Brunner Neuro ER Shock

38. The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications? A) Vertebral fracture B) Hematoma at the surgical site C) Scoliosis D) Renal trauma

Ans: B Feedback: Based on all the assessment data, the potential complications of diskectomy may include hematoma at the surgical site, resulting in cord compression and neurologic deficit and recurrent or persistent pain after surgery. Renal trauma and fractures are unlikely; scoliosis is a congenital malformation of the spine.

10. While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity

Ans: B Feedback: In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonicñclonic contraction) during the seizure.

39. A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A) Viral agents B) Nerve agents C) Pulmonary agents D) Blood agents

Ans: B Feedback: Latency is the time from absorption to the appearance of signs and symptoms. Sulfur mustards and pulmonary agents have the longest latency, whereas vesicants, nerve agents, and cyanide produce signs and symptoms within seconds.

28. A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A) Unclassified seizure B) Absence seizure C) Generalized seizure D) Focal seizure

Ans: C Feedback: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonicñclonic contraction). This pattern of rigidity does not occur in patients who experience unclassified, absence, or focal seizures.

14. A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patient's indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

Ans:A Feedback: A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the patient's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.

37. A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal? A) Establish a timed voiding schedule. B) Avoid foods that change the pH of urine. C) Perform intermittent catheterization q6h. D) Administer anticholinergic drugs as ordered.

Ans:A Feedback: A timed voiding schedule addresses many of the challenges with urinary continence that face the patient with MS. Interventions should be implemented to prevent the need for catheterization and anticholinergics are not normally used.

5. A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance

Ans:A Feedback: Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.

24. A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A) Control the patient's hemorrhage. B) Assess for cognitive effects of the injury. C) Splint the patient's fractures. D) Assess the patient's neurologic status.

Ans:A Feedback: After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.

1. A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? A) Loss of hearing, tinnitus, and vertigo B) Loss of vision, change in mental status, and hyperthermia C) Loss of hearing, increased sodium retention, and hypertension D) Loss of vision, headache, and tachycardia

Ans:A Feedback: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The patient with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia.

21. A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A) The patient should mobilize as soon as she is physically able. B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The patient should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the patient's risk of stroke recurrence.

Ans:A Feedback: As soon as possible, the patient is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the patient initiates.

23. The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this patient? A) Assessing the patient's verbal response B) Assessing the patient's ability to follow complex commands C) Assessing the patient's judgment D) Assessing the patient's response to pain

Ans:A Feedback: Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.

29. The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A) Ensure that the player is not moved. B) Obtain the player's vital signs, if possible. C) Perform a rapid assessment of the player's range of motion. D) Assess the player's reflexes.

Ans:A Feedback: At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the patient's vital signs. It would be inappropriate to test ROM or reflexes.

30. The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)

Ans:A Feedback: Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in patients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.

18. The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside. B) Pad the patient's bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day.

Ans:A Feedback: Because of the patient's risk of aspiration, it is important to have a suction apparatus at hand. Bed rest should be generally be minimized, not maximized, and there is no need to pad the patient's bed rails or to provide multiple small meals.

37. A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A) Urinary retention can have serious consequences in patients with SCIs. B) Urinary function is permanently lost following an SCI. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage.

Ans:A Feedback: Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.

3. A nursing home patient has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents? A) Contact B) Droplet C) Airborne D) Positive pressure isolation

Ans:A Feedback: Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for organisms that can be transmitted by close, face-to-face contact, such as influenza or meningococcal meningitis. Airborne precautions are required for patients with presumed or proven pulmonary TB or chickenpox. Positive pressure isolation is unnecessary and ineffective.

5. A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A) Applying a protective eye shield at night B) Chewing on the affected side to prevent unilateral neglect C) Avoiding the use of analgesics whenever possible D) Avoiding brushing the teeth

Ans:A Feedback: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The patient should be encouraged to eat on the unaffected side, due to swallowing difficulties. Analgesics are used to control the facial pain. The patient should continue to provide self-care including oral hygiene.

28. A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man's current mental health problem? A) The man is experiencing a common response following a disaster. B) The man fails to appreciate the fact that he survived the disaster. C) The man most likely feels guilty about his actions during the disaster. D) The man's depression most likely predated the disaster.

Ans:A Feedback: Depression is a common response to disaster. It does not suggest that the patient feels guilty about his actions or that he does not appreciate the fact that he survived. It is possible, but less likely, that the patient was depressed prior to the disaster.

17. A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A) Vigilant monitoring of fluid balance B) Continuous BP monitoring C) Serial arterial blood gases (ABGs) D) Monitoring of the patient's airway for patency

Ans:A Feedback: Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary. None of the other listed assessments directly addresses the major manifestations of diabetes insipidus.

19. A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle? A) The patient is likely to have an increased appetite. B) The patient is likely to required enzyme supplements. C) The patient will likely require a clear liquid diet. D) The patient will benefit from a low-protein diet.

Ans:A Feedback: Due to the continuous involuntary movements, patients will have a ravenous appetite. Despite this ravenous appetite, patients usually become emaciated and exhausted. As the disease progresses, patients experience difficulty in swallowing and thin liquids should be avoided. Protein will not be limited with this disease. Enzyme supplements are not normally required.

25. A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A) Practice outside of her normal area of clinical expertise. B) Perform interventions that are not based on assessment data. C) Prioritize psychosocial needs over physiologic needs. D) Prioritize the interests of older adults over younger patients.

Ans:A Feedback: During a disaster, nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses.

17. A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

Ans:A Feedback: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

14. The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

Ans:A Feedback: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

38. An 83-year-old patient is brought in by ambulance from a long-term care facility. The patient's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true? A) Older adults may have an altered response to treatment. B) Older adults are often reluctant to adhere to prescribed treatment. C) Older adults have difficulty giving a health history. D) Older adults often stigmatize their peers who use the ED.

Ans:A Feedback: Emergencies in this age group may be more difficult to manage because elderly patients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors. The elderly patient may perceive the emergency as a crisis signaling the end of an independent lifestyle or even resulting in death. Stigmatization and nonadherence to treatment are not commonly noted. Older adults do not necessarily have difficulty giving a health history.

37. When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A) Frustration around changes in function and communication B) Unmet physiologic needs C) Changes in brain activity during sleep and wakefulness D) Temporary changes in metabolism

Ans:A Feedback: Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out.

9. The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting

Ans:A Feedback: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and patients less commonly experience dysrhythmias or vomiting.

31. The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk? A) Change the patient's position frequently. B) Provide a high-protein diet. C) Provide light massage at least daily. D) Teach the patient deep breathing and coughing exercises.

Ans:A Feedback: Frequent position changes are among the best preventative measures against pressure ulcers. A high-protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage and deep breathing do not protect or restore skin integrity.

19. A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patient's frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patient's frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.

Ans:A Feedback: Frozen extremities are usually placed in a 37∞C to 40∞C (98.6∞F to 104∞F) circulating bath for 30- to 40-minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

7. A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patient's blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

Ans:A Feedback: Hypoglycemia can mimic alcohol intoxication and should be assessed in a patient suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

19. An adult patient in the ICU has a central venous catheter in place. Over the past 24 hours, the patient has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the patient's care may have increased susceptibility to CLABSI? A) The patient's central line was placed in the femoral vein. B) The patient had blood cultures drawn from the central line. C) The patient was treated for vancomycin-resistant enterococcus (VRE) during a previous admission. D) The patient has received antibiotics and IV fluids through the same line.

Ans:A Feedback: In adult patients, the femoral site should be avoided in order to reduce the risk of CLABSI. Drawing blood cultures, receiving treatment for VRE, and receiving fluids and drugs through the same line are not known to increase the risk for CLABSI.

23. A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A) Perform life-saving measures. B) Classify patients according to acuity. C) Provide health promotion education. D) Modify the emergency operations plan.

Ans:A Feedback: In an emergency, patients are immediately tagged and transported or given life-saving interventions. One person performs the initial triage while other emergency medical services (EMS) personnel perform life-saving measures and transport patients. Health promotion is not a priority during the acute stage of the crisis. Classifying patients is the task of the triage nurse. EMS personnel prioritize life-saving measures; they do not modify the operations plan.

23. A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? A) The effects of brain tumors are often attributed to the cognitive effects of aging. B) Brain tumors in older adults do not normally produce focal effects. C) Older adults typically have numerous benign brain tumors by the eighth decade of life. D) Brain tumors cannot normally be treated in patient over age 75.

Ans:A Feedback: In older adult patients, early signs and symptoms of intracranial tumors can be easily overlooked or incorrectly attributed to cognitive and neurologic changes associated with normal aging. Brain tumors are not normally benign and they produce focal effects in all patients. Treatment options are not dependent primarily on age.

26. The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort has increased. What is the nurse's most appropriate response? A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patient's LOC. C) Increase the patient's bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered.

Ans:A Feedback: Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the patient and administering bronchodilators are insufficient responses, even though these actions may later be ordered.

33. After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? A) Positioning to avoid hypoxia B) Maximizing PaCO2 C) Administering hypertonic IV solution D) Initiating early mobilization

Ans:A Feedback: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol), maintaining the partial pressure of carbon dioxide (PaCO2) within the range of 30 to 35 mm Hg, and positioning to avoid hypoxia. Hypertonic IV solutions are not used unless sodium depletion is evident. Mobilization would take place after the immediate threat of increased ICP has past.

12. The nurse places a patient in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection? A) Mode of transmission B) Agent C) Susceptible host D) Portal of entry

Ans:A Feedback: Isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques do not directly affect the agent, host, or portal of entry.

37. A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained? A) Frequently assess the patient's skin integrity. B) Inform the patient that he is likely to be charged with assault. C) Avoid interacting with the patient until the restraints are removed. D) Take the opportunity to perform a full physical assessment.

Ans:A Feedback: It is important to assess skin integrity when physical restraints are used. Criminal charges are not the responsibility of the nurse and the nurse should still interact with the patient. A full physical assessment, however, would likely be delayed until the patient is not combative.

6. The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient? A) MS is a progressive demyelinating disease of the nervous system. B) MS usually occurs more frequently in men. C) MS typically has an acute onset. D) MS is sometimes caused by a bacterial infection.

Ans:A Feedback: MS is a chronic, degenerative, progressive disease of the central nervous system, characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known, and the disease affects twice as many women as men.

25. A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect? A) Prolactinoma B) Angioma C) Glioma D) Adrenocorticotropic hormone (ACTH)ñproducing adenoma

Ans:A Feedback: Male patients with prolactinomas may present with impotence and hypogonadism. An ACTH-producing adenoma would cause acromegaly. The scenario contains insufficient information to know if the tumor is an angioma, glioma, or neuroma.

29. The nurse is teaching a patient with Guillain-BarrÈ syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response? A) Guillain-BarrÈ spares the Schwann cell, which allows for remyelination in the recovery phase of the disease. B) In Guillain-BarrÈ, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible. C) I know you understand that nerve cells do not remyelinate, so the physician is the best one to answer your question. D) For some reason, in Guillain-BarrÈ, Schwann cells become activated and take over the remyelination process.

Ans:A Feedback: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The cell that produces myelin in the peripheral nervous system is the Schwann cell. In Guillain-BarrÈ syndrome, the Schwann cell is spared, allowing for remyelination in the recovery phase of the disease. The nurse should avoid downplaying the patient's concerns by wholly deferring to the physician.

38. A patient has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds with acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent? A) Hyperstimulation of the nerve endings B) Temporary deactivation of the nerve endings C) Binding of the nerve endings D) Destruction of the nerve endings

Ans:A Feedback: Nerve agents can be inhaled or absorbed percutaneously or subcutaneously. These agents bond with acetylcholinesterase, so that acetylcholine is not inactivated; the adverse result is continuous stimulation (hyperstimulation) of the nerve endings. Nerve endings are not deactivated, bound, or destroyed.

26. A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A) Having an ethical framework in place prior to an emergency B) Allowing staff to provide care anonymously during an emergency C) Assuring staff that they are not legally accountable for care provided during an emergency D) Teaching staff that principles of ethics do not apply in an emergency situation

Ans:A Feedback: Nurses can plan for the ethical dilemmas they may face during disasters by establishing a framework for evaluating ethical questions before they arise and by identifying and exploring possible responses to difficult clinical situations. Ethical principles do not become wholly irrelevant in emergencies. Care cannot be given anonymously and accountability for practice always exists, even in an emergency.

4. A nurse who provides care in a busy ED is in contact with hundreds of patients each year. The nurse has a responsibility to receive what vaccine? A) Hepatitis B vaccine B) Human papillomavirus (HPV) vaccine C) Clostridium difficile vaccine D) Staphylococcus aureus vaccine

Ans:A Feedback: Nurses should recognize their personal responsibility to receive the hepatitis B vaccine and an annual influenza vaccine to reduce potential transmission to themselves and vulnerable patient groups. HPV is not a threat because it is sexually transmitted. No vaccines are available against C. difficile and S. aureus.

33. A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patient's nursing care should involve which of the following? A) Protection of the affected limb from injury B) Passive and active ROM exercises for the affected limb C) Education about improvements to glycemic control D) Interventions to prevent contractures

Ans:A Feedback: Nursing care involves protection of the affected limb or area from injury, as well as appropriate patient teaching about mononeuropathy and its treatment. Nursing care for this patient does not likely involve exercises or assistive devices, since these are unrelated to the etiology of the disease. Improvements to diabetes management may or may not be necessary.

4. A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.

Ans:A Feedback: Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care team's responsibility to determine the circumstances of the accident.

30. An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinson's disease. Which of the wife's descriptions of her husband's health and function is most suggestive of Parkinson's disease? A) Lately he seems to move far more slowly than he ever has in the past. B) He often complains that his joints are terribly stiff when he wakes up in the morning. C) He's forgotten the names of some people that we've known for years. D) He's losing weight even though he has a ravenous appetite.

Ans:A Feedback: Parkinson's disease is characterized by bradykinesia. It does not manifest as memory loss, increased appetite, or joint stiffness.

37. A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses? A) Prepare an advance directive. B) Designate a most responsible physician (MRP) early in the course of the disease. C) Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. D) Ensure that witnesses are present when he provides instruction.

Ans:A Feedback: Patients with ALS are encouraged to complete an advance directive or living will to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.

17. A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient? A) The patient should be approached on the side where visual perception is intact. B) Attention to the affected side should be minimized in order to decrease anxiety. C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D) The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.

Ans:A Feedback: Patients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The patient can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the patient of the other side of the body and should later stand at a position that encourages the patient to move or turn to visualize who and what is in the room.

27. A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A) Gag reflex B) Deep tendon reflexes C) Abdominal girth D) Hearing acuity

Ans:A Feedback: Preoperatively, the gag reflex and ability to swallow are evaluated. In patients with diminished gag response, care includes teaching the patient to direct food and fluids toward the unaffected side, having the patient sit upright to eat, offering a semisoft diet, and having suction readily available. Deep tendon reflexes, abdominal girth, and hearing acuity are less commonly affected by brain tumors and do not affect the risk for aspiration.

17. A 16-year-old male patient comes to the free clinic and is subsequently diagnosed with primary syphilis. What health problem most likely prompted the patient to seek care? A) The emergence of a chancre on his penis B) Painful urination C) Signs of a systemic infection D) Unilateral testicular swelling

Ans:A Feedback: Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless chancre develops at the site of infection. Initial infection with syphilis is not associated with testicular swelling, painful voiding, or signs of systemic infection.

40. A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching? A) Care of the cervical collar B) Technique for performing neck ROM exercises C) Home assessment of ABGs D) Techniques for restoring nerve function

Ans:A Feedback: Prior to discharge, the nurse should assess the patient's use and care of the cervical collar. Neck ROM exercises would be contraindicated and ABGs cannot be assessed in the home. Nerve function is not compromised by a diskectomy.

34. The ED staff has been notified of the imminent arrival of a patient who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis? A) Impaired gas exchange B) Decreased cardiac output C) Chronic pain D) Excess fluid volume

Ans:A Feedback: Pulmonary agents, such as phosgene and chlorine, destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolarñcapillary oxygen transport mechanisms. Capillary leakage results in fluid-filled alveoli and gas exchange ceases to occur. Pain is likely, but is acute rather than chronic. Fluid volume excess is unlikely to be a priority diagnosis and cardiac output will be secondarily affected by the pulmonary effects.

35. The nursing supervisor at the local hospital is advised that your hospital will be receiving multiple trauma victims from a blast that occurred at a local manufacturing plant. The paramedics call in a victim of the blast with injuries including a head injury and hemorrhage. What phase of blast injury should the nurse expect to treat in this patient? A) Primary phase B) Secondary phase C) Tertiary phase D) Quaternary phase

Ans:A Feedback: Pulmonary barotraumas, including pulmonary contusions; head injuries, including concussion, other severe brain injuries; tympanic membrane rupture, middle ear injury; abdominal hollow organ perforation; and hemorrhage are all injuries that can occur in the primary phase of a blast. These particular injuries are not characteristic of the subsequent phases.

20. The nurse is developing a plan of care for a patient with Guillain-BarrÈ syndrome. Which of the following interventions should the nurse prioritize for this patient? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Providing aids to compensate for loss of vision D) Assessing frequently for loss of cognitive function

Ans:A Feedback: Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-BarrÈ syndrome does not affect cognitive function or vision.

33. A patient is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the patient's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? A) Recognize that this may represent the peak of post-surgical cerebral edema. B) Alert the surgeon to the possibility of an intracranial hemorrhage. C) Understand that the surgery may have been unsuccessful. D) Recognize the need to refer the patient to the palliative care team.

Ans:A Feedback: Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. As such, there is not necessarily any need to deem the surgery unsuccessful or to refer the patient to palliative care. A decrease in LOC is not evidence of an intracranial hemorrhage.

7. A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance? A) Office of Emergency Management B) Incident Command System C) Centers for Disease Control and Prevention (CDC) D) American Red Cross

Ans:A Feedback: The Office of Emergency Management coordinates the disaster relief efforts at state and local levels. The Incident Command System is a management tool to organize personnel, facilities, equipment, and communication in an emergency situation. The CDC is the agency for disease prevention and control and it supports state and local health departments. The American Red Cross provides additional support.

12. Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patient's clothing and then perform what action? A) Rinse the patient with water. B) Wash the patient with a dilute bleach solution. C) Wash the patient chlorhexidine. D) Rinse the patient with hydrogen peroxide.

Ans:A Feedback: The first step in decontamination is removal of the patient's clothing and jewelry and then rinsing the patient with water. This is usually followed by a wash with soap and water, not chlorhexidine, bleach, or hydrogen peroxide.

26. You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? A) Increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition

Ans:A Feedback: The goal of treatment using pyridostigmine bromide is improvement of muscle strength and control of fatigue. The drug is not intended to treat pain, or cognitive or GI functions.

33. The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of care that would include what goal? A) Promoting effective communication B) Controlling diarrhea C) Preventing cognitive decline D) Managing choreiform movements

Ans:A Feedback: The goals for the patient may include improving functional mobility, maintaining independence in ADLs, achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, and developing positive coping mechanisms. Constipation is more likely than diarrhea and cognition largely remains intact. Choreiform movements are related to Huntington disease.

34. The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal? A) Encouraging the patient to gain a sense of control over his or her life B) Collecting sufficient evidence to secure a criminal conviction C) Helping the patient understand that this will not happen again D) Encouraging the patient to verbalize what happened during the assault

Ans:A Feedback: The goals of management are to provide support, to reduce the patient's emotional trauma, and to gather available evidence for possible legal proceedings. All of the interventions are aimed at encouraging the patient to gain a sense of control over his or her life. The patient's well-being should be considered a priority over criminal proceedings. No health professional can guarantee the patient's future safety and having the patient verbalize the event is not a priority.

7. An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization? A) Centers for Disease Control and Prevention (CDC) B) American Medical Association (AMA) C) Environmental Protection Agency (EPA) D) American Nurses Association (ANA)

Ans:A Feedback: The goals of the CDC are to provide scientific recommendations regarding disease prevention and control to reduce disease, which it includes in publications. As such, outbreaks of unknown origin should normally be reported to the CDC. The AMA is the professional organization for medical doctors; the EPA oversees our environment; the ANA is the professional organization for American nurses.

8. The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient.

Ans:A Feedback: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the patient. This should be avoided because it may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The patient may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

29. When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH? A) Fluid restriction B) Transfusion of platelets C) Transfusion of fresh frozen plasma (FFP) D) Electrolyte restriction

Ans:A Feedback: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

14. A patient on Airborne Precautions asks the nurse to leave his door open. What is the nurse's best reply? A) "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in." B) "I'll keep the door open for you, but please try to avoid moving around the room too much." C) "I can open your door if you wear this mask." D) "I can open your door, but I'll have to come back and close it in a few minutes."

Ans:A Feedback: The nurse is placing the patient on airborne precautions, which require that doors and windows be closed at all times. Opening the curtains is acceptable. Antibiotics, wearing a mask, and standard precautions are not sufficient to allow the patient's door to be open.

21. The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized? A) Achieve as high a level of function as possible. B) Enhance the quantity of the patient's life. C) Teach the family proper care of the patient. D) Provide community assistance.

Ans:A Feedback: The overarching goals of care are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. This goal encompasses family and community participation.

13. A nurse takes a shift report and finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient? A) Standard precautions B) Airborne precautions C) Droplet precautions D) Contact precautions

Ans:A Feedback: The patient is not contagious, and anthrax cannot be spread from person to person, so standard precautions are initiated. Airborne, contact, and droplet precautions are not necessary.

29. Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient's plan of care? A) Supervise the patient's activities of daily living closely. B) Initiate early ambulation to prevent complications of immobility. C) Provide a high-calorie, low-protein diet. D) Perform all of the patient's hygiene and feeding.

Ans:A Feedback: The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. As such, independent ADLs and ambulation are contraindicated. There is no need for a high-calorie or low-protein diet.

27. The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2∞C (91.8∫F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this patient? A) Addressing the patient's hypothermia B) Addressing the patient's frostbite in his lower extremities C) Addressing the patient's alcohol intoxication D) Addressing the patient's malnutrition

Ans:A Feedback: The patient may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the patient's survival.

31. A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A) Administer morphine sulfate as ordered. B) Reposition the patient in a prone position. C) Apply a hot pack to the patient's scalp. D) Implement distraction techniques.

Ans:A Feedback: The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in patients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain.

1. Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

Ans:A Feedback: The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition.

8. The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A) Respect the patient's privacy during assessment. B) Shave all pubic hair for laboratory analysis. C) Place items for evidence in plastic bags. D) Bathe the patient before the examination.

Ans:A Feedback: The patient's privacy and sensitivity must be respected, because the patient will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the patient before the examination would destroy or remove key evidence.

34. The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel. B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state. C) Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing. D) The sudden, severe headache increases muscle tone and can cause further nerve damage.

Ans:A Feedback: The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

4. A patient with suspected Parkinson's disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor? A) When the patient is resting B) When the patient is ambulating C) When the patient is preparing his or her meal tray to eat D) When the patient is participating in occupational therapy

Ans:A Feedback: The tremor is present while the patient is at rest; it increases when the patient is walking, concentrating, or feeling anxious. Resting tremor characteristically disappears with purposeful movement, but is evident when the extremities are motionless. Consequently, the nurse should assess for the presence of a tremor when the patient is not performing deliberate actions.

15. A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of ≥180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months

Ans:A Feedback: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

37. A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety? A) Place the patient in a side-lying position. B) Pad the patient's bed rails. C) Administer antianxiety medications as ordered. D) Reassure the patient and family members.

Ans:A Feedback: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

30. The nurse is caring for a patient admitted with a drug overdose. What is the nurse's priority responsibility in caring for this patient? A) Support the patient's respiratory and cardiovascular function. B) Provide for the safety of the patient. C) Enhance clearance of the offending agent. D) Ensure the safety of the staff.

Ans:A Feedback: Treatment goals for a patient with a drug overdose are to support the respiratory and cardiovascular functions, to enhance clearance of the agent, and to provide for safety of the patient and staff. Of these responsibilities, however, support of vital physiologic function is a priority.

27. During a health education session, a participant asks the nurse how a vaccine can protect from future exposures to diseases against which she is vaccinated. What would be the nurse's best response? A) The vaccine causes an antibody response in the body. B) The vaccine responds to an infection in the body after it occurs. C) The vaccine is similar to an antibiotic that is used to treat an infection. D) The vaccine actively attacks the microorganism.

Ans:A Feedback: Vaccines are an antigen preparation that produces an antibody response in a human to protect him or her from future exposure to the vaccinated organism. A vaccine does not respond to an infection after it occurs; it does not act like an antibiotic and does not actively attack the microorganism.

2. The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking large amounts of fluids

Ans:A Feedback: Washing the face should be avoided if possible because this activity can trigger an attack of pain in a patient with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the skin to sunlight would not be harmful to this patient. Temperature extremes in beverages should be avoided.

15. Family members are caring for a patient with HIV in the patient's home. What should the nurse encourage family members to do to reduce the risk of infection transmission? A) Use caution when shaving the patient. B) Use separate dishes for the patient and family members. C) Use separate bed linens for the patient. D) Disinfect the patient's bedclothes regularly.

Ans:A Feedback: When caring for a patient with HIV at home, family members should use caution when providing care that may expose them to the patient's blood, such as shaving. Dishes, bed linens, and bedclothes, unless contaminated with blood, only require the usual cleaning.

10. A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice? A) Frequent handwashing reduces transmission of pathogens from one patient to another. B) Wearing gloves is known to be an adequate substitute for handwashing. C) Bar soap is preferable to liquid soap. D) Waterless products should be avoided in situations where running water is unavailable.

Ans:A Feedback: Whether gloves are worn or not, handwashing is required before and after patient contact because thorough handwashing reduces the risk of cross-contamination. Bar soap should not be used because it is a potential carrier of bacteria. Soap dispensers are preferable, but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a liquid hand sanitizer.

26. The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patient's tumor, the nurse should implement measures to prevent what complication? A) Falls B) Audio hallucinations C) Respiratory depression D) Labile BP

Ans:A Feedback: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the patient faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.

22. A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? A) MRI B) PET scan C) X-ray D) Ultrasound

Ans:A Feedback: CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function, not brain structure.

15. A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this patient has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent

Ans:A Feedback: Nerve agent exposure results in visual disturbances, nausea and vomiting, forgetfulness, irritability, and impaired judgment. This presentation is not suggestive of vesicants, pulmonary agents, or blood agents.

4. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea

Ans:A Feedback: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

9. The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as? A) Demobilization response B) Post-incident response C) Crisis diffusion D) Reversion

Ans:A Feedback: The demobilization response occurs when it is deemed that the facility may return to normal daily functioning. This is not known as the post-incident response, crisis diffusion or reversion.

24. An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury? A) Hematoma B) Skull fracture C) Embolus D) Stroke

Ans:A Feedback: Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions. Because of these factors, the patient's risk of a hematoma is likely greater than that of stroke, embolism, or skull fracture.

30. The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders? Select all that apply. A) Transcranial Doppler flow study B) Cerebral angiography C) MRI D) Cranial radiography E) Electromyelography (EMG)

Ans:A, B, C Feedback: Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.

36. A family member of a patient diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this patient and family receive from this organization? Select all that apply. A) Information about this disease B) Referrals C) Public education D) Individual assessments E) Appraisals of research studies

Ans:A, B, C Feedback: The Huntington's Disease Society of America helps patients and families by providing information, referrals, family and public education, and support for research. It does not provide individual assessments or appraisals of individual research studies.

38. A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP

Ans:A, B, C Feedback: For a spinal cord-injured patient, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not typical complications following the immediate recovery period.

40. An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply? A) Are you exposed to any toxins or chemicals at work? B) How would you describe your ability to cope with stress? C) What medications are you currently taking? D) When was the last time you were hospitalized? E) Does anyone else in your family struggle with headaches?

Ans:A, B, C, E Feedback: Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.

35. A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in patient teaching? Select all that apply. A) Inspect the lower extremities for skin breakdown. B) Footwear needs to be accurately sized. C) Immediate family members should be screened for the disease. D) Assistive devices may be needed to reduce the risk of falls. E) Dietary modifications are likely necessary.

Ans:A, B, D Feedback: The plan of care includes inspection of the lower extremities for skin breakdown. Footwear should be accurately sized. Assistive devices, such as a walker or cane, may decrease the risk of falls. Bath water temperature is checked to avoid thermal injury. Peripheral neuropathies do not have a genetic component and diet is unrelated.

29. A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply. A) Pain control B) Management of treatment complications C) Interpretation of diagnostic tests D) Assistance with self-care E) Administration of treatments

Ans:A, B, D, E Feedback: Home care needs and interventions focus on four major areas: palliation of symptoms and pain control, assistance in self-care, control of treatment complications, and administration of specific forms of treatment, such as parenteral nutrition. Interpretation of diagnostic tests is normally beyond the purview of the nurse.

38. A nurse is participating in a vaccination clinic at the local public health clinic. The nurse is describing the public health benefits of vaccinations to participants. Vaccine programs addressing which of the following diseases have been deemed successful? Select all that apply. A) Polio B) Diphtheria C) Hepatitis D) Tuberculosis E) Pertussis

Ans:A, B, E Feedback: The most successful vaccine programs have been ones for the prevention of smallpox, measles, mumps, rubella, polio, diphtheria, pertussis, and tetanus. There is no vaccine for tuberculosis. Hepatitis is not counted as one of the most successful vaccination programs, because vaccination rates for hepatitis leave room for improvement.

25. The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply. A) Possible nursing home placement B) Pain associated with physical therapy C) Increasing disability D) Becoming a burden on the family E) Loss of appetite

Ans:A, C, D Feedback: Elderly patients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite.

24. The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply. A) Contractures B) Hemorrhage C) Pressure ulcers D) Venous thromboembolism E) Pneumonia

Ans:A, C, D, E Feedback: Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.

35. During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A) National Institutes of Health Stroke Scale (NIHSS) score B) Race C) LOC at time of admission D) Gender E) Age

Ans:A, C, E Feedback: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not predictors of stroke outcome.

29. A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. A) Dysrhythmias B) Hypothermia C) Hypotension D) Hyperglycemia E) Delirium

Ans:A, C, E Feedback: The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.

28. The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A) Young age B) Frequent travel C) African American race D) Male gender E) Alcohol or drug use

Ans:A, D, E Feedback: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. Ethnicity and travel are not risk factors.

13. A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A) Assessing the patient's oral temperature frequently B) Ensuring continuous ECG monitoring C) Massaging the patient's skin surfaces to promote circulation D) Administering bronchodilators by nebulizer

Ans:B Feedback: A hypothermic patient requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the patient's respiratory needs.

12. The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patient's treatment? A) Computed tomography (CT) scan B) Lumbar puncture C) Magnetic resonance imaging (MRI) D) Venous Doppler studies

Ans:B Feedback: A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.

38. A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of the onset of a new headache? A) As soon as the patient's pain becomes unbearable B) As soon as the patient senses the onset of symptoms C) Twenty to 30 minutes after the onset of symptoms D) When the patient senses his or her symptoms peaking

Ans:B Feedback: A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain.

34. The nurse is caring for a patient diagnosed with Parkinson's disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? A) Use of a bedpan B) Use of a raised toilet seat C) Sitting quietly on the toilet every 2 hours D) Following the outlined bowel program

Ans:B Feedback: A raised toilet seat is useful, because the patient has difficulty in moving from a standing to a sitting position. A handicapped toilet is not high enough and will not aid in improving bowel elimination. Sitting quietly on the toilet every 2 hours will not aid in getting from the sitting to standing position; neither will following the outlined bowel program.

15. A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process? A) Cyclosporine (Neoral) B) Acyclovir (Zovirax) C) Cyclobenzaprine (Flexeril) D) Ampicillin (Prinicpen)

Ans:B Feedback: Acyclovir (Zovirax) or ganciclovir (Cytovene), antiviral agents, are the medications of choice in the treatment of HSV. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses.

32. A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A) Apply a dressing saturated with chlorhexidine. B) Wash the bites with soap and water. C) Arrange for the patient to receive a hepatitis B vaccination. D) Assess the patient's immunization history.

Ans:B Feedback: After forensic evidence has been gathered, cleansing with soap and water is necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed. The patient's immunization history does not directly influence the course of treatment and hepatitis B vaccination is not indicated. Chlorhexidine bandages are not recommended.

18. A patient has just returned to the unit from the PACU after surgery for a tumor within the spine. The patient complains of pain. When positioning the patient for comfort and to reduce injury to the surgical site, the nurse will position to patient in what position? A) In the high Fowler's position B) In a flat side-lying position C) In the Trendelenberg position D) In the reverse Trendelenberg position

Ans:B Feedback: After spinal surgery, the bed is usually kept flat initially. The side-lying position is usually the most comfortable because this position imposes the least pressure on the surgical site. The Fowler's position, Trendelenberg position, and reverse Trendelenberg position are inappropriate for this patient because they would result in increased pain and complications.

16. A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? A) Alcohol causes hormone fluctuations. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain.

Ans:B Feedback: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

3. When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonicñclonic seizures D) Shortness of breath

Ans:B Feedback: Alteration in LOC is the earliest sign of deterioration in a patient after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

28. A 2-year-old is brought to the clinic by her mother who tells the nurse her daughter has diarrhea and the child is complaining of pain in her stomach. The mother says that the little girl had not eaten anything unusual, consuming homemade chicken strips and carrot sticks the evening prior. Which bacterial infection would the nurse suspect this little girl of contracting? A) Escherichia coli B) Salmonella C) Shigella D) Giardia lamblia

Ans:B Feedback: Annually in the United States, Salmonella species contaminate approximately 2.2 million eggs (1 in 20,000 eggs) and one in eight chickens raised as meat. Diarrhea with gastroenteritis is a common manifestation associated with Salmonella. Recent outbreaks of E. coli have been associated with ingestion of undercooked beef. Shigella spreads through the fecalñoral route, with easy transmission from one person to another. People infected with Giardia lamblia contract the disease by drinking contaminated water.

16. An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? A) To decrease cerebral arterial pressure B) To avoid impeding venous outflow C) To prevent flexion contractures D) To prevent aspiration of stomach contents

Ans:B Feedback: Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.

3. A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

Ans:B Feedback: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

34. A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Decreased severity and duration of exacerbations

Ans:B Feedback: Baclofen, a -aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities.

34. The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A) Providing frequent small meals rather than three larger meals B) Teaching the patient to perform deep breathing and coughing exercises C) Keeping a urinary catheter in situ for the full duration of recovery D) Limiting intake of insoluble fiber

Ans:B Feedback: Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. No particular need exists to provide frequent meals and normally fiber intake should not be restricted. Urinary catheters should be discontinued as soon as possible.

15. A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography (CT) scan C) Complete blood count (CBC) D) Barium swallow

Ans:B Feedback: CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury.

30. A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? A) Ventricular tachycardia B) Atrial fibrillation C) Supraventricular tachycardia D) Bundle branch block

Ans:B Feedback: Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. The other listed dysrhythmias are less commonly associated with this type of stroke.

11. A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care? A) Elevate the head of the bed to 45 degrees. B) Maintain the patient on complete bed rest. C) Administer enemas when the patient is constipated. D) Avoid use of thigh-high elastic compression stockings.

Ans:B Feedback: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. No enemas are permitted, but stool softeners and mild laxatives are prescribed. Thigh-high elastic compression stockings or sequential compression boots may be ordered to decrease the patient's risk for deep vein thrombosis (DVT).

1. A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

Ans:B Feedback: Clinical manifestations of bacterial meningitis include a positive Brudzinski's sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski's sign. Positive Homan's sign (pain upon dorsiflexion of the foot) and negative Romberg's sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

38. A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A) Arrange for the patient to receive a low residue diet. B) Position the patient upright during feeding. C) Suction the patient following each meal. D) Withhold liquids until the patient has finished eating.

Ans:B Feedback: Correct, upright positioning is necessary to prevent aspiration in the patient with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration.

19. A 44-year-old male patient has been exposed to severe amount of radiation after a leak in a reactor plant. When planning this patient's care, the nurse should implement what action? A) The patient should be scrubbed with alcohol and iodine. B) The patient should be carefully protected from infection. C) The patient's immunization status should be promptly assessed. D) The patient's body hair should be removed to prevent secondary contamination.

Ans:B Feedback: Damage to the hematopoietic system following radiation exposure creates a serious risk for infection. There is no need to remove the patient's hair and the patient's immunization status is not significant. Alcohol and iodine are ineffective against radiation.

22. A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? A) Support the patient's full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patient's family members do not participate in mobilization.

Ans:B Feedback: During mobilization, a chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the patient's full body weight. Morning and evening activity are not necessarily problematic.

12. A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety and pain. D) Relieve sensory deprivation.

Ans:B Feedback: Each of the listed goals is appropriate in the care of a patient recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the patient's survival depends.

20. The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A) Administer prophylactic antibiotics. B) Survey the victims using a radiation survey meter. C) Irrigate victims' open wounds. D) Perform soap and water decontamination.

Ans:B Feedback: Each patient arriving at the hospital should first be surveyed with the radiation survey meter for external contamination and then directed toward the decontamination area as needed. This survey should precede decontamination efforts or irrigation of wounds. Antibiotics are not indicated.

16. When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A) Head turned slightly to the right side B) Elevation of the head of the bed C) Position changes every 15 minutes while awake D) Extension of the neck

Ans:B Feedback: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.

9. A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate? A) Noting that symptoms of physical illness are not relevant to the current diagnosis B) Asking the patient if she has ever thought about taking her own life C) Conducting interviews in a brief and direct manner D) Arranging for the patient to spend time alone to consider her feelings

Ans:B Feedback: Establishing if the patient has suicidal thoughts or intents helps identify the level of depression and intervention. Physical symptoms are relevant and should be explored. Allow the patient to express feelings, and conduct the interview at a comfortable pace for the patient. Never leave the patient alone, because suicide is usually committed in solitude.

3. The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants D) Avoiding naps during the day

Ans:B Feedback: Fatigue is a common symptom of patients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the patient with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

14. A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patient's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? A) Whether the tumor utilizes aerobic or anaerobic respiration B) The specific hormones secreted by the tumor C) The patient's pre-existing health status D) Whether the tumor is primary or the result of metastasis

Ans:B Feedback: Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary and the effects of the tumor depend largely on the identity of these hormones. This variable is more significant than the patient's health status or whether the tumor is primary versus secondary. Anaerobic and aerobic respiration is not relevant.

5. The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom? A) Hypertension with a wide pulse pressure B) Anhidrosis C) Copious diuresis D) Cheyne-Stokes respirations

Ans:B Feedback: Heat stroke is manifested by anhidrosis confusion, bizarre behavior, coma, elevated body temperature, hot dry skin, tachypnea, hypotension, and tachycardia. This health problem is not associated with anhidrosis or Cheyne-Stokes respirations.

2. A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1Ω hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A) Risk for impaired skin integrity B) Risk for injury C) Risk for autonomic dysreflexia D) Risk for suffocation

Ans:B Feedback: If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient's neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

20. Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma.

Ans:B Feedback: If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.

16. The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy when it is scheduled at what time? A) Immediately after meals B) In the morning C) Before bedtime D) In the early evening

Ans:B Feedback: Important activities for patients with postpolio syndrome should be planned for the morning, as fatigue often increases in the afternoon and evening.

38. A rehabilitation nurse caring for a patient who has had a stroke is approached by the patient's family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurse's best answer? A) We are trying to help her be as useful as she possibly can. B) The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible. C) We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home. D) Rehabilitation means helping patients do exactly what they did before their stroke.

Ans:B Feedback: In both acute care and rehabilitation facilities, the focus is on teaching the patient to resume as much self-care as possible. The goal of rehabilitation is not to be useful, nor is it to return patients to their prestroke level of functioning, which may be unrealistic.

27. A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following? A) Evaluate the care that he or she provided during the disaster. B) Discuss own emotional responses to the disaster. C) Explore the ethics of the care provided during the disaster. D) Provide suggestions for improving the emergency operations plan.

Ans:B Feedback: In debriefing, participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (e.g., flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifications. The EOP and the care the nurse provided are not evaluated.

24. A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis

Ans:B Feedback: In nondisaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. However, in a disaster, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. A first come, first served approach is unethical.

8. A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises

Ans:B Feedback: It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

9. A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status examination

Ans:B Feedback: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this patient, but would not be the priority in evaluating LOC.

1. The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What does this classification indicate? A) First responders can manage the situation. B) Regional efforts and aid from surrounding communities can manage the situation. C) Statewide or federal assistance is required. D) The area must be evacuated immediately.

Ans:B Feedback: Level II disasters indicate that regional efforts and aid from the surrounding communities will be able to manage the situation. Local efforts are likely to be overwhelmed, while state and federal assistance are not likely necessary. The disaster level does not indicate the necessity of evacuation.

2. The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? A) Maintaining accurate records of intake and output B) Maintaining a patent airway C) Inserting a nasogastric (NG) tube as ordered D) Providing appropriate pain control

Ans:B Feedback: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.

6. The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patient's BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

Ans:B Feedback: Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

13. The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? A) Intravenous phenobarbital (Luminal) B) Intravenous diazepam (Valium) C) Oral lorazepam (Ativan) D) Oral phenytoin (Dilantin)

Ans:B Feedback: Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

9. A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? A) Negative Brudzinski's sign B) Positive Kernig's sign C) Hyperpatellar reflex D) Sluggish pupil reaction

Ans:B Feedback: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig's sign, a positive Brudzinski's sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis.

31. A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patient's cardiopulmonary status, the nurse should prepare to perform what intervention? A) Administer a bolus of lactated Ringer's. B) Administer naloxone hydrochloride (Narcan). C) Insert an indwelling urinary catheter. D) Perform a focused neurologic assessment.

Ans:B Feedback: Narcan is an opioid antagonist that is administered for the treatment of narcotic overdoses. There is no definitive need for a urinary catheter or for a bolus of lactated Ringer's. The patient's basic neurologic status should be ascertained during the rapid assessment, but a detailed examination would be take precedence over administration of an antidote.

25. A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patient's care should the nurse begin to use a neurologic flow chart? A) When the patient's condition begins to deteriorate B) As soon as the initial assessment is made C) At the beginning of each shift D) When there is a clinically significant change in the patient's condition

Ans:B Feedback: Neurologic parameters are assessed initially and as frequently as the patient's condition requires. As soon as the initial assessment is made, the use of a neurologic flowchart is started and maintained. A new chart is not begun at the start of every shift.

10. A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A) Preparation for emergency craniotomy B) Watchful waiting and close monitoring C) Administration of inotropic drugs D) Fluid resuscitation

Ans:B Feedback: Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.

2. A 25-year-old female patient with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the patient is not receiving treatment for her brain metastases, what is the nurse's most appropriate action? A) Promoting the patient's functional status and ADLs B) Ensuring that the patient receives adequate palliative care C) Ensuring that the family does not tell the patient that her condition is terminal D) Promoting adherence to the prescribed medication regimen

Ans:B Feedback: Patients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods, but for most cure is not possible. Palliative care is thus necessary. This is a priority over promotion of function and the family should not normally withhold information from the patient. Adherence to medications such as analgesics is important, but palliative care is a high priority.

13. A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? A) Identify the triggers that precipitated the seizure. B) Implement precautions to ensure the patient's safety. C) Teach the patient's family about the relationship between brain tumors and seizure activity. D) Ensure that the patient is housed in a private room.

Ans:B Feedback: Patients with seizures are carefully monitored and protected from injury. Patient safety is a priority over health education, even though this is appropriate and necessary. Specific triggers may or may not be evident; identifying these is not the highest priority. A private room is preferable, but not absolutely necessary.

6. The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the patient's ADLs, what goal should the nurse prioritize? A) Promoting the patient's recovery from the disease B) Maximizing the patient's level of function C) Ensuring the patient's adherence to treatment D) Fostering the family's participation in care

Ans:B Feedback: Priority for the care of the child with muscular dystrophy is the need to maximize the patient's level of function. Family participation is also important, but should be guided by this goal. Adherence is not a central goal, even though it is highly beneficial, and the disease is not curable.

17. A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement? A) Perform active ROM exercises three times daily. B) Sleep on a firm mattress. C) Apply cool compresses to the back of the neck daily. D) Wear the cervical collar for at least 2 hours at a time.

Ans:B Feedback: Proper positioning on a firm mattress and bed rest for 1 to 2 days may bring dramatic relief from pain. The patient may need to wear a cervical collar 24 hours a day during the acute phase of pain from a cervical disk herniation. Hot, moist compresses applied to the back of the neck will increase blood flow to the muscles and help relax the spastic muscles.

14. To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment? A) Concurrent use of calcium supplements is contraindicated. B) Blood levels of the drug must be monitored. C) The drug is likely to cause hyperactivity and agitation. D) Tegretol can cause tinnitus during the first few days of treatment.

Ans:B Feedback: Side effects of Tegretol include nausea, dizziness, drowsiness, and aplastic anemia. The patient must also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia, and tinnitus are not side effects of Tegretol.

26. A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? A) Have your heart checked regularly. B) Stop smoking as soon as possible. C) Get medication to bring down your sodium levels. D) Eat a nutritious diet.

Ans:B Feedback: Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

25. A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions? A) Wearing a mask and gown when starting an IV line B) Washing hands immediately after removing gloves C) Recapping all needles promptly after use to prevent needlestick injuries D) Double-gloving when working with a patient who has a blood-borne illness

Ans:B Feedback: Standard precautions are used to prevent contamination from blood and body fluids. Gloves are worn whenever exposure is possible, and hands should be washed after removing gloves. Needles are never recapped after use because this increases the risk of accidental needlesticks. Under ordinary circumstances, masks and gowns are not necessary for starting an IV line. Double-gloving is not a recognized component of standard precautions.

34. A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A) Generalized seizure B) Absence seizure C) Focal seizure D) Unclassified seizure

Ans:B Feedback: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

18. A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status? A) Reflex activity B) Level of consciousness C) Cognitive ability D) Sensory involvement

Ans:B Feedback: The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.

8. A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication? A) Tegretol is not known to have serious adverse effects. B) The patient should be monitored for bone marrow depression. C) Side effects of the medication include renal dysfunction. D) The medication should be first taken in the maximum dosage form to be effective.

Ans:B Feedback: The anticonvulsant agents carbamazepine (Tegretol) and phenytoin (Dilantin) relieve pain in most patients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. Carbamazepine should be gradually increased until pain relief is obtained.

29. A public health nurse is teaching a mother about vaccinations prior to obtaining informed consent for her child's vaccination. What should the nurse cite as the most common adverse effect of vaccinations? A) Temporary sensitivity to the sun B) Allergic reactions to the antigen or carrier solution C) Nausea and vomiting D) Joint pain near the injection site

Ans:B Feedback: The most common adverse effects are an allergic reaction to the antigen or carrier solution and the occurrence of the actual disease (often in modified form) when live vaccine is used. Reactions to vaccines do not typically include sensitivity to the sun, nausea and vomiting, or joint pain.

35. The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient? A) How would you describe your mood over the past few days? B) Have you ever thought about taking your own life? C) How do you think that your life is most likely to end? D) How would you rate the severity of your depression right now on a 10-point scale?

Ans:B Feedback: The nurse should address the patient's possible plans for suicide in a direct yet empathic manner. The nurse should avoid oblique or indirect references to suicide and should not limit questions to the patient's depression.

14. A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis

Ans:B Feedback: The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

15. The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? A) Position the patient supine. B) Maintain head of bed (HOB) elevated at 30 to 45 degrees. C) Position patient in prone position. D) Maintain bed in Trendelenberg position.

Ans:B Feedback: The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

4. The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis? A) Change the patient's position as indicated. B) Monitor serum electrolytes. C) Maintain NPO status. D) Monitor arterial blood gas (ABG) values.

Ans:B Feedback: The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral edema. Changing the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume.

31. A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A) Victims' pre-existing medical conditions are exacerbated. B) Victims are thrown by the pressure wave. C) Victims experience burns from the blast. D) Victims suffer injuries caused by debris or shrapnel from the blast.

Ans:B Feedback: The tertiary phase of the blast injury results from the pressure wave that causes the victims to be thrown, resulting in traumatic injury. None of the other listed events occurs in this specific phase of a blast.

30. A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what? A) Every day for 1 week B) Determined by the patient's response C) Alternate days for 10 days D) Determined by the patient's weight

Ans:B Feedback: The typical course of plasmapheresis consists of daily or alternate-day treatment, and the number of treatments is determined by the patient's response.

26. A patient is admitted from the ED diagnosed with Neisseria meningitides. What type of isolation precautions should the nurse institute? A) Contact precautions B) Droplet precautions C) Airborne precautions D) Observation precautions

Ans:B Feedback: This patient requires droplet precautions because the organism can be transmitted through large airborne droplets when the patient coughs, sneezes, or fails to cover the mouth. Smaller droplets can be addressed by airborne precautions, but this is insufficient for this microorganism.

22. A patient is alarmed that she has tested positive for MRSA following culture testing during her admission to the hospital. What should the nurse teach the patient about this diagnostic finding? A) There are promising treatments for MRSA, so this is no cause for serious concern. B) This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces. C) The vast majority of patients in the hospital test positive for MRSA, but the infection doesn't normally cause serious symptoms. D) This finding is only preliminary, and your doctor will likely order further testing.

Ans:B Feedback: This patient's testing results are indicative of colonization, which is not synonymous with infection. The test results are considered reliable, and would not be characterized as preliminary. Treatment is not normally prescribed for colonizations.

20. What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis? A) To decreased nurses' susceptibility to health care-associated infections B) To decrease risk of transmission to vulnerable patients C) To eventually eradicate the influenza virus in the United States D) To prevent the emergence of drug-resistant strains of the influenza virus

Ans:B Feedback: To reduce the chance of transmission to vulnerable patients, health care workers are advised to obtain influenza vaccinations. The vaccine will not decrease nurses' risks of developing health care-associated infections, eradicate the influenza virus, or decrease the risk of developing new strains of the influenza virus.

21. An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A) Place all potential victims on reverse isolation. B) Establish a triage outside the hospital. C) Have hospital staff put on personal protective equipment. D) Place hospital staff on abbreviated shifts of no more than 4 hours.

Ans:B Feedback: Triage outside the hospital is the most effective means of preventing contamination of the facility itself. None of the other listed actions has the potential to prevent the contamination of the hospital itself.

4. The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? A) White female, age 60, with history of excessive alcohol intake B) White male, age 60, with history of uncontrolled hypertension C) Black male, age 60, with history of diabetes D) Black male, age 50, with history of smoking

Ans:B Feedback: Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group includes African Americans, where the incidence of first stroke is almost twice that as in Caucasians.

11. A male patient with gonorrhea asks the nurse how he can reduce his risk of contracting another sexually transmitted infection. The patient is not in a monogamous relationship. The nurse should instruct the patient to do which of the following? A) Ask all potential sexual partners if they have a sexually transmitted disease. B) Wear a condom every time he has intercourse. C) Consider intercourse to be risk-free if his partner has no visible discharge, lesions, or rashes. D) Aim to limit the number of sexual partners to fewer than five over his lifetime.

Ans:B Feedback: Wearing a condom during intercourse considerably reduces the risk of contracting STIs. The other options may help reduce the risk for contracting an STI, but not to the extent that wearing a condom will. A monogamous relationship reduces the risk of contracting STIs.

39. An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients' acuity as well as what other variable? A) The likelihood of a repeat visit to the ED in the next 7 days B) The resources that the patient is likely to require C) The patient's or insurer's ability to pay for care D) Whether the patient is known to ED staff from previous visits

Ans:B Feedback: With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs. Ability to pay, the likelihood of repeat visits, and the history of prior visits are not explicitly considered.

31. An older adult patient tells the nurse that she had chicken pox as a child and is eager to be vaccinated against shingles. What should the nurse teach the patient about this vaccine? A) Vaccination against shingles is contraindicated in patients over the age of 80. B) Vaccination can reduce her risk of shingles by approximately 50%. C) Vaccination against shingles involves a series of three injections over the course of 6 months. D) Vaccination against shingles is only effective if preceded by a childhood varicella vaccination.

Ans:B Feedback: Zostavax, a vaccine to reduce the risk of shingles, is recommended for people older than 60 years of age because it reduces the risk of shingles by approximately 50%. It does not need to be preceded by childhood varicella vaccine. The vaccine consists of a single injection.

2. A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration? A) Labile BP B) Weak pulse C) Fever D) Diaphoresis

Ans:B Feedback: Assessment of dehydration includes evaluation of thirst, oral mucous membrane dryness, sunken eyes, a weakened pulse, and loss of skin turgor. Diaphoresis, labile BP, and fever are not characteristic signs and symptoms of dehydration.

10. The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia

Ans:B Feedback: Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus.

6. A patient has a concentration of S. aureus located on his skin. The patient is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? A) Infection B) Colonization C) Disease D) Bacteremia

Ans:B Feedback: Colonization refers to the presence of microorganisms without host interference or interaction. Infection is a condition in which the host interacts physiologically and immunologically with a microorganism. Disease is the decline in wellness of a host due to infection. Bacteremia is a condition of bacteria in the blood.

4. A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? A) Level A B) Level B C) Level C D) Level D

Ans:B Feedback: Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection. Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical resistant gloves, and boots. Level D is the same as a work uniform.

3. A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel

Ans:B Feedback: Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel. The liver is also injured frequently, but it is a solid organ.

2. The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? A) Anxiety and denial B) Remorse and guilt C) Anger D) Grief

Ans:B Feedback: Remorse and guilt are natural processes of the stages of a crisis and should be facilitated for the family members to process the crisis. The family's sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety.

5. The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? A) Pruritus B) Dyskinesia C) Lactose intolerance D) Diarrhea

Ans:B Feedback: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.

21. A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply. A) Blood pressure greater than 140/90 mm Hg B) Heart rate greater than 120 bpm C) Older age D) Low Glasgow Coma Scale E) Lack of previous immunizations

Ans:B, C, D Feedback: Risks for an unfavorable outcome of meningitis include older age, a heart rate greater than 120 beats/minute, low Glasgow Coma Scale score, cranial nerve palsies, and a positive Gram stain 1 hour after presentation to the hospital. A BP greater than 140/90 mm Hg is indicative of hypertension, but is not necessarily related to poor outcomes related to meningitis. Immunizations are not normally relevant to the course of the disease.

19. The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. A) Absence of pain response B) Apnea C) Coma D) Absence of brain stem reflexes E) Absence of deep tendon reflexes

Ans:B, C, D Feedback: The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death.

22. A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Ascites B) Rebound tenderness C) Changes in bowel sounds D) Muscular rigidity E) Copious diarrhea

Ans:B, C, D Feedback: Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

32. The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply. A) Progressive weakening of human immune systems B) Use of extended-spectrum antibiotics C) Population movements D) Increased global travel E) Globalization of food supplies

Ans:B, C, D, E Feedback: Many factors contribute to newly emerging or re-emerging infectious diseases. These include travel, globalization of food supply and central processing of food, population growth, increased urban crowding, population movements (e.g., those that result from war, famine, or man-made or natural disasters), ecologic changes, human behavior (e.g., risky sexual behavior, IV/injection drug use), antimicrobial resistance, and breakdown in public health measures. Not noted is an overall decline in human immunity.

32. As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

Ans:B, D, E Feedback: Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).

22. After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patient's initial symptoms, the care team should anticipate what event? A) A return to full health B) Internal bleeding C) A latent phase D) Massive tissue necrosis

Ans:C Feedback: A latent phase commonly follows the prodromal phase of radiation exposure. The patient is deemed a possible survivor, not a probable survivor, so an immediate return to health is unlikely. However, internal bleeding and massive tissue necrosis would not be expected in a patient categorized as a possible survivor.

40. A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously

Ans:C Feedback: A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.

14. A group of medical nurses are being certified in their response to potential bioterrorism. The nurses learn that if a patient is exposed to the smallpox virus he or she becomes contagious at what time? A) 6 to 12 hours after exposure B) When pustules form C) After a rash appears D) When the patient becomes febrile

Ans:C Feedback: A patient is contagious after a rash develops, which initially develops on the face, mouth, pharynx, and forearms. The patient exposed to the smallpox virus is not contagious immediately after exposure; only when pustules form, or with a body temperature of 38∞C.

6. A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care team's most appropriate treatment? A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Referring to psychiatry

Ans:C Feedback: A patient who has swallowed an acidic substance, such as toilet bowl cleaner, may be given milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A psychiatric consult may be considered once the patient is physically stable and it is deemed appropriate by the physician. Syrup of ipecac is no longer used in clinical settings.

41. A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? A) Place the patient in the prone position for 30 minutes/day. B) Assist the patient in acutely flexing the thigh to promote movement. C) Place a pillow in the axilla when there is limited external rotation. D) Place patient's hand in pronation.

Ans:C Feedback: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.

8. While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place? A) Deciding when the facility will go from disaster response to daily activities B) Conducting practice drills for the community and facility C) Conducting a critique and debriefing for all involved in the incident D) Replacing the resources in the facility

Ans:C Feedback: A post-incident response includes critiquing and debriefing all parties involved immediately and at later dates. It does not include the decision to go from disaster response to daily activities; it does not include practice drills; and it does not include replacement of resources in the facility.

8. A patient with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patient's nutritional needs should be met by what method? A) Total parenteral nutrition (TPN) B) Provision of a low-residue diet C) Semisolid food with thick liquids D) Minced foods and a fluid restriction

Ans:C Feedback: A semisolid diet with thick liquids is easier for a patient with swallowing difficulties to consume than is a solid diet. Low-residue foods and fluid restriction are unnecessary and counterproductive to the patient's nutritional status. The patient's status does not warrant TPN.

24. A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A) Serial assessments of hemoglobin levels B) Blood glucose monitoring C) Close monitoring of fluid balance D) Assessment of pain along dermatomes

Ans:C Feedback: A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia. As such, it is important to monitor the patient's intake and output closely.

36. A nurse has had contact with a patient who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment? A) Watchful waiting B) Treatment with colony-stimulating factors (CSFs) C) Vaccination D) Treatment with ceftriaxone

Ans:C Feedback: All people who have had household or face-to-face contact with a patient with small pox after the fever begins should be vaccinated within 4 days to prevent infection and death. Watchful waiting would be inappropriate and CSFs are not used for treatment. Vaccination, rather than antibiotics, is the treatment of choice.

28. A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1∫C (104.2∞F). What would be the priority nursing action for this patient? A) Monitor cardiovascular effects. B) Administer antipyretics. C) Ensure airway and ventilation. D) Prevent seizure activity.

Ans:C Feedback: Although all of the listed actions may be necessary for this patient's care, the priority is to establish a patent airway and adequate ventilation.

1. The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A) Epistaxis B) Periorbital edema C) Bruising over the mastoid D) Unilateral facial numbness

Ans:C Feedback: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

5. A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? A) Insertion of an intracranial monitoring device B) Treatment with antihypertensives C) Emergency craniotomy D) Administration of anticoagulant therapy

Ans:C Feedback: An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this patient.

33. A patient has been admitted to the medical unit with signs and symptoms that are suggestive of anthrax infection. The nurse should anticipate what intervention? A) Administration of acyclovir B) Hematopoietic stem cell transplantation (HSCT) C) Administration of penicillin D) Hemodialysis

Ans:C Feedback: Anthrax infection is treated with penicillin. Acyclovir is ineffective because anthrax is a bacterium. Dialysis and HSCT are not indicated.

24. A clinic nurse is caring for a male patient diagnosed with gonorrhea who has been prescribed ceftriaxone and doxycycline. The patient asks why he is receiving two antibiotics. What is the nurse's best response? A) There are many drug-resistant strains of gonorrhea, so more than one antibiotic may be required for successful treatment. B) The combination of these two antibiotics reduces the later risk of reinfection. C) Many people infected with gonorrhea are infected with chlamydia as well. D) This combination of medications will eradicate the infection twice as fast than a single antibiotic.

Ans:C Feedback: Because patients are often coinfected with both gonorrhea and chlamydia, the CDC recommends dual therapy even if only gonorrhea has been laboratory proven. Although the number of resistant strains of gonorrhea has increased, that is not the reason for use of combination antibiotic therapy. Dual therapy is prescribed to treat both gonorrhea and chlamydia, because many patients with gonorrhea have a coexisting chlamydial infection. This combination of antibiotics does not reduce the risk of reinfection or provide a faster cure.

28. A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? A) Assessment of peripheral nervous function B) Assessment of cranial nerve function C) Assessment of nutritional status D) Assessment of respiratory status

Ans:C Feedback: Cachexia is a wasting syndrome of weight loss, muscle atrophy, fatigue, weakness, and significant loss of appetite. Consequently, nutritional assessment is paramount.

23. A patient's diagnostic testing revealed that he is colonized with vancomycin-resistant enterococcus (VRE). What change in the patient's health status could precipitate an infection? A) Use of a narrow-spectrum antibiotic B) Treatment of a concurrent infection using vancomycin C) Development of a skin break D) Persistent contact of the bacteria with skin surfaces

Ans:C Feedback: Colonization can progress to infection if there is a portal of entry by which bacteria can invade body tissues. The use of vancomycin, or any other antibiotic, would not necessarily precipitate a VRE infection. Prolonged skin contact is similarly unlikely to cause infection, provided the skin remains intact.

20. Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patient's current LOC? A) The patient occasionally makes incomprehensible sounds. B) The patient's current LOC will likely become a permanent state. C) The patient may occasionally make nonpurposeful movements. D) The patient is incapable of spontaneous respirations.

Ans:C Feedback: Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal or external stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes may be present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary. Comas are not permanent states.

23. A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient's complaints of headache? A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate B) Administering hydromorphone (Dilaudid) IV as needed C) Dimming the lights and reducing stimulation D) Distracting the patient with activity

Ans:C Feedback: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Non-opioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patient's pain.

11. A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A) Encephalitis B) CSF leak C) Meningitis D) Catheter occlusion

Ans:C Feedback: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter.

2. The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) Depression D) Disassociation

Ans:C Feedback: Depression is a common and serious problem in the patient who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the patient with a loss of independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the stroke on self-esteem. Denial, fear, and disassociation are not the most common patient response to a change in body image, although each can occur in some patients.

40. A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning? A) Administering IV antibiotics B) Assessing immunization status C) Determining the source and type of food poisoning D) Determining if anyone else in the family is ill

Ans:C Feedback: Determining the source and type of food poisoning is essential to treatment, and is more important than determining other sick family members. Antibiotics are not normally indicated and immunizations are not relevant to diagnosis or treatment of food poisoning.

25. A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patient's care? A) Intubating the patient B) Notifying family members C) Ensuring IV access D) Delivering specimens to the laboratory

Ans:C Feedback: ED nursing responsibilities include ensuring airway and IV access. Nurses are not normally responsible for notifying family members. Nurses collect specimens, but are not responsible for their delivery. Physicians or other team members with specialized training intubate the patient.

17. A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

Ans:C Feedback: Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngeal airway, which is used in patients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

23. A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? A) How to differentiate between hemorrhagic and ischemic stroke B) Risk factors for ischemic stroke C) How to correctly modify the home environment D) Techniques for adjusting the patient's medication dosages at home

Ans:C Feedback: For a patient with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the patient live with the disability. This is more important to the patient's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

4. A patient with Guillain-BarrÈ syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula.

Ans:C Feedback: For the patient with Guillain-BarrÈ syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed actions is likely insufficient to meet the patient's oxygenation needs.

6. A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patient's plan of care? A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered

Ans:C Feedback: Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.

13. The nurse is caring for a patient who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting? A) Using antibacterial soap when bathing patients with MRSA B) Conducting culture surveys on a regularly scheduled basis C) Performing hand hygiene before and after contact with every patient D) Using aseptic housekeeping practices for environmental cleaning

Ans:C Feedback: Handwashing is the major infection control measure to reduce the risk of transmission of MRSA and other nosocomial pathogens. No convincing evidence exists to support that bathing patients with antibacterial soap is effective. Culture surveys can help establish the true prevalence of MRSA in a facility, but are used only to help implement where and when infection-control measures are needed. Hand hygiene is known to be more clinically important than housekeeping.

31. A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? A) Metastasis B) Risk for stroke C) Emotional and personality changes D) Pathologic bone fractures

Ans:C Feedback: Huntington disease causes profound changes to personality and behavior. It is a nonmalignant disease and stroke is not a central risk. The disease is not associated with pathologic bone fractures.

10. The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care? A) The patient's hip joint should be maintained in a flexed position. B) The patient should be in a supine position unless ambulating. C) The patient should be placed in a prone position for 15 to 30 minutes several times a day. D) The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.

Ans:C Feedback: If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenberg position is not indicated.

39. The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. The patient states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action? A) Palpate the surgical site. B) Remove the dressing to assess the surgical site. C) Call the surgeon to report the patient's pain. D) Administer a dose of an NSAID.

Ans:C Feedback: If the patient experiences a sudden increase in pain, extrusion of the graft may have occurred, requiring reoperation. A sudden increase in pain should be promptly reported to the surgeon. Administration of an NSAID would be an insufficient response and the dressing should not be removed without an order. Palpation could cause further damage.

9. Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A) Keep the head of the bed (HOB) flat at all times. B) Teach the patient to perform the Valsalva maneuver. C) Administer benzodiazepines on a PRN basis. D) Perform endotracheal suctioning every hour.

Ans:C Feedback: If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP.

31. The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury? A) Avoid watching television or using a computer for more than 1 hour at a time. B) Use OTC antibiotic eye drops for at least 14 days. C) Avoid rubbing the eye on the affected side of the face. D) Rinse the eye on the affected side with normal saline daily for 1 week.

Ans:C Feedback: If the surgery results in sensory deficits to the affected side of the face, the patient is instructed not to rub the eye because the pain of a resulting injury will not be detected. There is no need to limit TV viewing or to rinse the eye daily. Antibiotics may or may not be prescribed, and these would not reduce the risk of injury.

20. A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition? A) Chronic confusion B) Impaired urinary elimination C) Impaired verbal communication D) Bowel incontinence

Ans:C Feedback: Impaired communication is an appropriate nursing diagnosis; the voice in patients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in patients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.

10. A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? A) Determining whether the incident was managed effectively B) Educating survivors on potential coping strategies for future disasters C) Providing individuals with education about recognizing stress reactions D) Determining if individuals responded appropriately during the incident

Ans:C Feedback: In defusing, patients are given information about recognizing stress reactions and how to deal with handling the stress they may experience. Debriefing involves asking patients about their current emotional coping and symptoms, following up, and identifying patients who require further assessment and assistance in dealing with the stress experienced. The CISM team does not focus primarily on the management of the incident or on providing skills for future incidents.

15. A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

Ans:C Feedback: In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

32. A patient suffering from blast lung has been admitted to the hospital and is exhibiting signs and symptoms of an air embolus. What is the nurse's most appropriate action? A) Place the patient in the Trendelenberg position. B) Assess the patient's airway and begin chest compressions. C) Position the patient in the prone, left lateral position. D) Encourage the patient to perform deep breathing and coughing exercises.

Ans:C Feedback: In the event of an air embolus, the patient should be placed immediately in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber. Chest compressions, deep breathing, and coughing would exacerbate the patient's condition. Trendelenberg positioning is not recommended.

39. A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups? A) Preschool-aged children B) Adults with diabetes and/or renal failure C) Older adults with compromised health status D) Infants under the age of 12 months

Ans:C Feedback: Influenza vaccination is particularly beneficial in preventing death among older adults, especially those with compromised health status or those who live in institutional settings. It is recommended for children and adults, but carries the greatest reduction in morbidity and mortality in older adults.

35. A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond? A) It's important to drink plenty of fluids while you're taking laxatives. B) Make sure that you supplement your laxatives with a nutritious diet. C) Let's explore other options, because laxatives can have side effects and create dependency. D) You should ideally be using herbal remedies rather than medications to promote bowel function.

Ans:C Feedback: Laxatives should be avoided in patients with Parkinson's disease due to the risk of adverse effects and dependence. Herbal bowel remedies are not necessarily less risky.

40. A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack? A) Cover their eyes. B) Put on a personal protective equipment mask. C) Stand up. D) Crawl to an exit.

Ans:C Feedback: Most chemicals are heavier than air, except for hydrogen cyanide. Therefore, in the presence of most chemicals, people should stand up to avoid heavy exposure because the chemical will sink toward the floor or ground. For this reason, covering their eyes, putting on a PPE mask, or crawling to an exit will not decrease exposure.

19. A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinski's reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Ans:C Feedback: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski's reflex is found in MS. Abdominal reflexes are absent with MS.

39. The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowler's position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.

Ans:C Feedback: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the patient's risk of muscle spasticity.

12. A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day

Ans:C Feedback: Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures.

3. The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health circumstances. In establishing this plan of care for the patient, the nurse should include what intervention? A) The patient will receive antianxiety medications every 4 hours. B) The patient's family will be instructed on planning the patient's care. C) The patient will be encouraged to verbalize concerns related to the disease and its treatment. D) The patient will begin intensive therapy with the goal of distraction.

Ans:C Feedback: Patients need the opportunity to exercise some control over their situation. A sense of mastery can be gained as they learn to understand the disease and its treatment and how to deal with their feelings. Distraction and administering medications will not allow the patient to gain control over anxiety. Delegating planning to the family will not help the patient gain a sense of control and autonomy.

30. A mother brings her 12 month-old son into the clinic for his measles-mumps-rubella (MMR) vaccination. What would the clinic nurse advise the mother about the MMR vaccine? A) Photophobia and hives might occur. B) There are no documented reactions to an MMR. C) Fever and hypersensitivity reaction might occur. D) Hypothermia might occur.

Ans:C Feedback: Patients should be advised that fever, transient lymphadenopathy, or a hypersensitivity reaction might occur following an MMR vaccination. Reactions to an MMR do not include photophobia or hypothermia.

39. A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A) The patient will likely require lifelong treatment with anticholinergic medications. B) The patient has a disproportionate risk of developing myasthenia gravis later in life. C) The patient needs to be assessed for MS. D) The disease is self-limiting and the patient will achieve pain relief over time.

Ans:C Feedback: Patients that develop trigeminal neuralgia before age 50 should be evaluated for the coexistent of MS because trigeminal neuralgia occurs in approximately 5% of patients with MS. Treatment does not include anticholinergics and the disease is not self- limiting. Trigeminal neuralgia is not associated with an increased risk of myasthenia gravis.

22. The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurse's best response? A) Your tumor originated from somewhere outside the CNS. B) Your tumor likely started out in one of your glands. C) Your tumor originated from cells within your brain itself. D) Your tumor is from nerve tissue somewhere in your body.

Ans:C Feedback: Primary brain tumors originate from cells and structures within the brain. Secondary brain tumors are metastatic tumors that originate somewhere else in the body. The scenario does not indicate that the patient's tumor is a pituitary tumor or a neuroma.

17. A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest

Ans:C Feedback: Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should be avoided near bedtime if possible.

27. The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient? A) Suctioning secretions B) Facilitating ABG analysis C) Providing ventilatory assistance D) Administering tube feedings

Ans:C Feedback: Providing ventilatory assistance takes precedence in the immediate management of the patient with myasthenic crisis. It may be necessary to suction secretions and/or provide tube feedings, but they are not the priority for this patient. ABG analysis will be done, but this is not the priority.

27. The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A) Naproxen 250 PO b.i.d. B) Calcium carbonate 1,000 mg PO b.i.d. C) Aspirin 81 mg PO o.d. D) Lorazepam 1 mg SL b.i.d. PRN

Ans:C Feedback: Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

3. The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patient's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A) Position the patient in the high Fowler's position as tolerated. B) Administer osmotic diuretics as ordered. C) Participate in interventions to increase cerebral perfusion pressure. D) Prepare the patient for craniotomy.

Ans:C Feedback: The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the patient's condition.

36. Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when? A) At the patient's request B) Each morning and evening C) Every 2 hours D) One hour prior to mobility exercises

Ans:C Feedback: The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When used, the splints are removed and reapplied every 2 hours.

42. A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? E) To decrease cerebral edema F) To prevent seizure activity that is common following a TIA G) To remove atherosclerotic plaques blocking cerebral flow H) To determine the cause of the TIA

Ans:C Feedback: The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

36. A patient is brought to the ED by family members who tell the nurse that the patient has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this patient? A) Keep the patient in a confined space. B) Use therapeutic touch appropriately. C) Give the patient honest answers about likely treatment. D) Attempt to convince the patient that his or her fears are unfounded.

Ans:C Feedback: The nurse should offer appropriate and honest explanations in order to foster rapport and trust. Confinement is likely to cause escalation, as is touching the patient. The nurse should not normally engage in trying to convince the patient that his or her fears are unjustified, as this can also cause escalation.

1. A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to administer what priority medication? A) Hydrochlorothiazide (HydroDIURIL) B) Furosemide (Lasix) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

Ans:C Feedback: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.

13. The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected. B) Take ibuprofen for complaints of a serious headache. C) Take antihypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.

Ans:C Feedback: The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the patient to return home. Patient and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal; complaints of a serious headache should be reported to the physician before any medication is taken. Drowsiness is not normal or expected.

11. You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations? A) Engage the patient in a process of health education. B) Administer opioid analgesics as ordered. C) Place the patient in a private, well-lit room. D) Provide television or a radio as therapeutic distraction

Ans:C Feedback: The patient should be placed in a quiet single room with lights on and in a calm nonstressful environment. TV and radio stimulation should be avoided. Analgesics are not normally necessary, and would potentially contribute to hallucinations. Health education would be inappropriate while the patient is experiencing acute withdrawal.

5. When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the portal of entry for tuberculosis? A) Integumentary system B) Urinary system C) Respiratory system D) Gastrointestinal system

Ans:C Feedback: The portal of entry for M. tuberculosis is through the respiratory tract.

35. A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? A) Sudden electrolyte changes throughout the brain B) A dysrhythmia in the peripheral nervous system C) A dysrhythmia in the nerve cells in one section of the brain D) Sudden disruptions in the blood flow throughout the brain

Ans:C Feedback: The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.

36. The nurse is providing care for an older adult patient who has developed signs and symptoms of Calicivirus (Norovirus). What assessment should the nurse prioritize when planning this patient's care? A) Respiratory status B) Pain C) Fluid intake and output D) Deep tendon reflexes and neurological status

Ans:C Feedback: The vomiting and diarrhea that accompany Norovirus create a severe risk of fluid volume deficit. For this reason, assessments relating to fluid balance should be prioritized, even though each of the listed assessments should be included in the plan of care.

26. The nurse planning the care of a patient with head injuries is addressing the patient's nursing diagnosis of sleep deprivation. What action should the nurse implement? A) Administer a benzodiazepine at bedtime each night. B) Do not disturb the patient between 2200 and 0600. C) Cluster overnight nursing activities to minimize disturbances. D) Ensure that the patient does not sleep during the day.

Ans:C Feedback: To allow the patient longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the patient is disturbed less frequently. However, it is impractical and unsafe to provide no care for an 8-hour period. The use of benzodiazepines should be avoided.

35. The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A) Limit the amount of assistance provided with ADLs. B) Collaborate with the physical therapist and immobilize the patient's extremities temporarily. C) Increase the frequency of ROM exercises. D) Educate the patient about the importance of frequent position changes.

Ans:C Feedback: To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The patient is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The patient must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

32. A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension? A) Administer an IV bolus of normal saline prior to repositioning. B) Maintain bed rest until normal BP regulation returns. C) Monitor the patient's BP before and during position changes. D) Allow the patient to initiate repositioning.

Ans:C Feedback: To prevent hypotensive episodes, close monitoring of vital signs before and during position changes is essential. Prolonged bed rest carries numerous risks and it is not possible to provide a bolus before each position change. Following the patient's lead may or may not help regulate BP.

7. A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)

Ans:C Feedback: Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.

16. A nurse is preparing to administer a patient's scheduled dose of subcutaneous heparin. To reduce the risk of needlestick injury, the nurse should perform what action? A) Recap the needle before leaving the bedside. B) Recap the needle immediately before leaving the room. C) Avoid recapping the needle before disposing of it. D) Wear gloves when administering the injection.

Ans:C Feedback: Used needles should not be recapped. Instead, they are placed directly into puncture- resistant containers near the place where they are used. Gloves do not prevent needlestick injuries.

39. A nurse is collaborating with the interdisciplinary team to help manage a patient's recurrent headaches. What aspect of the patient's health history should the nurse identify as a potential contributor to the patient's headaches? A) The patient leads a sedentary lifestyle. B) The patient takes vitamin D and calcium supplements. C) The patient takes vasodilators for the treatment of angina. D) The patient has a pattern of weight loss followed by weight gain.

Ans:C Feedback: Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect.

22. The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient? A) Maintaining the patient's functional independence B) Providing health education C) Monitoring neurologic status closely D) Promoting mobility

Ans:C Feedback: Vigilant neurologic monitoring is a key aspect of caring for a patient who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.

24. A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patient's vomiting is most consistent with a brain tumor? A) The patient's vomiting is accompanied by epistaxis. B) The patient's vomiting does not relieve his nausea. C) The patient's vomiting is unrelated to food intake. D) The patient's emesis is blood-tinged.

Ans:C Feedback: Vomiting is often unrelated to food intake if caused by a brain tumor. The presence or absence of blood is not related to the possible etiology and vomiting may or may not relieve the patient's nausea.

8. The infectious control nurse is presenting a program on West Nile virus for a local community group. To reduce the incidence of this disease, the nurse should recommend what action? A) Covering open wounds at all times B) Vigilant handwashing in home and work settings C) Consistent use of mosquito repellants D) Annual vaccination

Ans:C Feedback: West Nile virus is transmitted by mosquitoes, which become infected by biting birds that are infected with the virus. Prevention of mosquito bites can reduce the risk of contracting the disease. Handwashing and bandaging open wounds are appropriate general infection control measures, but these actions do not specifically prevent West Nile virus for which no vaccine currently exists.

18. A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowler's position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.

Ans:C Feedback: When admitted for blunt trauma, patients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out.

9. An immunosuppressed patient is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family? A) Family members should avoid receiving vaccinations until the patient has recovered from his or her illness. B) Wipe down hard surfaces with a dilute bleach solution once per day. C) Maintain cleanliness in the home, but recognize that the home does not need to be sterile. D) Avoid physical contact with the patient unless absolutely necessary.

Ans:C Feedback: When assessing the risk of the immunosuppressed patient in the home environment for infection, it is important to realize that intrinsic colonizing bacteria and latent viral infections present a greater risk than do extrinsic environmental contaminants. The nurse should reassure the patient and family that their home needs to be clean but not sterile. Common-sense approaches to cleanliness and risk reduction are helpful. The family need not avoid vaccinations and it is unnecessary to avoid all contact or to wipe down surfaces daily.

25. A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite? A) Female gender B) Asian American race C) Advanced age D) Smoking

Ans:C Feedback: Advanced age, male gender, and race are well-known nonmodifiable risk factors for stroke. High-risk groups include people older than 55 years of age; the incidence of stroke more than doubles in each successive decade. Men have a higher rate of stroke than that of women. Another high-risk group is African Americans; the incidence of first stroke in African Americans is almost twice that as in Caucasian Americans; Asian American race is not a risk factor. Smoking is a modifiable risk.

39. A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? A) Acute pain B) Septicemia C) Bleeding D) Seizures

Ans:C Feedback: Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

25. The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Furosemide

Ans:C Feedback: If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

18. There has been a radiation-based terrorist attack and a patient is experiencing vomiting, diarrhea, and shock after the attack. How will the patient's likelihood of survival be characterized? A) Probable B) Possible C) Improbable D) Extended

Ans:C Feedback: Patients who experience vomiting, diarrhea, and shock after radiation exposure are categorized as improbable survival, because they are demonstrating symptoms of exposure levels of more than 800 rads of total body-penetrating irradiation.

20. A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries? A) Myocardial infarction B) Hypoglycemia C) Hemorrhage D) Peritonitis

Ans:C Feedback: The signs and symptoms the patient is experiencing suggest a volume deficit from an internal bleed. That the symptoms follow an acute injury suggests hemorrhage rather than myocardial infarction or hypoglycemia. Peritonitis would be an unlikely result of a femoral fracture.

35. A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members. The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what? A) Shigella B) Escherichia coli C) Clostridium difficile D) Norovirus

Ans:C Feedback: The spore form of the bacterium C. difficile is resistant to alcohol and other hand disinfectants; therefore, the use of gloves and handwashing (soap and water for physical removal) are required when C. difficile has been identified. Each of the other listed microorganisms is susceptible to alcohol-based cleansers.

32. A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure? A) Cerebellum B) Hypothalamus C) Pituitary gland D) Pineal gland

Ans:C Feedback: The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or hypothalamus.

21. The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that the effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply. A) Intracranial hemorrhage B) Infection of cerebrospinal fluid C) Increased ICP D) Focal neurologic signs E) Altered pituitary function

Ans:C, D, E Feedback: The effects of neoplasms are caused by the compression and infiltration of tissue. A variety of physiologic changes result, causing any or all of the following pathophysiologic events: increased ICP and cerebral edema, seizure activity and focal neurologic signs, hydrocephalus, and altered pituitary function.

11. A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patient's analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patient's urinary catheter became occluded.

Ans:D Feedback: A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in mediations or blood transfusions are unlikely causes.

14. A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A) Sit with the patient for a few minutes. B) Administer an analgesic. C) Inform the nurse-manager. D) Call the physician immediately.

Ans:D Feedback: A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. The physician will decide whether administration of an analgesic is indicated. Informing the nurse-manager is not necessary. Sitting with the patient is appropriate, once the physician has been notified of the change in the patient's condition.

7. The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan? A) Encourage patient to void every hour. B) Order a low-residue diet. C) Provide total assistance with all ADLs. D) Instruct the patient on daily muscle stretching.

Ans:D Feedback: A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The patient should participate in daily muscle stretching to help alleviate and relax muscle spasms.

9. While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients' cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? A) Page the physician and report this sign of infection. B) Reinforce the dressing and reassess in 1 to 2 hours. C) Reposition the patient to prevent further hemorrhage. D) Inform the surgeon of the possibility of a dural leak.

Ans:D Feedback: After a cervical diskectomy, the nurse will monitor the operative site and dressing covering this site. Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis, but is not a direct sign of infection. This should be reported to the surgeon, not just reinforced and observed.

18. A patient on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? A) Standard precautions only B) Droplet precautions C) Standard and contact precautions D) Standard and airborne precautions

Ans:D Feedback: Airborne precautions are required for proven or suspected pulmonary TB. Standard precaution techniques are used in conjunction with the transmission-based precautions, regardless of the patient's diagnosis. Droplet and contact precautions are insufficient.

37. The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants? A) Floors must be scrubbed with undiluted bleach. B) Waste must be promptly incinerated. C) The ventilation system should be deactivated. D) Air ducts and vents should be sealed.

Ans:D Feedback: All air ducts and vents must be sealed to prevent spread. Waste is controlled through double-bagging and the use of plastic-lined containers outside of the facility rather than incineration. Bleach would be ineffective against radiation and the ventilation system may or may not be deactivated.

21. The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A) Promoting adequate circulation B) Treating the child's increased ICP C) Assessing secondary brain injury D) Preserving brain homeostasis

Ans:D Feedback: All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event. The scenario does not indicate the child has increased ICP or a secondary brain injury at this point. Promoting circulation is likely secondary to the broader goal of preserving brain homeostasis.

28. A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration.

Ans:D Feedback: Alteration in LOC often is the earliest sign of deterioration in a patient with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a patient with an acute stroke is usually contraindicated.

5. A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.

Ans:D Feedback: An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

8. The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.

Ans:D Feedback: An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of disturbed sensory perception. The outcome of registers normal body temperature relates to the diagnosis of potential for ineffective thermoregulation. Body image disturbance would have a potential outcome of pays attention to grooming.

28. The nurse caring for a patient in ICU diagnosed with Guillain-BarrÈ syndrome should prioritize monitoring for what potential complication? A) Impaired skin integrity B) Cognitive deficits C) Hemorrhage D) Autonomic dysfunction

Ans:D Feedback: Based on the assessment data, potential complications that may develop include respiratory failure and autonomic dysfunction. Skin breakdown, decreased cognition, and hemorrhage are not complications of Guillain-BarrÈ syndrome.

22. The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A) The ability of the patient to follow instructions during the seizure. B) The success or failure of the care team to physically restrain the patient. C) The patient's ability to explain his seizure during the postictal period. D) The patient's activities immediately prior to the seizure.

Ans:D Feedback: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the patient is not possible during a seizure and physical restraint is not attempted. The patient's ability to explain the seizure is not clinically relevant.

21. A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action? A) Give written instructions to patient. B) Give verbal instructions to one of the patient's family members. C) Telephone the patient the next day with verbal instructions. D) Give verbal and written instructions to patient and a family member.

Ans:D Feedback: Before discharge, verbal and written instructions for continuing care are given to the patient and the family or significant others. Discharge teaching is completed prior to the patient leaving the ED, so phoning the patient the next day in not acceptable.

18. What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A) Cushing syndrome B) Syndrome of inappropriate antidiuretic hormone (SIADH) C) Adrenal crisis D) Diabetes insipidus

Ans:D Feedback: Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

11. The nurse caring for a patient diagnosed with Guillain-BarrÈ syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the patient should reflect the possibility of what sign or symptom of the disease? A) Intermittent hearing loss B) Tinnitus C) Tongue enlargement D) Vocal paralysis

Ans:D Feedback: Guillain-BarrÈ syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with the disease.

27. The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping? A) Help the family understand that the patient could have died. B) Emphasize the importance of accepting the patient's new limitations. C) Have the members of the family plan the patient's inpatient care. D) Assist the family in setting appropriate short-term goals.

Ans:D Feedback: Helpful interventions to facilitate coping include providing family members with accurate and honest information and encouraging them to continue to set well-defined, short-term goals. Stating that a patient's condition could be worse downplays their concerns. Emphasizing the importance of acceptance may not necessarily help the family accept the patient's condition. Family members cannot normally plan a patient's hospital care, although they may contribute to the care in some ways.

10. A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do? A) Stand him up and perform the abdominal thrust maneuver from behind. B) Lay him down, straddle him, and perform the abdominal thrust maneuver. C) Leave him to get assistance. D) Stay with him and encourage him, but not intervene at this time.

Ans:D Feedback: If the patient is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the patient standing. If the patient is unconscious, the nurse should lay the patient down. A nurse should never leave a choking patient alone.

23. A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has? A) Diffuse axonal injury B) Grade 1 concussion with frontal lobe involvement C) Contusion D) Grade 3 concussion with temporal lobe involvement

Ans:D Feedback: In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe involvement results in amnesia. Frontal lobe involvement can cause uncharacteristic behavior and a grade 1 concussion does not involve loss of consciousness. Diagnostic studies may show no apparent structural sign of injury, but the duration of unconsciousness is an indicator of the severity of the concussion. Diffuse axonal injury (DAI) results from widespread shearing and rotational forces that produce damage throughout the brainóto axons in the cerebral hemispheres, corpus callosum, and brain stem. In cerebral contusion, a moderate to severe head injury, the brain is bruised and damaged in a specific area because of severe acceleration- deceleration force or blunt trauma.

11. A patient has just been diagnosed with Parkinson's disease and the nurse is planning the patient's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patient's family? A) Risk for infection B) Impaired spontaneous ventilation C) Unilateral neglect D) Risk for injury

Ans:D Feedback: Individuals with Parkinson's disease face a significant risk for injury related to the effects of dyskinesia. Unilateral neglect is not characteristic of the disease, which affects both sides of the body. Parkinson's disease does not directly constitute a risk for infection or impaired respiration.

23. A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? A) Refer the family to psychiatry in order to provide them with support. B) Explore the causes of the patient's suicide attempt with the family. C) Encourage the family to participate in the bedside care of the patient. D) Ensure that the family receives appropriate crisis intervention services.

Ans:D Feedback: It is essential that family crisis intervention services are available for families of ED patients. It would be inappropriate and insensitive to explore causes of the patient's suicide attempt with the family. Family participation in bedside care is often impractical in the ED setting. Psychiatry is not the normal source of psychosocial support and crisis intervention.

34. The nurse is caring for a patient with secondary syphilis. What intervention should the nurse institute when caring for this patient? A) Ensure that the patient is housed in a private room. B) Administer hydrocortisone ointment to the lesions as ordered. C) Administer combination therapy with antiretrovirals as ordered. D) Wear gloves if contact with lesions is possible.

Ans:D Feedback: Lesions of primary and secondary syphilis may be highly infective. Gloves are worn when direct contact with lesions is likely, and hand hygiene is performed after gloves are removed. Isolation in a private room is not required. Corticosteroids antiviral medications are not indicated.

11. Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that the equipment will include what? A) A self-contained breathing apparatus B) A vapor-tight, chemical-resistant suit C) A uniform only D) An air-purified respirator

Ans:D Feedback: Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical-resistant gloves, and boots. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection, incorporating a vapor- tight, chemical-resistant suit and self-contained breathing apparatus (SCBA). Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection, incorporating a chemical-resistant suit and SCBA. Level D is the same as a work uniform.

27. A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A) Hemiplegia B) Dry mucous membranes C) Signs of internal bleeding D) Loss of brain stem reflexes

Ans:D Feedback: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

12. The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what? A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion

Ans:D Feedback: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It is not a genetic disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

10. A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the patient's metastatic brain disease? A) Chronic pain B) Respiratory distress C) Fixed pupils D) Personality changes

Ans:D Feedback: Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered mentation (memory loss and confusion), focal weakness, paralysis, aphasia, and seizures. Pain, respiratory distress, and fixed pupils are not among the more common neurologic signs and symptoms of metastatic brain disease.

40. The nurse receives a phone call from a clinic patient who experienced fever and slight dyspnea several hours after receiving the pneumococcus vaccine. What is the nurse's most appropriate action? A) Instruct the patient to call 911. B) Inform the patient that this is an expected response to vaccination. C) Encourage the patient to take NSAIDs until symptoms are relieved. D) Ensure that the adverse reaction is reported.

Ans:D Feedback: Nurses should ask adult vaccine recipients to provide information about any problems encountered after vaccination. As mandated by law, a Vaccine Adverse Event Reporting System (VAERS) form must be completed with the following information: type of vaccine received, timing of vaccination, onset of the adverse event, current illnesses or medication, history of adverse events after vaccination, and demographic information about the recipient. NSAIDs are not necessarily required and no evidence of distress warrants a call to 911. This is not an expected response to vaccination.

12. The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patient's plan of care? A) Firmly redirect the patient's head when feeding. B) Administer phenothiazines after each meal as ordered. C) Encourage the patient to keep his or her feeding area clean. D) Apply deep, gentle pressure around the patient's mouth to aid swallowing.

Ans:D Feedback: Nursing interventions for a patient who has inadequate nutritional intake should include the following: Apply deep gentle pressure around the patient's mouth to assist with swallowing, and administer phenothiazines prior to the patient's meal as ordered. The nurse should disregard the mess of the feeding area and treat the person with dignity. Stiffness and turning away by the patient during feeding are uncontrollable choreiform movements and should not be interrupted.

33. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider? A) The patient will be unable to use a wheelchair. B) The patient will be unable to swallow food. C) The patient will be continent of urine, but incontinent of bowel. D) The patient will require full assistance for all aspects of elimination.

Ans:D Feedback: Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but is able to swallow. The patient will be capable of using an electric wheelchair.

19. During the examination of an unconscious patient, the nurse observes that the patient's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.

Ans:D Feedback: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

1. A male patient comes to the clinic and is diagnosed with gonorrhea. Which symptom most likely prompted him to seek medical attention? A) Rashes on the palms of the hands and soles of the feet B) Cauliflower-like warts on the penis C) Painful, red papules on the shaft of the penis D) Foul-smelling discharge from the penis

Ans:D Feedback: Signs and symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are a sign of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.

33. A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing? A) Reorganization phase B) Denial phase C) Heightened anxiety phase D) Acute disorganization phase

Ans:D Feedback: The acute disorganization phase may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered. These varied responses to the assault are not associated with a denial, heightened anxiety, or reorganization phase.

18. What should be included in the patient's care plan when establishing an exercise program for a patient affected by a stroke? A) Schedule passive range of motion every other day. B) Keep activity limited, as the patient may be over stimulated. C) Have the patient perform active range-of-motion (ROM) exercises once a day. D) Exercise the affected extremities passively four or five times a day.

Ans:D Feedback: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day.

32. A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patient's medication regimen? A) The patient is in a honeymoon period when adverse effects of levodopa- carbidopa are not yet evident. B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. C) The patient's temporary improvement in status is likely unrelated to levodopa- carbidopa. D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

Ans:D Feedback: The beneficial effects of levodopa therapy are most pronounced in the first year or two of treatment. Benefits begin to wane and adverse effects become more severe over time. However, a honeymoon period of treatment is not known.

36. A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient? A) Older adults are often vague historians. B) The elderly have fewer peripheral nerves than younger adults. C) Many older adults are hesitant to admit that their body is changing. D) Many symptoms can be the result of normal aging process.

Ans:D Feedback: The diagnosis of peripheral neuropathy in the geriatric population is challenging because many symptoms, such as decreased reflexes, can be associated with the normal aging process. In this scenario, the patient has come to the clinic seeking help for his problem; this does not indicate a desire on the part of the patient to withhold information from the health care giver. The normal aging process does not include a diminishing number of peripheral nerves.

33. An older adult patient has been diagnosed with Legionella infection. When planning this patient's care, the nurse should prioritize which of the following nursing actions? A) Monitoring for evidence of skin breakdown B) Emotional support and promotion of coping C) Assessment for signs of internal hemorrhage D) Vigilant monitoring of respiratory status

Ans:D Feedback: The lungs are the principal organs of Legionella infection. The patient develops increasing pulmonary symptoms, including productive cough, dyspnea, and chest pain. Consequently, respiratory support is vital. Hemorrhage and skin breakdown are not central manifestations of the disease. Preservation of the patient's airway is a priority over emotional support, even though this aspect of care is important.

40. A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what? A) Guillain-BarrÈ syndrome B) Myasthenia gravis C) Trigeminal neuralgia D) Peripheral nerve disorder

Ans:D Feedback: The major symptoms of peripheral nerve disorders are loss of sensation, muscle atrophy, weakness, diminished reflexes, pain, and paresthesia (numbness, tingling) of the extremities. Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of pain in the area innervated by any of the three branches, but most commonly the second and third branches of the trigeminal nerve. Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Guillain-BarrÈ syndrome is an autoimmune attack on the peripheral nerve myelin.

7. An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents

Ans:D Feedback: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%).

15. A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first? A) Perform oral suctioning. B) Page the physician. C) Insert a tongue depressor into the patient's mouth. D) Turn the patient on his side.

Ans:D Feedback: The nurse's first response should be to place the patient on his side to prevent him from aspirating emesis. Inserting something into the seizing patient's mouth is no longer part of a seizure protocol. Obtaining supplies to suction the patient would be a delegated task. Paging or calling the physician would only be necessary if this is the patient's first seizure.

6. A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? A) Range-of-motion exercises to prevent contractures B) Encouraging independence with ADLs to promote recovery C) Early initiation of physical therapy D) Absolute bed rest in a quiet, nonstimulating environment

Ans:D Feedback: The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raise BP.

24. After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? A) Administer a bolus of normal saline as ordered. B) Prepare the patient for thrombolytic therapy as ordered. C) Facilitate testing for hypothalamic dysfunction. D) Prepare to administer 3% NaCl by IV as ordered.

Ans:D Feedback: The patient may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or thrombolytic therapy.

3. A patient has been witness to a disaster involving a large number of injuries. The patient appears upset, but states that he feels capable of dealing with his emotions. What is the nurse's most appropriate intervention? A) Educate the patient about the potential harm in denying his emotions. B) Refer the patient to social work or spiritual care. C) Encourage the patient to take a leave of absence from his job to facilitate emotional healing. D) Encourage the patient to return to normal social roles when appropriate.

Ans:D Feedback: The patient should be encouraged to return to normal social roles when appropriate if he is confident and genuine about his ability to cope. The nurse should use active listening to the patient's concerns and emotions to enable the patient to process the situation. The patient is not necessarily being unrealistic or dishonest. As a result, social work or spiritual care may not be needed. Time away from work may not be required.

36. A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patient's plan of care? A) Adult failure to thrive B) Post-trauma syndrome C) Hyperthermia D) Disturbed sensory perception

Ans:D Feedback: The patient who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.

12. An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention? A) Prompt administration of an antidote B) Gastric lavage C) Administration of activated charcoal D) Helping the patient drink large amounts of water

Ans:D Feedback: The patient who has ingested a corrosive poison, such as bleach, is given water or milk to drink for dilution. Gastric lavage is not used to treat ingestion of corrosives and activated charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.

19. A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties? A) Keep the lighting in the patient's room low. B) Place the patient's clock on the affected side. C) Approach the patient on the side where vision is impaired. D) Place the patient's extremities where she can see them.

Ans:D Feedback: The patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the patient constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the patient can see them. Patients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The patient can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

16. A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? A) Cognitive declines B) Personality changes C) Contractures D) Difficulty in coordination

Ans:D Feedback: The primary symptoms of MS most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures usually occur later in the disease.

5. A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A) Integumentary assessment B) Assessment for signs of hemorrhage C) Neurologic assessment D) Assessment of respiratory status

Ans:D Feedback: The second stage of anthrax infection by inhalation includes severe respiratory distress, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first stage includes flu-like symptoms. The second stage of infection by inhalation does not include headache, vomiting, or syncope.

29. The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment is appropriate. What does level D PPE include? A) A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots B) A self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor- tight, chemical-resistant suit with chemical-resistant gloves and boots. C) The SCBA and a chemical-resistant suit, but the suit is not vapor tight D) The nurse's typical work uniform

Ans:D Feedback: The typical work uniform is appropriate for Level D protection

7. A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care? A) The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B) Elevation of the arm and hand can lead to further complications associated with edema. C) Passively exercising the affected extremity is avoided in order to minimize pain. D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

Ans:D Feedback: To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The patient is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the patient is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.

13. A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? A) Restrain the patient as ordered. B) Administer opioids PRN as ordered. C) Arrange for friends and family members to sit with the patient. D) Pad the side rails of the patient's bed.

Ans:D Feedback: To protect the patient from self-injury, the nurse uses padded side rails. The nurse should avoid restraints, because straining against them can increase ICP or cause other injury. Narcotics used to control restless patients should be avoided because these medications can depress respiration, constrict the pupils, and alter the patient's responsiveness. Visitors should be limited if the patient is agitated.

37. The nurse who provides care at a wilderness camp is teaching staff members about measures that reduce campers' and workers' risks of developing Giardia infections. The nurse should emphasize which of the following practices? A) Making sure not to drink water that has not been purified B) Avoiding the consumption of wild berries C) Removing ticks safely and promptly D) Using mosquito repellant consistently

Ans:D Feedback: Transmission of the protozoan Giardia lamblia occurs when food or drink is contaminated with viable cysts of the organism. People often become infected while traveling to endemic areas or by drinking contaminated water from mountain streams within the United States. Berries, mosquitoes, and ticks are not sources of this microorganism.

30. The nurse is preparing to admit patients who have been the victim of a blast injury. The nurse should expect to treat a large number of patients who have experienced what type of injury? A) Chemical burns B) Spinal cord injury C) Meningeal tears D) Tympanic membrane rupture

Ans:D Feedback: Tympanic membrane (TM) rupture is the most frequent injury after subjection to a pressure wave resulting from a blast injury because the TM is the body's most sensitive organ to pressure. In most cases, other injuries such as meningeal tears, spinal cord injury, and chemical injuries are likely to be less common.

26. A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patient's bladder is distended. What is the nurse's most appropriate action? A) Withhold fluids from the patient. B) Perform intermittent urinary catheterization. C) Insert a narrow-gauge indwelling urinary catheter. D) Await orders following the urologist's assessment.

Ans:D Feedback: Urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required. The nurse would withhold fluids, but urologic assessment is the priority.

16. A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A) Ask the social worker to come and sign the consent. B) Contact the police to obtain the patient's identity. C) Obtain a court order to treat the patient. D) Clearly document LOC and health status on the patient's chart.

Ans:D Feedback: When patients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. A social worker is not asked to sign the consent. Finding the patient's identity is not a priority. Obtaining a court order would take too long.

36. The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient? A) Prednisone B) Dexamethasone C) Cafergot D) Phenytoin

Ans:D Feedback: Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.

16. A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine

Ans:D Feedback: Atropine is administered when a patient is exposed to a nerve agent. Exposure to blood agents, such as cyanide, requires treatment with amyl nitrate, sodium nitrite, and sodium thiosulfate. Dimercaprol is administered IV for systemic toxicity and topically for skin lesions when exposed to vesicants. Erythromycin is an antibiotic, which is ineffective against nerve agents.

32. A patient diagnosed with Bell's palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A) Blowing up balloons B) Deliberately frowning C) Smiling repeatedly D) Whistling

Ans:D Feedback: Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Blowing up balloons, frowning, and smiling are not considered facial exercises.

21. A patient has presented at the ED with copious diarrhea and accompanying signs of dehydration. During the patient's health history, the nurse learns that the patient recently ate oysters from the Gulf of Mexico. The nurse should recognize the need to have the patient's stool cultured for microorganisms associated with what disease? A) Ebola B) West Nile virus C) Legionnaire's disease D) Cholera

Ans:D Feedback: In the U.S., cholera should be suspected in patients who have watery diarrhea after eating shellfish harvested from the Gulf of Mexico.

17. A patient was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The patient's skin will eventually show what manifestation? A) Erythema B) Ecchymosis C) Desquamation D) Necrosis

Ans:D Feedback: Necrosis of the skin will become evident within a few days to months at doses of more than 5,000 rads. With 600 to 1,000 rads, erythema will occur; it can disappear within hours and then reappear. At greater than 1,000 rads, desquamation (radiation dermatitis) of the skin will occur. Ecchymosis does not occur.

6. When assessing patients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A) Nerve agent B) Blood agent C) Pulmonary agent D) Vesicant

Ans:D Feedback: Sulfur mustard is a vesicant chemical that causes blistering and results in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death. Nerve agents include sarin, soman, tabun, VX, and organophosphates (pesticides). Hydrogen cyanide is a blood agent that has a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin. Chlorine is a pulmonary agent, which destroys the pulmonary membrane that separates the alveolus from the capillary bed.

13. A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient? A) Cerebral angiography B) ABG analysis C) CT D) EEG

Ans:D Feedback: The EEG reveals a characteristic pattern over the duration of CJD. A CT scan may be used to rule out disorders that may mimic the symptoms of CJD. ABGs would not be necessary until the later stages of CJD; they would not be utilized as a diagnostic test. Cerebral angiography is not used to diagnose CJD.

7. A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of motor function and sensation. The physician suspects the patient has a spinal cord tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose spinal cord compression from a tumor, the nurse will most likely prepare the patient for what test? A) Anterior-posterior x-ray B) Ultrasound C) Lumbar puncture D) MRI

Ans:D Feedback: The MRI scan is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.

2. A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second- and third-degree burns, but he is conscious. How would this person be triaged? A) Green B) Yellow C) Red D) Black

Ans:D Feedback: The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The patient would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery.