower eyelid and then the upper eyelid C. irrigate the eye with opious amounts of water D. shield the eye from pressure, and seek medical help 7. A sudden loss of an area of vision, as if a curtain were being drawn, is a principal symptom of? A. retinal detachment B. glaucoma C. cataracts D. keratitis (damage in cornea) 8. Postoperative care following stapedectomy would not include which of the following A. out of bed as desired B. no moisture in the affected ear C. avoid sneezing D. no bending over or lifting 9. Dimenhydrinate (Dramamine) is given after a stapedectomy A. to accelerate the auditory process B. to dull the pain experienced with the semicircular canal is disturbed C. to minimize the sensations of equilibrium disturbances and imbalance D. to prevent an increase tendency toward nausea 10. A client with Meniere’s syndrome (idiopathicendolymphatic hydrops, is a disorder of the inner ear. Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. ) is extremely uncomfortable because of which of these? A. severe earache B. many perceptual difficulties C. vertigo and resultant nausea D. facial paralysis 11. What is the cataract of the eyes? A. opacity of the cornea B. clouding of the aqueous humor C. opacity of the lens D. papilledema 12. Treating a cataract primarily involves which of the following? A. instillation of miotics B. installation of mydriatics C. removal of the lens D. enucleation 13. Preoperative instruction will not need to include A. type of surgery B. how to use the call bell C. how to prevent paralytic illeus D. how to prevent respiratory infetins 14. In preparing to teach patient about adjustment to cataract lenses, the nurse needs to know that the lenses will. A. magnify objects by one-third- with central vision B. magnify objects by one-third with peripheral vision C. reduce objects by one-third with central vision D. reduce objects by one-third with peripheral vision 15. In the immediate postoperative period the one action that is contraindicated for patient compared with clients after most other operations is which of the following? A. coughing B. turning on the unoperative side C. measures to control nausea and vomiting D. eating after nausea passes 16. Immediate nursing care following cataract extraction is directed primarily toward preventing
A. Atelectasis Atelectasis B. infection of the cornea C. hemorrhage D. prolapse of the iris 17. The patient is confused during her first night after eye surgery. What would the nurse do? A. tell her to stay in bed B. apply restraints to keep her in bed C. explain why she cannot get out of bed, keep side rails up, and check her frequently D. sedate her 18. Discharge teaching would probably not need to include A. staying in a darkened room as much as possible B. avoiding alcoholic drinks,; limiting the use of tea and coffee C. using no eye washes or dr ops unless they were prescribed by the physician D. avoiding being excessively sedentary 19. Patient also needs to be instructed to limit. A. sewing B. watching TV C. walking D. weeding her garden (water) Situation: Lea visit her ophthalmologist and receives a mydriatic drug in order to facilitate the examination. After returning home, she experiences severe pain, nausea and vomiting, and blurred vision. During a visit to the emergency room, a diagnosis of acute glaucoma is made. 20. Lea’s glaucoma has been caused by the dilation of the pupil. A. blockage of the outflow of aqueous humor by the dilation of the pupil B. blockage of the outflow of aqueous humor by the constriction of the pupil C. increase intraocular pressure resulting from the increased production of aqueous humor D. decrease intraocular pressure resulting from decrease production of aqueous humor 21. Intraocular pressure is measured clinically by tonometer. What tonometer reading would be indicative of glaucoma? A. pressure of 10 mmHg B. pressure of 15 mmHg C. pressure of 20 mmHg D. pressure of 25 mmHg 22. Which cranial nerve transmits visual impulses? A. I (olfactory) B. II (optic) C. III (oculomotor) D. IV (abducens) 23. Untreated or uncontrolled glaucoma damages the optic nerve. Three of the following signs and symptoms result from optic nerve atrophy; which one does not? A. colored halos around lights B. severe pain in the eye C. dilated and fixed pupils D. opacity of the lens 24. Glaucoma is conservatively managed with miotic eye drops. Mydriatic eye drops are contraindicated for glaucoma. Which of the following drugs is a mydriatic (it dilates the pupil)? pupil)? A. neostigmine B. pilocarpine C. physostigmatine D. atropine 25. Glaucoma may require surgical treatment. Preoperatively, the client would be taught to expect which of the following postoperatively? A. cough and deep-breathing qh. B. turn only to the unaffected side C. medication for severe eye pain D. restriction of fluids for the first 24 hours
Situation: Roy, a 55-year-old man, is admitted to the hospital with wide-angle glaucoma 26. What was the symptom that probably brought Roy to the ophthalmologist initially? A. decreasing vision B. extreme pain in eye C. redness and tearing of the eye D. seeing colored flashes of light 27. The teaching plan for Roy would include which of the following? A. reduce fluid intake B. add extra lighting in the home C. wear dark glasses/during the day D. avoid exercise 28. Miotics are used in the treatment of glaucoma. What is an example of a commonly used miotic (substance causes the constriction of the pupil of the eye) ? A. atropine (mydriatic) B. pilocarpine C. acetazolamide (Diamox) D. scopolamine 29. What is the rationale for using miotics in the treatment of glaucoma? A. they decrease the rate of aqueous humor production B. pupil constriction increases outflow of aqueous humor C. increased pupil size relaxes the ciliary muscles D. the blood flow to the conjunctiva is increased 30. When instilling eye drops for a client with glaucoma, what procedure would the nurse follow? A. place the medication in the middle of the lower lid, and put pressure on the lacrimal lacrimal duct after instillation. B. Instill the drug to the outer angle of the eye, have client tilt head back C. instill the drug at the innermost angle; wipe with cotton away from inner aspect D. instill medication in middle eye, have client blink for better absorption 31. Carbonic anhydrase inhibitors are sometimes used in the treatment of glaucoma because they: A. depress secretion of a aqueous humor B. dilate the pupil C. paralyze the power of accommodation D. increase the power o f accommodation 32. Teaching a client with glaucoma will not include which of the following? A. vision can be restored only if the client remains under a physician’s care B. avoid stimulant (eg., caffeine) C. take all medications conscientiously D. prevent constipation and avid heavy lifting and emotional excitement 33. Glaucoma is a progressive disease that that can lead to blindness. It can be managed if diagnosed early. Preventive health teaching would best include which of the points? A. early surgical action may be necessary B. all clients over 40 years of age should have an annual tonometry exam C. the use of contract lances in older clients is not advisable D. clients should seek early treatment for eye infections 34. A client with progressive glaucoma may be experiencing sensory deprivation. Which of the following actions would best minimize this problem? A. speak in a louder voice B. ensure that a sedative is ordered C. orient the client to time, place, and person D. use touch frequently when providing care Situation: 5-Gary is seen in the emergency room with the diagnosis of epitaxis. 35. It is unlikely that Gary’s history will include A. minor trauma to the nose
B. a deviated septum C. acute sinusitis D. hypotension 36. Which of the following medications would be used with in order to promote vasoconstriction and control bleeding? A. epinephrine B. lidocaine C. pilovarpine D. cylospentolate 37. Which of the following positions would be most desirable for Gary? A. trendelenburg’s to control shock B. a sitting position, unless he is hypotensive C. side-lying, to prevent aspiration D. prone, to prevent aspiration 38. The physician decides to insert nasal packing. Of the following nursing actions, which would have the highest priority? A. encourage Gary to breath through his mouth, because he may feel panicky after the insertion. B. advice Gary to expectorate the blood in the nasopharynx gently and not to swallow it C. periodically check the position of the nasal packing, because airway obstruction can occur if the packing packing accidentally accidentally slip slip out of place D. take rectal temperature, because he must r ely on mouth breathing and would be unable unable to keep his mouth closed on the thermometer. thermometer. 39. After bleeding has been controlled, Gary taken to surgery to correct a deviated nasal septum. Which of the following is likely complication of this surgery? A. loss of the ability to smell B. inability to breath through the nose C. infection D. hemorrhage 40. Upon his discharge, the nurse instructs Gary on the use of vasoconstrictive nose drops and cautions him to avoid too frequent, and excessive use to these drugs, which of the following provides the best rationale for this caution A. A rebound effect occurs in which stuffness worsens after each successive dose B. cocaine, a frequent ingredient in nose drops, may lead to psychological addiction C. these medications may be absorbed systematically, systematically, causing severe hypotension D. persistent vasoconstriction of the nasal mucosa can lead to alterations in the olfactory nerve Situation: Brix had redial and neck surgery for cancer of the larynx. 41. Brix has tracheostomy. When suctioning through laryngectomy
tube . When doing these two procedures at the same time, the nurse would not do which of the ff: A. Use sterile technique B. turn head to right to suction left bronchus C. suction for no longer then 10 to 15 seconds D. observe for tachycardia
42. Brix requires both nasopharyngeal suctioning and suctioning through laryngectomy tube. When doing these two procedures at the same time, the nurse would not do wh ich of the ff: A. use a sterile suction setup B. suction the nose first, then the laryngectomy tube C. suction the laryngectomy tube first, then the nose D. lubricate the catheter with saline 43. A nasogastric tube is used to provide Brix with with fluids and nutrient for approximately 10 days, for which of the following reasons? A. to prevent pain while swallowing B. to prevent contamination of the suture line C. to decrease need for swallowing D. to prevent need for holding head up to ear 44. Brix’s children are concerned about their own risk of developing cancer. All but one of the following are facts that describe malignant neoplasia and must be considered by the nurse in her responses. Which one is correct? A. family factors may influence an individual’s susceptibility to neoplasia B. long-term use of corticosteroids corticosteroids enhances the body’s defense C. Sexual differences influence an individuals susceptibility to specific neoplasm D. living in industrialized areas increase an individual’s susceptibility to a malignant neoplasm 45. When would Brix best begin speech rehabilitation? rehabilitation? A. when he leaves the hospital B. when the esophageal suture line is healed C. three months after surgery D. when he regains all his strength 46. The nurse is complaining the initial morning assessment on the client. Which physical examination technique would be used first when assessing the abdomen? A. inspection B. light palpation C. auscultation D. percussion 47. The client has orders for a nasogastric (NG) tube tube insertion. During the procedure, instruction that will assist in insertion would be: A. instruct the client to tilt his head back for insertion into the nostril, then flex his neck for final insertion B. after insertion into the nostril, instruct the client to extend his neck C. introduce the tube with the client’s head tilted back, then instruct him to keep his head upright for final insertion D. instruct the client to hold his chin down, then back for insertion of the tube 48. The most important pathophysiologic pathophysiologic factor contributing contributing to the formation of esophageal varices is: A. decreased prothrombin formation B. decreased albumin formation by the liver C. portal hypertension D. increased central venous pressure 49. The nurse analyzes the results of the blood chemistry tests done on a client with acute pancreatitis. Which of the following results would the nurse expect to find? A. low glucose B. low alkaline phosphatase C. elevated amylase D. elevated creatinine 50. A client being treated for esophageal varices has a SengstakenBlakemore tube inserted to control the bleeding. The most important assessment is for the nurse to: A. check that a hemostat is at the bedside B. monitor IV fluids for the shift C. regularly assess respiratory status D. check that the balloon is deflated on a regular basis
51. A female client complains of gnawing (bite/chew) midepigastric pain for a few hours after meals. At times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out: A. cancer of the stomach B. peptic ulcer disease C. chronic gastritis D. pylorospasm 52. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be: A. assisting in inserting a Miller-Abbott tube B. assisting in inserting an atrial pressure line C. inserting a nasogastric tube D. inserting an IV 53. A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being treated with a histamine receptor antagonists (cimetidine), antacids, antacids, and d iet. The nurse doing discharge planning will teach him that the action of cimetidine is to: A. reduce gastric acid output B. protect the ulcer surface C. inhibit the production of hydrochloric acid (HCl) D. inhibit vagal nerve stimulation 54. The nurse is admitting a client with Crohn’s disease who is scheduled for intestinal surgery. Which surgical procedure would the nurse anticipate for the treatment of this condition: A. ileostomy with total colectomy B. sigmoid colostomy with mucous fistula C. intestinal resection with end-to-end anastomosis D. colonoscopy with biopsy and polypectomy 55. A client who has just returned ho me following ileostomy surgery will need a diet that is supplemented: A. potassium B. vitamin B12 C. sodium D. fiber 56. A client scheduled for colostomy surgery. An appropriate preoperative diet will include: A. broiled chicken, baked potato, and wheat bread B. ground hamburger, rice, and salad C. broiled fish, rice, squash, and tea (deodorant) D. steak, mashed potatoes, raw carrots, and celery 57. As the nurse is completing evening care for a client, he observes that the client is upset, quiet, and withdrawn. The nurse knows that the client is scheduled for diagnostic tests the following day. An important assessment question to ask the client is: A. “would you like to go to the dayroom to watch TV?” B. “are you prepared for the test tomorrow?” C. “have you talked with anyone about the test tomorrow?” D. “have you asked your physician to give you a sleeping pill tonight?” 58. Following abdominal surgery, a client complaining of “gas pains” will have a rectal tube inserted. The client should be positioned on his: A. left side, recumbent B. left side, sims C. right side, semi-fowler’s D. left side, semi-Fowler’s 59. Which of the following statements is most correct regarding colostomy irrigations? A. the solution temperature should be 100 deg. F B. 1000 ml/1L is the usual amount of solution for the irrigation C. the solution container should be placed 10 inches above the stoma D. the irrigation cone is inserted in an upward direction in relation to the stoma 60. The nurse is teaching a client with a new colostomy how to apply an appliance to a colostomy. How much skin should remain exposed between the stoma and the ring of the appliance? A. 1/8 inch B. ½ inch C. ¾ inch
D. 1 inch 61. Following a liver biopsy, the highest priority assessment of the client’s condition is to check for: A. pulmonary edema B. uneven respiratory pattern C. hemorrhage D. pain 62. A client has a bile duct obstruction and is jaundiced. Which intervention will be most effective in controlling the itching associated with his jaundice? A. keep the client’s nails clean and short B. maintain the client’s room temperature at 72 to 75 deg. F C. provide tepid water for bathing D. use alcohol for back rubs 63. When a client is in liver failure, which of the following behavioral changes is the most important assessment to report? A. shortness of breath B. lethargy C. fatigue D. nausea 64. A client with a history of cholecystitis is now being admitted to the hospital for possible surgical intervention. The orders include NPO, IV therapy, and bed rest. In addition to assessing for nausea, vomiting and anorexia, the nurse should observe for pain: A. in the right lower quadrant B. after ingesting food C. radiating to the left shoulder D. in the upper quadrant 65. The nurse taking a nursing history from a newly admitted client learns that he has a Denver shunt. This suggest that he has a history of: A. hydrocephalus B. renal failure C. peripheral occlusive disease D. cirrhosis 66. A female client had a laparoscopic laparoscopic cholecystectomy cholecystectomy this morning. She is now complaining of right shoulder pain. The nurse would explain to the client this symptom is: A. common following this operation B. expected after general anesthesia C. unusual and will be reported to the sur geon D. indicative of a need to use the incentive spirometer 67. For a client with the diagnosis of acute pancreatitis, pancreatitis, the nurse would plan for which critical component of his care? A. testing for Homan’s sign B. measuring the abdominal girth C. performing a glucometer test D. straining the urine 68. After removing a fecal impaction, the client complains of feeling lightheaded and the pulse rate is 44. The priority intervention is: A. monitoring vital signs B. place in shock position C. call the physician D. begin CPR 69. Peritoneal reaction to acute pancreatitis results in a shift of fluid from the vascular space into the peritoneal cavity. If this occurs, the nurse would evaluate for: A. decreased serum albumin B. abdominal pain C. oliguria D. peritonitis 70. The assessment finding should be reported immediately if it develop in the client with acute pancreatitis which is: A. nausea and vomiting B. abdominal pain C. decreased bowel sounds D. shortness of breath 71. Following brain surgery, the client suddenly exhibits polyuria and begins voiding 15 to 20 L/day. Specific gravity of the urine is
1.006. The nurse will recognize these symptoms as the possible development of: A. diabetes insipidus B. diabetes, type 1 C. diabetes, type 2 D. Addison’s disease 72. A person with a d iagnosis of adult Diabetes, type 2, should understand the symptoms of a hyperglycemic reaction. The nurse will know this client understands if she says these symptoms are: A. thirst, polyuria and decreased appetite B. flushed cheeks, acetone breath, and increased thirst C. nausea, vomiting and diarrhea D. weight gain, normal breath and thirst 73. The non-insulin dependent diabetic who is obese is best controlled by weight loss because obesity: A. reduces the number of insulin receptors B. causes pancreatic islet cell exhaustion C. reduces insulin binding T receptor sites D. reduces pancreatic insulin production 74. A nursing assessment for initial signs of hypoglycemia will include: A. Pallor, blurred vision, weakness, behavioral changes B. frequent urination, flushed face, pleural friction rub C. abdominal pain, diminished deep tendon reflexes, double vision D. weakness, lassitude, irregular pulse, dilated pupils 75. Which of the following nursing diagnosis would be most appropriate for the client with decreased thyroid function: A. alteration in growth and development related to increased growth hormone production B. alteration in thought processes related to decreased neurologic function C. fluid volume deficit related to polyuria D. hypothermia related to decreased metabolic rate 76. The RN should assess for which of the following clinical manifestations in the client with Cushing’s syndrome? A. hypertension, diaphoresis, nausea and vo miting B. tetany, irritability, dry skin and seizures C. unexplained weight gain, energy loss, and cold intolerance D. water retention, moon face, hirsutism and purple striae 77. The client hyperparathyroidism should have extremities handled gently because: A. decreased calcium bone deposits can lead to pathologic fractures B. edema causes stretched tissue to tear easily C. hypertension can lead to stroke with residual paralysis D. polyuria leads to dry skin and mucous membrane that can breakdown 78. Which of the following priority nursing implementation for a client with a tumor of the posterior lobe of the pituitary gland who has had a urine output of 3 L in the last hour with a specific gravity of 1.002? A. measure and record vital signs each shift B. turn client every 2 hours to pr event skin breakdown C. administer Pitressin Tannate as ordered D. maintain a dark and quiet room 79. A client has a diagnosis of d iabetes. His physician has ordered short and long acting insulin. When administering two type of insulin, the nurse would: A. withdraw the long acting insulin into the syringe before the short acting insulin B. withdraw the short acting insulin into the syringe before the long acting insulin C. draw up in two separate syringes, then combine in one syringe D. withdraw long acting insulin, inject air into regular insulin, and withdraw insulin 80. Certain physiological changes will result from the treatment for myxedem. The symptoms that may indicate adverse changes in the body that the nurse should observe for are: A. increased respiratory excursion
B. increased the frequency of rest periods C. initiate postural drainage D. continue with routine nursing care 81. A client with myxedema has been in the hospital for 3 days. The nursing assessment reveals the following clinical manifestations: respiratory rate 8/min, diminished breath sounds in the right lower lobe, crackles in the left lower lobe. The most appropriate nursing intervention is to: A. increased the use of ROM, turning, deep breathing exercises B. increased the frequency of rest periods C. initiate postural drainage D. continue with routine nursing care 82. In an individual with the diagnosis of hyperparathyroidism, the nurse will assess for which primary symptom: A. fatigue, muscular weakness B. cardiac arrhytmias C. tetany D. constipation 83. The nurse explains to a client who has just received the diagnosis of type 2 non-insulin dependent diabetes mellitus (NIDDM) that sulfonylureas, one group of oral hypoglycemic agents, as act by: A. stimulating the pancreas to produce or release insulin B. making the insulin that is produce more available for use C. lowering the blood sugar by facilitating the uptake and utilization of glucose D. altering both fat and protein metabolism 84. A client has been admitted to the hospital with a tentative diagnosis of adrenocortical hyperfucntion. In assessing the client, an observable sign the nurse would chart is: A. butterfly rash on the face B. moon face C. positive Chvostek’s sign D. bloated extremities 85. The nurse is teaching a diabetic client to monitor glucose using a glucometer. The nurse will know the client is competent in performing her finger-stick to obtain blood when she: A. uses a ball of a finger as the puncture site B. uses the side of fingertip as the puncture site C. avoid using the fingers of her dominant hand as puncture sites D. avoid using the thumbs as pun cture sites 86. A client is scheduled for a v oiding cystogram. Which nursing intervention would be essential to carry put several hours before the test? A. maintain NPO status B. medicating with urinary antiseptics C. administering bowel preparations D. forcing fluids 87. A retention catheter for a male client is correctly taped if it is: A. on the lower abdomen B. on the umbilicus C. under the thigh D. on the inner thigh 88. A client with a diagnosis of go ut will betaking colchicines and allopurinol BID to prevent recurrence. The most common early sign of colchicines toxicity that the nurse assess for is: A. blurred vision B. anorexia C. diarrhea D. fever 89. A client’s laboratory results have been returned and the creatinine level is 7 mg/dl. This finding would lead the nurse to place the highest priority on assessing: A. temperature B. intake andoutput C. capillary refill D. pupillary reflex 90. After the lungs, the kidneys work to maintain body pH. The best explanation of how the kidneys accomplish regulation of pH is that they:
A. secrete hydrogen ions and sodium B. secrete ammonia C. exchange hydrogen and sodium in the kidney tubules D. decrease sodium ions, hold on to the hydrogen ions, and then secrete sodium bicarbonate 91. Conditions known to predispose to renal calculi formation include: A. Polyuria B. dehydration, immobility C. glycosuria D. presence of an indwelling Foley catheter 92. the most appropriate nursing intervention, based on physician’s orders, for treating metabolic acidosis is to: A. replace potassium ions immediately to prevent hypokalemia B. administer oral sodium bicarbonate to act as a buffer C. administer IV cathecholamines (Levophed) to prevent hypertension D. administer fluids to prevent dehydration 93. IV is attached to a controller to maintain the flow rate. If the alarm sounds on the controller: A. ensure that drip chamber is full B. assess that height of IV container is at least 30 inches above venipuncture site C. ensure that the drop sensor is properly placed on the drip chamber D. evaluate the needle and IV tubing to determine if they are patent and positioned appropriately 94. A 76-year-old woman who has been in good health develops urinary incontinence over a period of several days and is admitted to the hospital for a diagnostic workup. The nurse wou ld assess the client for other indicators of: A. renal failure B. urinary tract infection C. fluid volume excess D. dementia 95. A 60-year-old male client’s physician schedules a prostatectomy and orders a straight urinary drainage system to be inserted preoperatively. For the system to be effective, the nurse would: A. coil the tubing above the level of the bladder B. position the collection bag above the level of the bladder C. check that the collection bag is vented and distensible D. determine that the tubing is less that 3 feet in length 96. During a retention catheter insertion or bladder irrigation, the nurse must use: A. sterile equipment and wear sterile gloves B. clean equipment and maintain surgical asepsis C. sterile equipment and maintain medical asepsis D. clean equipment and technique 97. The physician has ordered a 24 hours urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen. This specimen is the: A. discarded, then collection begins B. saved as part of the 24 hours collection C. tested, then discarded D. placed in a separate container and later added to collection 98. The most common cause of bladder infection in the client with a retention catheter is contamination: A. due to insertion technique B. at the time of the catheter removal C. of the urethral/ catheter interface D. of the internal lumen of the catheter 99. A client in acute renal failure receive an IV infusion of 10 percent dextrose in water with 20 units of regular insulin. The nurse understands that the rational for this therapy is to: A. correct the hyperglycemia that occurs with acute renal failure B. facilitate the intracellular movement of potassium C. provide calories to prevent tissue catabolism and azotemia D. force potassium into cells to prevent arrhythmias
100. A client with chronic renal failure is on continuous ambulatory peritoneal dialysis (CAPD). Which nursing diagnosis should have the highest priority? A. powerlessness B. high risk for infection C. altered nutrition: less than body requirements D. high risk for fluid volume deficit\
IV AM-CARE AM-CA RE Review Revie w Academy Acade my for for Nurses Nurses Room 301 3rd Floor P & J Lim Bldg. Tiano Brothers Kalambaguhan Sts., Cagayan de Oro City Tel. No. (08822) 721-805 NLE DECEMBER 2005 MEDICAL SURGICAL NURSING IV Situation: John Lee is an 18-year old high school student who suffered an injury to his cervical spine in a football game. 1. In directing emergency care until the ambulance arrives, it is most important that the school nurse A. place a small makeshift pillow under his head B. check to see if he can move all of his extremities C. keep him flat and immobilized immobilized in a natural position D. cover him with a blanket 2. A primary goal of nursing care when John is brought into the emergency room will be A. prevention of spinal shock B. maintenance of respiration C. maintenance of orientation D provision for pain relief Situation: Crutchfield tongs are used to apply traction to realign the spinal cord. 3. A nursing measure for john while he is in cervical traction should be to A. massage the back of his head B. position him from side to side C. remove the weights at least once a shift D. encourage involvement in his own care Situation: John is found to have a temperature of 36ºC (96.8ºF). 4. The most appropriate initial nursing measure for John in response to his hypothermia would be to A. cover him with additional blankets B. place a hot-water bottle at his feet C. check for signs of shock D. notify his p hysician Situation: John has a tracheostomy performed and is on assisted ventilation. 5. The alarm on the ventilator sounds. The initial response by the nurse should be to quickly A. notify the respiratory therapist B. check all connections from the respirator C. notify the respiratory therapist to come immediately D. use a self-inflating bag to ventilate John 6. When suctioning John, the nurse sho uld A. ensure that he is able to take a breath between insertions of the catheter B. suction him for at least 30 seconds with each catheter insertion C. apply suction and gently rotate the catheter while inserting it into the bronchial bifurcation D. use clean technique during the suction procedure 7. John suddenly becomes diaphoretic, his blood pressure rises to 190/110, and he complains of a headache. The nurse should assess the patient for signs of A. increased intracranial pressure
B. spinal meningitis C. pulmonary congestion D. fecal impaction 8. Upon admission John had a complete loss of motor ability. Within 48 hours he is noted to be having having muscle spasms. His family becomes very excited when they notice these movements. Which of the following choices would be the most appropriate response response by the nurse? A. at this stage, muscle spasms are expected, but it is too soon to evaluate the extent of the injury or its its permanent permanent effects effects B. I can understand your excitement. These movements are a good sign that he is making progress C. these movements are an indication that he is trying to move and that his will is very strong D. these movements are reflex activities that indicate that his spinal cord is intact Situation: Mark Richards has a compound fracture of the temporal bone. 9. The nurse notices bleeding from the orifice of the ear. Which of the following actions by the nurse can be safely used to determine if the drainage contains cerebrospinal fluid (CSF)? The nurse should A. swab the orifice of the ear with sterile applicator and send the specimen to the laboratory B. blot the drainage with a sterile gauze pad and look for a clear halo or ring around the spot of blood C. gently suction the ear an send the specimen to the laboratory D. test the CSF with a Tes-Tape and get a negative reading for sugar 10. The nursing care plans states “Observe for early signs of increased intracranial intracranial pressure (IIP).” Early symptoms of IIP include A. widening pulse pressure and dilated pupils B. rising blood pressure and bradycardia C. elevated temperature and decerebrate posturing D. nausea, vomiting, and restlessness 11. During the initial period after a head injury, nursing intervention for Mr. Richards should include A. packing the ear with cotton balls to stop bleeding B. awakening the patient every 2 hours to determine his level of consciousness C. placing the patient in Trendelenburg’s position D. forcing fluids to restore hydration 12. Before discharge, a computerized axial tomogram will be performed to rule out any intracranial or extracranial bleeding. bleeding. Mr. Richards should be told that A. the procedure is noninvasive and he will not feel any pain B. he will experience a burning sensation as the dye is being injected C. the procedure is done in the operating room under anesthesia D. local anesthetic is used b efore injecting air into the ventricles of the brain via the spinal canal Situation: Tonnie Miccio is a 43-year old divorced man who has been rushed to the emergency room with an acute gouty arthritis. 13. While admitting Mr. Miccio to the hospital, the nurse should recognize those factors that can can precipitate an acute attack. They include A. excessive smoking B. large alcohol intake C. emotional stress D. improper rest 14. A serum uric acid level is performed by the hospital laboratory. In acute gout, the uric acid level is approximately A. 1.0 mg/100 ml B. 2.1 mg/100 ml C. 6.5 mg/100 ml D. 10 mg/100 ml 15. Colchicine is the standard drug used to treat acute gout: The physician orders colchicines, colchicines, 1.0 mg every 2 hours. After receiving the third dose, the patient complains of nausea, vomiting, and diarrhea. The nurse should recognize that this this is
A. a transient side effect and give the next dose B. a sign of toxicity and withhold the medication C. an allergic response to the drug and notify the physician D. a psychogenic response to the severe pain 16. The expected outcome for colchicine is to A. reduce uric acid levels B. relieve joint pain and inflammation C. increase blood flow to the kidney D. detoxify purines in the liver 17. During the night, Mr. Miccio complains of severe pain in his toe and asks the nurse for 2 aspirin aspirin tablets. The nurse should A. give the patient the 2 aspirin tablets B. elevate the foot on a pillow C. notify the physician D. offer the patient a cup of tea 18. Some physicians prescribe an alkali-ash diet to enhance the effect of the medications. medications. Which of the following foods are allowed? allowed? A. liver, shellfish, and fats B. cranberries, cheese, and whole grain cereals C. milk, vegetables, and most fruits D. eggs, milk, prunes, and plums 19. After the acute attack subsides, the physician orders allopurinol (Zyloprim), 300 mg/day. mg/day. The expected outcome for this drug is to to A. lower the plasma and urinary uric acid level B. reduce inflammation of the affected joints C. produce diuresis D. relieve pain 20. A teaching program for Mr. Miccio should include A. emphasizing that aspirin is contraindicated in patient’s taking allopurinol B. restricting fluid intake to 1,000 ml/day C. explaining that acute gouty attacks often occur during initiation of allopurinol therapy D. stating that a low-purine diet should be followed while taking allopurinol 21. About 2 months after taking the allopurinol, Mr. Miccio develops a skin rash. The nurse should A. recognize this as a minor side effect that will subside B. ask the patient if he has been taking any aspirin while taking the allopurinol C. recognize this is an indication to discontinue the drug D. be aware that concomitant use of colchicines with allopurinol causes this reaction 22. One day, Jennifer asks her roommate, Erin, how her scoliosis was first recognized. Erin replies, replies, “The school health nurse told me that there may be a problem after all the girls in my class were asked to stand erect while she examined our backs.” The nurse suspected scoliosis when she observed observed that Erin’s shoulder on one side was elevated and her A. head appeared aligned to the opposite side B. leg on the same side appeared shorter C. hip on the opposite side appeared prominent D. arm on the same side appeared longer 23. When Erin’s scoliosis was diagnosed after x-ray examination of her spine, she was fitted with a Milwaukee brace. Erin Erin asks the nurse when it could be removed each day. Which of the the following would be the best response? A. only when you are lying flat, either resting or sleeping B. for 1 hour a day when you bathe, shower, or go swimming C. only for special occasions, such as a party D. for 3 hours a day: one in the morning, one in the afternoon, and one in the evening Situation: Erin’s admission to the hospital for spinal fusion was necessary because hr scoliosis did not respond to the Milwaukee brace. 24. Preoperative preparation for Erin includes explaining that for 2 weeks after surgery she will be positioned A. on either side or prone B. sitting upright
C. flat and will be logrolled D. on her back 25. When Erin is told that after surgery she will wear a body cast for about 1 year, she begins to sob. She tells the nurse she will look like a football player, not a girl. Which of the following is the best response the nurse can make? A. the people who really care about you won’t even notice your cast B. it only will be for a year. You’re mature enough to wait C. just ignore any comments that people make D. a pretty hairstyle and some loose peasant blouses will keep you looking feminine 26. After surgery, the nurse applies slight pressure to Erin’s toes and asks Erin is he can feel her foot being touched. Erin replies, “No, I don’t feel anything.” The nurse should then A. wait 1 hour and supply pressure again B. record Erin’s expected response C. ask Erin if her toes feel cold D. report Erin’s response to the surgeon Situation: Virginia K is a 25- year old woman who works as a lifeguard at the local beach. On her way to work she is in an automobile accident and is rushed to the hospital by ambulance. A diagnosis of complete transaction of the spinal cord at the third lumbar (L3) level is made. 27. While assess Ms. K for neurologic function, the nurse can expect she will be unable to A. shrug her shoulders B. tighten her abdominal muscles C. bend her elbow D. straighten her legs 28. Long-term goals for Ms. K include developing skills in A. performing wheelchair ambulation B. activating an electric wheelchair C. walking with leg braces and crutches D. walking without aids 29. observing for symptoms of which of the following is the priority of care for Ms. K in the acute stages of complete transaction transaction of the lumbar cord? A. spinal shock B. respiratory insufficiency C. autonomic hyperreflexia D. hypertensive crisis 30. To prevent the complication of urinary tract infections, which of the following measures should be included in the nursing care care plan? A. encouraging extra fluid intake B. offering at least two servings of citrus fruit juice per day C. telling the patient to avoid fruit juices such as plum, prune, and cranberry D. notifying the dietician to include a container of milk at all meals Situation: Jim, a 17-year old senior in high school, has sustained a simple fracture of the mandible after falling from his motorbike. 31. Upon admission to the emergency room, which of the following choices should the nurse expect to observe? A. bleeding in the external auditory canal B. dropped prominence of the cheek on the affected side C. edema of the eyes and cheeks D. teeth unevenly lined up Situation: An open reduction with wiring of the lower jaw to the upper jaw has been done by the surgeon. 32. In anticipating the postoperative needs o the patient, which of the following actions has the priority priority for Jim? A. placing paper and pencil at the bedside B. providing a tracheostomy set for tracheostomy care C. taping a wire cutter to the head of the bed D. inserting a gauze wick in the inside of the cheek 33. While teaching Jim mouth care the nurse should A. show him how to use moistened gauze sponges to clean his mouth and tongue
B. demonstrate how an oral irrigation can be performed by inserting the catheter along the inside of the mouth between the teeth and the cheek C. explain to him that mouth care should not be done until the wires are removed D. tell him to use an astringent mouthwash to remove all the debris
Mrs. Marian H is a 50-year old woman who has a spinal cord lesion at the fourth thoracic (T4) vertebra. 34. When there are lesions above T4 and T6, the patient may experience autonomic hyperreflexia. hyperreflexia. This condition can be prevented by A. avoiding bladder distention B. changing the patient’s position hourly C. wearing supportive elastic hose D. doing a neurologic check 35. Mrs. H complains of severe headache and is extremely anxious. The nurse checks her blood pressure and finds it is 210/110. The nurse should then A. check the patency of the urinary catheter B. apply ice packs to her head C. place the patient in a flat position D. sit with the patient until the symptoms subside Situation: Dorothy C, RN, age 35, is at work. After moving a particularly heavy patient, she suddenly develops severe pain in the lumbosacral area that radiates down her right leg. The preliminary diagnosis is rupture of an intervertebral disk. 36. Proper body mechanics may have prevented this injury to Ms. C. If she had adhered to to the correct method of turning a patient patient from the supine position to the left side, she would have crossed the patient’s right arm over chest, and crossed the right leg over the left leg. Then, while standing with her feet A. together at the patient’s right side, she would gently turn the patient by pushing at the shoulder and sacral areas B. apart at the right side of the b ed, she would turn the patient by gently pushing at at the shoulder and and center of the back C. apart at the left side of the bed, she would gently roll the patient toward her while keeping her legs legs straight D. apart at the left side of the bed, she would gently roll the patient toward her while flexing her knees 37. Instructions for Ms. C’s recuperation at home should include the use of a bed board, firm mattress, mattress, and rest in which of the following following positions? A. completely flat in bed B. head elevated on a pillow, and knees and feet elevated with pillows C. head elevated with several pillows, and her legs flat D. Head elevated with several pillows, and several pillows under her knees 38. Ms. C should be reminded that if she is turning on her side, it is best if she A. grasps a chair leg by the side of the bed, and slowly pulls herself over, flexing the uppermost knee B. keeps her legs extended while crossing them to the side to which she is turning, and then uses her arms to help turn the upper portion of her body C. crosses her arms, flexes the uppermost knee toward the side to which which she is is turning, turning, and and then rolls over D. crosses her arms, crosses her legs while they are extended to the side toward which she is turning, and then rolls over 39. The physician gives Ms. C a prescription for methocarbamol (Robaxin). Because of her nursing background, Ms. C will know that the mediation is having the desired effects if which of the fo llowing occurs? A. She feels drowsy, and is sleeping more B. she has a feeling of euphoria C. there is a decrease in muscle spasms
D. there is an increase in the knee-jerk reflex Situation: After a week of bed rest at home, Ms. C’s condition remains about the same. She is admitted to the hospital for further treatment and diagnostic tests. 40. Phenylbutazone (Butazolidin) is ordered for Ms. C. Planning for the administration of this medication medication should include directions to A. administer it immediately before or after eating B. avoid administering it with dairy products C. administer it at least 2 hours after eating D. administer it at specific time intervals, without regard to meals 41. In addition to the order for phenylbutazone, Ms. C is placed on bed rest and in pelvic traction. To diminish adverse responses to this treatment, the nurse should request an order for A. acetylsalicylic acid (aspirin) B. diphenoxylate hydrochloride (Lomotil) C. prochlorpeazine (Compazine) D. dioctyl sodium sulosuccinate (Colace) 42. A myelogram is performed on Mrs. C with a water-soluble contrast medium. Care Care after this procedure procedure should include A. limiting fluid intake and elevating the head of the bed to 15 to 30 degrees B. not allowing anything by mouth and keeping the bed flat C. encouraging fluid intake and keeping the bed flat D. encouraging fluid intake and raising the head of the bed to 15 to 30 degrees 43. Ms. C has a laminectomy. Postoperatively, she complains that the pain is no different now than than it was before surgery. The nurse should A. administer analgesics as ordered, and explain that the pain is to be expected because of the edema that that results from the surgery B. administer the analgesics as ordered, but request that the physician check the patient immediately C. withhold the analgesic and notify the physician D. administer the analgesics as ordered, and tell Ms. C it will give her relief shortly 44. Rehabilitation will be facilitated if Ms. C is encouraged to do which of the following? A. sleep in prone position B. sit up for at least part of he day C. perform abdominal-strengthening abdominal-strengthening exercise D. perform full trunk range-of-motion exercises Situation: Martha S is a 27-year old patient who has experienced increasing generalized stiffness, especially in the morning, fatigue, general malaise, and swelling and pain in the finger joints. She has a tentative diagnosis of rheumatoid arthritis. 45. Upon admission, Mrs. S is noted to have a rectal temperature of 37.7ºC (100ºF). A white blood blood count is ordered, and the report comes back at 8,500/mm³. The nurse should recognize this as being consistent with rheumatoid arthritis arthritis because it is is A. within normal limits B. evidence of leukopenia C. only slightly elevated D. indicative of a generalized infectious process 46. Which of the following blood-analysis tests would be consistent with diagnosis of rh eumatoid arthritis? A. an elevated erythrocyte sedimentation rate and negative Creactive protein B. an elevated erythrocyte sedimentation rate and positive Creactive protein C. a low erythrocyte sedimentation rate and n egative C-reactive protein D. a low erythrocyte sedimentation sedimentation rate and positive C-reactive protein 47. The primary goal of nursing care for Mrs. S during this initial acute phase of rheumatoid rheumatoid arthritis should be to A. prevent deformity and reduce inflammation inflammation B. prevent the spread of the inflammation to other joints C. provide for comfort and r elief of pain
D. assist her to accept the fact that rheumatoid arthritis is a logterm illness 48. During hospitalization, the nurse should explain to Mrs. Samuel that analgesics of choice would be A. codeine B. acetylsalicylic acid (aspirin) C. acetaminophen (Tylenol) D. proppoxyphene hydrochloride (Darvon) 49. During the acute phase of Mrs. S’s illness, which of the following measures would be the most appropriate? A. frequent periods of active exercises B. frequent periods of bed rest C. rest for he affected joints only D. encouragement to perform activities of daily living independently 50. The nurse understands that the main nursing goal in helping Mrs. S adapt to her chronic illness and plan is to A. provide the care she is unable to give herself B. provide guidance so that she will not repress her illness C. plan for social contacts so that she will not feel alone D. arrange for her after-care with the home health aide 51. Mrs. S is given instructions for using paraffin for her hands. The nurse should include the fact that the dips will be most effective if they are performed A. before exercising her hands B. after exercising her hands C. instead of exercising her fingers D. while exercising her fingers 52. Whenever Mrs. S feels pain from her arthritis, she tells the nurse she feels not only the the pain but that her “whole body feels threatened.” Which response by the nurse is the most therapeutic? A. I will have someone stay with you so you won’t harm yourself B. I will teach you some relaxing exercises so you won’t be so tense C. you must have some medication to help you gain control D. arthritic pain will lessen if you try to grin and bear it 53. When Mrs. S is discharged, she is instructed to take aspirin at home. It is important that she be told to to take the drug A. on a regular basis throughout the day B. only when other measures are not effective C. upon arising and again at bedtime D. between meals to promote its absorption 54. When Mrs. S is discharged, the nursing staff refers her to a nurse therapist who will assist her in dealing dealing with the anxiety over her arthritis and the changes it has made in her life. The nursing team recognizes that the role of the the nurse therapist is to A. work in conjunction with a psychiatrist B. provide individual nursing psychotherapy C. lead groups in therapy for those with similar problems D. give family nursing psychotherapy Situation: Twenty years after Mrs. S was first diagnosed with rheumatoid arthritis, she is admitted for a right total hip replacement. She has experienced severe right hip pain that has not responded to treatment for several years, and has had increasing difficulty moving about because of damage to the right hip joint. 55. Preoperative teaching for Mrs. S should include A. isometric exercises of the quadriceps and gluteal muscles B. instructions on the necessity for keeping the right leg perfectly straight after surgery C. the need to flex the involved h ip postoperatively to maintain mobility D. the avoidance of aspirin for 4 days prior to surgery 56. Which of the following should the nurse consider to be most significant if noted when checking Mrs. S 3 days postoperatively? postoperatively? A. pain in the operative site B. swelling of the operative sites C. pain and tenderness in the calf D. orthostatic hypotension
57. The physical therapist orders exercises of Mrs. S’s right hip, knee, and foot to gradually gradually increase range of motion to the right hip. The nurse can best assist Mrs. S by A. administering an analgesic before the exercises B. stopping the exercises if Mrs. S experiences pain C. performing the exercises for Mrs. S D. observing Mrs. S’s ability to perform the exercises 58. Mrs. S should be instructed to avoid A. adduction of her right leg B. abduction of hr right leg C. bearing any weight on her right leg D. the prone position in bed 59. The nurse and Mrs. S plan for her rehabilitation. Mrs. S asks the nurse, “What do I have to do in therapy?” Which reply by the nurse most accurately describes describes the task of the patient in rehabilitation? rehabilitation? To A. follow the instructions of the rehabilitation team B. regain some function that was lost C. prevent further loss of your ability to function D. learn to deal realistically with your disability 60. When the rehabilitation therapist tells Mrs. S that the outcome of her therapy depends on “the ability of the nursing staff” as well as on her motivation, Mrs. S questions the nurse on the meaning of this phrase. The nurse should reply that “the nurse’s role in rehabilitation is to A. make the patient as comfortable as possible B. follow the directions of the rehabilitation therapist C. supervise the patient’s therapy appointments and exercise program D. assist the patient in establishing therapy priorities priorities and goals 61. Mrs. S asks the nurse if her new joint will function normally. The nurse can best answer answer this by saying saying that A. the new joint will be stronger than the old one B. the new joint won’t function as well as a normal joint, but it will be better than the arthritic joint C. the new joint will function almost as well as a normal joint, particularly particularly if you perform your exercise faithfully D. the doctor will be able to assess your limitations in 6 weeks and then explain them to you Situation: Mr. Lee is a 20-year-old patient who sustains a compound fracture of the right shaft of the femur and a simple fracture of the ulna in a motorcycle accident. 62. While serving as a member of a first aid squad, Mary V, RN, reaches the scene of the motorcycle motorcycle accident and administers emergency treatment, which includes the application of a splint. It is important that the splint A. be applied while the limb is in goo d alignment B. be applied to the limb in the position in which it is found C. extend from the fracture site downward D. extend from the fracture site upward 63. While Mr. Lee is being transported in the ambulance to the hospital, he should be positioned positioned with the affected limbs A. elevated B. in a flat position C. lower than his heart D. slightly abducted 64. While taking a history from the patient, the nurse determines that his last booster injection injection for tetanus immunization was 5 years ago. The nurse should recognize that this information is important because it means that he should receive A. a full tetanus immunization program B. nothing, because he is sufficiently immunized against tetanus C. an additional booster injection D. human tetanus immune globulin Situation: Mr. Lee is taken to the operating room and the wound caused by the fracture of the femur is cleansed and debrided. The fracture is then reduced, and a Steinmann pin for skeletal traction is
inserted. A closed reduction of the ulna is performed, and a cast is applied. 65. The most important nursing measure in the immediate postoperative period will be A. encouragement of isometric exercises B. cleansing of the area around the Steinmann pin C. careful observation of vital signs D. massage of pressure areas 66. After Mr. Lee returns to his room, he complains of pain in his right arm. The initial initial action of the nurse should be to A. administer analgesics as ordered B. check his fingers C. notify his physician immediately D. pad the edges of the cast 67. To maintain proper alignment and immobilization of the femur, the physician has ordered skeletal traction with a Thomas Thomas splint. While caring for Mr. Lee, the nurse should explain to him that he A. cannot turn or sit up B. cannot turn but can sit up C. can turn but cannot sit up D. can turn and can sit up 68. In dealing with the weights that are applying the traction, the nurse should A. allow them to hang freely in place B. hold them up if the patient is shifting position in bed C. remove them if the patient is being moved up in bed D. lighten them for short periods if the patient complains of pain 69. Mr. Lee has a Thomas knee splint in p lace. In addition to the usual measures for a patient in traction, traction, it will be important that the nurse observe A. the groin area for pressure B. for constipation C. his skin for sings of decubiti D. for signs of hypostatic pneumonia 70. If Mr. Lee should show an increase in blood pressure and signs of confusion and increased restlessness, restlessness, the nurse should suspect A. a concussion B. impending shock C. fat emboli D. anxiety 71. Because of the nature of Mr. Lee’s wound and the insertion of a Steinmann pin, it is especially especially important that the nurse observe for A. a foul odor B. foot drop C. pulmonary congestion D. fecal impaction 72. Mr. Lee develops an acute localized osteomyelitis. He is placed on intravenous antibiotic therapy. The wound is incised and drained, drained, and neomycin irrigations are ordered four times a day. It is important that these irrigations irrigations be performed A. with strict aseptic techniques B. with a warm solution C. for at least 5 minutes D. at equal time intervals Situation: Maria Alfredo is a 30-year old married woman who has systemic lupus erythematosus (SLE). 73. While doing as nursing history on Mrs. Alfredo, the nurse should recognize that the most common initial initial symptoms of SLE are A. petechiae in the skin, nosebleeds, and pallor B. hematuria, increased blood pressure, and edema C. tachycardia, tremors, and loss of weight D. painful muscles and joints, stiffness, and inflammation of joints 74. Mrs. Afredo is instituted on long-term prednisone therapy. Her daily maintenance dose is is 5 mg/day. In the instructions to Mrs. Alfredo, the nurse should emphasize that A. once the symptoms of SLE subside, the medication will be discontinued gradually
B. a weight gain 2 pounds per week should be reported to the physician C. the maintenance dose will be the lowest dose that controls symptoms D. if adrenal atrophy occurs, adrenocorticotropic hormone (ACTH) will have to be prescribed 75. Mrs. Alfredo questions the nurse about family planning and birth control. Which of the following following choices should the nurse include in her answer? A. oral contraceptives can precipitate an acute exacerbation exacerbation of your condition B. Intrauterine devices are the recommended brithcontrol measures C. there are no contraindications for pregnancy, as long as the disease is being treated D. studies indicate that the corticosteroids produce fetal damage 76. The nursing care plan states, “Observe for signs of Raynaud’s phenomenon.” The nurse should recognize that this this phenomenon A. occurs as a side effect of p rednisone B. is aggravated by smoking C. is relieved by application of cold compresses to the hands D. is the priority care 77. Although many abnormal laboratory findings are found in SLE, there is no one specific specific diagnostic test. test. The test that is is positive in over 95 percent of all patients with SLE is the blood test for A. the lupus erythematosus (LE) factor B. the rheumatoid factor C. antinuclear antibodies (ANA) D. C-reactive protein (CRP) 78. The teaching program for Mrs. Alfredo planned by the nurse should include emphasis emphasis on which of the following? A. once the symptoms are controlled, the corticosteroids will be discontinued B. if hair loss occurs, it is irreversible C. overexposure to the sun can produce an exacerbation of symptoms D. a low-potassium, low-protein diet is recommended 79. Mrs. Alfredo tells the nurse that she has had black, tarry stools. The nurse should A. reassure the patient that this is a minor side effect of prednisone B. tell the patient that if she takes the prednisone with milk, black, tarry stools will be avoided C. tell the patient that she will ask the physician to prescribe aluminum hydroxide D. notify the physician because black, tarry stools can be an indication of bleeding peptic ulcer 80. Mrs. Alfredo calls the physician’s office and complains that she has chills, a fever, fever, and a cough. The nurse should A. advise that she remain in bed, drink extra fluids, and take aspirin every 4 hours B. recommended that she increase her dose of prednisone until her temperature is normal C. recommended that she come to the office to be examined by the physician D. tell Mrs. Alfredo to call for an appointment when she is feeling better Situation: Irene P is being treated in the emergency room for an acute attack of Meniere’s syndrome 81. The nurse should recognize that the triad of symptoms associated with Meniere’s syndrome is A. nystagmus, arthralgia, and vertigo B. nausea, vomiting, and arthralgia C. syncope, headache, and hearing loss D. hearing loss, vertigo, and tinnitus 82. Patient teaching for Mrs. P includes helping her to recognize that A. Meniere’s syndrome is psychogenic and is brought on by stress
B. most patients can be successfully treated with a low-salt diet and diuretics C. acute infection can precipitate an attack D. a labyrinthectomy is the pr eferred treatment for relieving symptoms and restoring hearing 83. Nursing intervention during an acute attack includes A. encouraging the patient to walk B. placing the patient in a semi-Fowler’s position C. Having the patient lie flat D. placing the patient in Trendelenburg’s position Situation: Mrs. C, 30 years old, has symptoms of diplopia, fatigue, slight vertigo, and a lack of coordination. After a neurological workup she is diagnosed as having multiple sclerosis. 84. The main goal of nursing care for Mrs. C during the acute phase of the disease should be to A. promotes rest B. prevent constipation C. maintain normal functioning D. encourage activities of daily living 85. Mrs. C is note d to be having mood swings. In deciding what approach to use with her, her, the nursing staff should recognize that that this A. is probably the result of an underlying mental disorder B. indicates that Mrs. C is having difficulty accepting her diagnosis C. may be a result of pathology and involvement of the limbic system in the disease D. indicates that Mrs. C’s intellectual capacity has been compromised 86. Mrs. C questions the nurse concerning the usual course of multiple sclerosis. Which Which would be the best reply by the nurse? A. each individual is very different; we cannot tell what will happen B. I know you are worried, but it is too soon to predict what will happen C. usually, acute episodes like this are followed by remissions, remissions, which may last a long time D. the future will take care of itself; let’s concentrate on the present 87. As Mrs. C’s condition improves, it is most important that she be given guidance in A. developing a program of exercise B. learning to handle stressful situations C. seeking v ocational rehabilitation D. limiting her activities to those that are absolutely necessary Situation: Barbara is a 23-year-old woman who lives with her mother, sister, and brother in a private residence. She is attending the neurological out-patient clinic for the first time. Her health history includes two grand mal seizures./ A diagnosis of idiopathic epilepsy has been made. The physician has ordered an electroencephalogram electroencephalogram (EEG) and phenytoin sodium (Dilantin), 300 mg/day 88. While doing a nursing history on Barbara, the nurse should recognize that A. persons with idiopathic epilepsy have a lower intelligence level B. grand mal seizures do not cause mental deterioration C. a common characteristic of idiopathic epilepsy is committing acts of violence D. idiopathic epilepsy is a form of mental illness 89. To prepare Barbara for EEG, the nurse should explain that A. during the test she will experience small electric shocks that feels like pin pricks B. the test measures mental status as well as electrical brain waves C. during the hyperventilation portion of the test, she may experience dizziness D. she will be unconscious during the test 90. Health teaching for Barbara includes ensuring that she understands that
A. proper prophylactic medication can control the incidence of seizures B. moderate use of alcohol is permitted C. forcing fluids helps to reduce the incidence of seizures D. the incidence of seizures is related to hyperglycemia 91. During a follow-up clinic visit, Barbara tells the nurse that her urine has had a reddish-brown color. The nurse should should A. reassure Barabara Barabara that this is a harmless side effect effect of phenytoin sodium (Dilantin) B. tell Barbara that this is a sign of hepatic toxicity C. recommend that Barbara go to the laboratory for a serum Dilantin concentration test D. notify the physician that Barbara has hematuria 92. A long-term goal for Barbara is to minimize the gingival hyperplasia associated with Dilantin Dilantin therapy. The nurse should recognize that A. another anticonvulsant will be prescribed if it occurs B. the physician will reduce the dosage at the first sign of hyperplasia C. a regular plan of good oral hygiene is essential D. vitamin C should be taken daily with the Dilantin 93. Barbara’s serum concentration level Dilantin is 15 µg/ml. The nurse should recognize this as A. a desired therapeutic serum level B. below the desired therapeutic level C. above the recommended serum level D. a toxic serum level 94. Family members should be instructed about caring Barbara during a grand mal seizure. Immediate care care during a seizure should include A. restraining Barbara’s arms and legs B. forcing the mouth open to insert an airway C. giving orange juice before the clonic stage begins D. turning Barbara’s head to the side 95. The nurse explains to Barbara that safety precautions can be taken by those who have warning symptoms before the seizure. seizure. (These symptoms are not part of the seizure, as the aura is.) What warning symptoms should the nurse tell Barbara to be aware of? A. Hot and cold sensations, gastrointestinal problems, anxiety, and mood changes B. Muscle twitching, lapse of consciousness, anxiety, and gastrointestinal problems C. tingling in a local region, anxiety, and lapse of consciousness D. increased tonicity of muscles and autonomic behavior 96. The nurse should tell Barbara’s family that after a seizure she will be in a confused state state and will need some supervision. It is most important for the caring one to be calm because the confused state of the epileptic is considered to be A. One mood swings and a feeling of general inadequacy and fatigue that result in a decrease of interest B. an adaptive period, when one slowly learns to cope with the devastating insults to one’s psychological psychological and physical integrity C. a gross impairment in social and intellectual functioning with crude, tactless, and impulsive behavior D. a helpless state, with intellectual deterioration, difficulty in communication, and regression to the infantile state 97. Barbara asks the nurse if it is true that there is an “epileptic personality.” Which Which of the following choices would be the nurse’s best response/ A. the person must be aware that anxiety over anticipation of a seizure may cause personality prob lems B. No, deviation in personality is caused by restrictions imposed by society C. Yes, one may learn to induce seizures as a way of getting attention from others D. the person may take on a sick role if mismanaged at home or in the community
Situation: Ms. R, a 35-year old woman, has myasthenia gravis. She has been referred to the neurology clinic by her ph ysician. 98. While doing a nursing history on Ms. R, the nurse should expect her to complain of which of the following symptoms? A. passive tremors, cogwheel rigidity, and drooling B. spastic weakness of the limbs, intention tremors, and incontinence C. diplopia, ptosis, and fatigue D. nystagmus, ataxia, and tinnitus 99. In preparing a teaching plan for Ms. R, the nurse should emphasize that A. the anticholinesterase medications cause fewer side effects when taken on an empty stomach B. physical activity should be planned for the late afternoon early evening C. a member of the family should be taught how to use suction for emergency use D. edrophonium chloride (Tensilon) is the drug of choice in the treatment of myasthenia gravis 100. Respiratory distress is common in people with myasthenic crisis? Marked improvement improvement of respirations occurs after the administration of intravenous A. diazepam (Valium) B. hydrocortisone C. atropine sulfate D. edrophonium chloride (Tensilon) 101. The medication used to treat cholinergic crisis A. atropine sulfate B. neostigmine (Prostigmin) C. aminophylline D. hydrocortisone 102. The physician has prescribed pyridostigmine (Mestinon), 180 mg/day. Ms. R tells the the nurse that each time she takes the medication medication she feels nauseated. The nurse should tell Ms. R to A. crush the tablet before taking it B. take the tablet with f ood or milk C. take the tablet on an empty stomach D. not to take the medication until she notifies the physician Mr. Go, who has had Parkinsosn’s disease for 4 years, visits his wife daily during her hospital stay. His illness is being treated with levodopa (L-dopa). 103. When Mr. Go visits his wife, he is observed to be walking rather slowly. The nurse should recognize recognize that Mr. Go is A. exhibiting a long-range side effect of L-dopa B. exhibiting a symptom that is characteristic characteristic of stage II Parkinson’s disease C. beginning to experience atrophy of the cerebral cortex and cellular changes D. probably doing this on purpose as a way of 104. The nurse can help him to be more comfortable by A. discussing this problem and how he handles it, and discussing hygiene measures with him B. opening the windows and prov iding as much ventilation as possible while he is visiting C. suggesting that he is probably dressing too warmly for the hospital environment D. explaining that this is a side effect of his medication, and encouraging increased intake of fluids Situation: Mr. go has a sudden exacerbation of symptoms. He develops tachycardia, a respiratory rate of 40, and appears extremely anxious. He is hospitalized with a diagnosis of parkinsonian crisis. 105. Planning for Mr. Go’s care should include measures to A. provide a quiet, restful environment B. maintain joint range of motion C. decrease social isolation D. improve his nutritional status 106. Mr. Go responds to treatment, and his condition gradually improves. However, he complains that he feels dizzy whenever he tries to stand up from a lying position. The nurse should
A. explain that this is just part of his illness B. tell him that his doctor will be notified of this symptom C. encourage him to change his position slowly D. discuss his feelings about his wife’s hospitalization 107. Mr. Go has problems in dressing himself as a result of tremors, but he refuses all assistance. assistance. Which of the following is the best initial action by the nurse in response to this complaint? A. tell him he needs assistance, and gradually help him B. give him more time and encouragement to dress himself C. suggest that for the present he wear only the hospital gown D. listen to his refusal, but give him assistance as needed 108. Mr. Go discusses his work as an accountant with the nurse. He states that he his glad that he will will be able to continue working. An appropriate initial response would be based on the nurse’s recognition that he A. should be encouraged to be active
B. should be cautioned against overfatigue C. is being unrealistic about his future D. needs to recognize that his situation is unique 109. Mr. Go tells the nurse that someone told him that people with Parkinson’s disease develop develop early senility. In response, response, the nurse should explain that A. Parkinson’s disease progresses very slowly over a period of years, and and it is only only in the late stages that any mental changes might take place B. his information is false, because Parkinson’s disease does not cause any changes in the individual’s intellectual capacities C. he does not have to worry about senility because he is responding so well to treatment D. although Parkinson’s disease does cause mental confusion, this condition is clinically different from senility
