Med Surg/Neuro Test bank
23. The nurse caring for a patient in ICU diagnosed with Guillain-Barre' syndrome should prioritize monitoring for what potential complication? A) Impaired skin integrity B) Cognitive deficits C) Hemorrhage
D) Autonomic dysfunction
A male patient with a metastatic brain tumor is having a 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.
D
. A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patient's health problems? A) Cerebellar dysfunction B) A lesion in the pons C) Dysfunction of the medulla D) A hemorrhage in the midbrain
A
. The nurse is planning the care of a patient who has been 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
A
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)-producing adenoma
A
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
A
A nurse is conducting an assessment of a client who is suspected of having a brain tumor. Assessment reveals reports of a headache, for which the nurse gathers additional information. The nurse determines that these reports support the suspicion of a brain tumor when the client reports that the headache occurs: A) early in the morning. B) around lunchtime. C) in the middle of the afternoon. D) at bedtime.
A
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
A
10. The nurse should recognize the greatest risk for the development of blindness in which of the following patients? A) A 58-year-old Caucasian woman with macular degeneration B) A 28-year-old Caucasian man with astigmatism C) A 58-year-old African American woman with hyperopia D) A 28-year-old African American man with myopia
A) A 58-year-old Caucasian woman with macular degeneration
A female client is admitted to the medical unit for evaluation of cerebral metastasis from a primary site. When reviewing the client's history, the nurse would most likely find which site as being the primary site? A) lung B) prostate C) renal D) uterus
A: Lung
. 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
B
A patient is having a "fight or flight response" after receiving news about his prognosis. What affect will this have on the patient's sympathetic nervous system? A) Constriction of blood vessels in the heart muscle B) Constriction of bronchioles C) Increase in the secretion of sweat D) Constriction of pupils
C
A patient who has been experiencing numerous episodes of 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.
C
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
C, D, E
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
D
6. A patient, diagnosed with cancer of the lung, has just been tested for 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
D
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
A) Cardiac and respiratory status
A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond? A) "Overuse of these drops could soften your cornea and damage your eye." B) "You could lose the peripheral vision in your eye if you used these drops too much." C) "I'm sorry, this medication is considered a controlled substance and patients cannot take it home." D) "I know these drops will make your eye feel better, but I can't let you take them home."
A) "Overuse of these drops could soften your cornea and damage your eye.
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."
A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."
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
A) Absence of reflexes along with flaccid extremities
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
A) Applying a protective eye shield at night
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 exercise
A) Change the patient's position frequently.
A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A) Constricted pupils B) Dilated bronchioles C) Decreased peristaltic movement D) Relaxed muscular walls of the urinary bladder
A) Constricted pupils
17. A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply. A) Diabetic retinopathy B) Trauma C) Macular degeneration D) Cytomegalovirus E) Glaucoma
A) Diabetic retinopathy, C) Macular degeneration, E) Glaucoma
7. A patient's ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patient's discharge education? A) Disturbed body image B) Chronic pain C) Ineffective protection D) Unilateral neglect
A) Disturbed body image
The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the patient? A) Ensure adequate lighting in the patient's room. B) Provide a dimly lit room to aid vision by limiting contrast. C) Carefully point out color differences for the patient. D) Carefully point out fine details for the patient.
A) Ensure adequate lighting in the patient's room.
12. 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
A) Evidence of hemorrhagic stroke
20. A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? A) Explain the location of items using clock cues. B) Explain that each of the items on the tray is clearly separated C) Describe the location of items from the bottom to top. D) Ask the patient to describe the location of items before confirming their location.
A) Explain the location of items using clock cues.
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
A) Facial droop
12. The nurse is admitting a 55-year-old patient diagnosed with a left eye retinal detachment. While assessing this patient, what characteristic symptom would the nurse expect to find? A) Flashing lights in the visual field B) Sudden eye pain C) Loss of color vision D) Colored halos around lights
A) Flashing lights in the visual field
24. 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
A) Frustration around changes in function and communication
. A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing? A) Function of the hypoglossal nerve B) Function of the vagus nerve C) Function of the spinal nerve D) Function of the trochlear nerve
A) Function of the hypoglossal nerve
11. A 6-year-old is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? A) Handwashing can prevent the spread of the disease B) The importance of compliance with antibiotic therapy C) Signs and symptoms of complications, such as meningitis and septicemia D) The likely need for surgery to prevent scarring of the tissue
A) Handwashing can prevent the spread of the disease
A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A) Hot or cold packs B) Analgesics C) Anti-inflammatory medications D) Whirlpool baths
A) Hot or cold packs
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
A) Increased muscle strength
8. A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera
A) Instill the medication in the conjunctival sac.
22. A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A) Lumbar puncture B) MRI C) Cerebral angiography D) EEG
A) Lumbar puncture
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
A) MRI
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.
A) MS is a progressive demyelinating disease of the nervous system
12. The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A) Maintain the irrigation fluid at a warm temperature. B) Instill short, sharp bursts of fluid into the ear canal. C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D) Have the patient stand during the procedure.
A) Maintain the irrigation fluid at a warm temperature.
16. A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient? A) Patient is likely unable to hear the nurse during test. B) A person adept in sign language must be present during test C) Lip reading will be the method of communication that is necessary. D) The nurse should interact with the patient like any other patient
A) Patient is likely unable to hear the nurse during test.
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.
A) Place the patient in a side-lying position.
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.
A) Provide a board of commonly used needs and phrases.
6 A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient? A) Sit or stand in front of the patient when speaking. B) Use exaggerated lip and mouth movements when test C) Stand in front of a light or window when speaking. D) Say the patient's name loudly before starting to talk.
A) Sit or stand in front of the patient when speaking
4. The nurse is providing discharge education for a patient with a new diagnosis of Ménière's disease. What food should the patient be instructed to limit or avoid? A) Sweet pickles B) Frozen yogurt C) Shellfish D) Red meat
A) Sweet pickles
7. A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient? A) The hearing loss will likely resolve with time after the drug is discontinued. B) The patient's hearing loss and tinnitus are irreversible at this point. C) The patient's tinnitus is likely multifactorial, and not directly related to aspirin use. D) The patient's tinnitus will abate as tolerance to aspirin developes
A) The hearing loss will likely resolve with time after the drug is discontinued.
14. 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 the visual perception is intact to promote recovery
A) The patient should be approached on the side where visual perception is intact.
25. A patient with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the patient? A) The patient should discuss this new remedy with her ophthalmologist promptly. B) The patient should monitor her IOP closely for the next several weeks. C) The patient should do further research on the herbal D) The patient should report any adverse effects to her pharmacist.
A) The patient should discuss this new remedy with her ophthalmologist promptly.
2. The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should understand that this patient's health history includes which of the following? Select all that apply. A) The patient was diagnosed with sensorineural hearing loss. B) The patient's hearing did not improve appreciably with the use of hearing aids C) The patient has deficits in peripheral nervous function. of hearing aids. D) The patient's hearing deficit is likely accompanied by a cognitive deficit. E) The patient is unable to lip-read.
A) The patient was diagnosed with sensorineural hearing loss. B) The patient's hearing did not improve appreciably with the use of hearing aids
16. An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding? A) The patient's hearing is likely normal. B) The patient is at risk for tinnitus. C) The patient likely has otosclerosis. D) The patient likely has sensorineural hearing loss.
A) The patient's hearing is likely normal
11. The nurse is discussing the results of a patient's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss? A) The sound is heard better in the ear in which hearing is better. B) The sound is heard equally in both ears. C) The sound is heard better in the ear in which hearing is poorer. D) The sound is heard longer in the ear in which hearing is better.
A) The sound is heard better in the ear in which hearing is better.
8. A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiences occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patient's complaint? A) These pains are an expected finding during the first few weeks of recovery. B) The patient's complaints are suggestive of a postoperative infection. C) The patient may have experienced a spontaneous rupture of the tympanic membrane. D) The patient's surgery may have been unsuccessful.
A) These pains are an expected finding during the first few weeks of recovery.
A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding? A) This is a normal aging process of the eye. B) Glasses will minimize this phenomenon. C) The patient may be exhibiting signs of glaucoma. D) This may be a result of weakened ciliary muscles.
A) This is a normal aging process of the eye.
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
A) Urinary retention can have serious consequences in patients with SCIs.
17. 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 that apply. A) Young age B) Frequent travel C) African American race D) Male gender E) Alcohol or drug use
A) Young age , D) Male gender, E) Alcohol or drug use
23. A nurse suspects that an older adult client may be experiencing hearing loss. Which finding would support the nurse's suspicion? Select all that apply. A) dropping of word endings B) disinterest in conversations C) social withdrawal D) domination of conversations E) quick decision making
A) dropping of word endings B) disinterest in conversations C) social withdrawal D) domination of conversations
25. A client develops a perforated eardrum. When teaching the client about this condition, the nurse would identify which condition as a most likely cause? A) infection B) otosclerosis C) Meniere's disease D) cholesteatoma
A) infection
17. A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse notes that the client has a history of dry eyes. This information is indicating a problem with which structure? A) lacrimal apparatus B) sclera C) cornea D) pupil
A) lacrimal apparatus
19. A nurse is interviewing a middle-aged client at the clinic. During the interview, the client states, "I've noticed that I keep having to move the newspaper farther away to read it. Soon my arms will be too short!" The nurse interprets this finding as indicative of which age-related change? A) loss of accommodation B) shrinkage of the vitreous body C) meibomian gland dysfunction (MBG) D) loss of skin elasticity
A) loss of accommodation
18. A nurse is conducting an examination of a client's inner eye. When viewing the retina, which structure would the nurse identify as a retinal landmark? Select all that apply. A) optic disk B) macula C) posterior chamber D) vitreous humor E) ciliary bod
A) optic disk B) macula
24. A client is scheduled for audiometry to evaluate hearing. When teaching the client about this test, which characteristic would the nurse include as being evaluated? Select all that apply. A) pitch B) frequency C) intensity D) compliance E) postural control capabilities
A) pitch B) frequency C) intensity
20. While inspecting the external eye of a client, the nurse notices that the client's right eyelid droops. Which term would the nurse use to document this finding? A) ptosis B) entropion C) ectropion D) presbyopia
A) ptosis
23. A older adult client comes to the clinic for an evaluation and says, "It just doesn't seem like I hear as well as I used to hear." As part of the assessment, the nurse evaluates the client's gross auditory acuity. Which test would the nurse most likely conduct? A) whisper test B) Weber test C) Rinne test D) audiometry
A) whisper test
A client is diagnosed with a brain tumor of the parietal lobe. Based on the tumor's location, which assessment finding would the nurse most likely note? Select all that apply. A) difficulty with reading B) problems with mathematical calculations C) impaired reasoning D) memory changes E) changing moods
A, B
23. A client is exhibiting late signs of increased intracranial pressure. Which finding would the nurse most likely assess? Select all that apply. A) hypertension B) bradycardia C) respiratory depression D) headache E) papilledema
A, B, C
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
A, B, D
21. A nurse is conducting a presentation about brain cancer for a community group. During the presentation, one of the group members asks, "What causes brain tumors?" Which response by the nurse would be most appropriate? A) "There is scientific evidence that cigarette smoking the list of causes." B) "The cause of most brain tumors is still really not known." C) "It's a known fact that using cell phones increases your risk for a tumor." D) "Exposure to residential power lines is a definite cause of brain tumors."
B
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
B
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 tumors and seizure activity. D) Ensure that the patient is housed in a private room
B
A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifically mean. What's the correct response by the nurse? A) "A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away." B) "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." C) "A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away D) "A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away."
B) "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away."
16. A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patient's medication regimen. The patient states that she is eager to "beat this disease" and looks forward to the time that she will no longer require medication. How should the nurse best respond? A) "You have a great attitude. This will likely shorten the amount of time that you need medications." B) "In fact, glaucoma usually requires lifelong treatment with medications." C) "Most people are treated until their intraocular pressure is below 50 mm Hg." D) "You can likely expect a minimum of 6 months of treatment."
B) "In fact, glaucoma usually requires lifelong treatment with medications."
18. 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."
B) "Stop smoking as soon as possible."
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
B) Acyclovir (Zovirax)
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) Tonic-clonic seizures D) Shortness of breath
B) Alteration in level of consciousness (LOC)
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
B) Apnea, C) Coma, D) Absence of brain stem reflexes
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 DVT from occurring? A) Placing the patient on a fluid restriction as ordered to prevent a DVT B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises
B) Applying thigh-high elastic stockings
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 patients condition
B) As soon as the initial assessment is made
18. The nurse is providing discharge education to an adult patient that will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively? A) Assess the patient for any previous inability to self-manage medications. B) Ask the patient to demonstrate the instillation of of her medications. C) Determine whether the patient can accurately describe the appropriate method of administering her medications . D) Assess the patient's functional status.
B) Ask the patient to demonstrate the instillation of of her medications.
2. During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately? A) Ask the social worker to investigate alternative housing arrangements. B) Ask the social worker to investigate community support agencies. C) Encourage the patient to explore surgical correctional problem. D) Arrange for referral to a rehabilitation facility for vision training.
B) Ask the social worker to investigate community support agencies.
23. A patient has become legally blind as a result of macular degeneration. When attempting to meet this patient's psychosocial needs, what nursing action is most appropriate? A) Encourage the patient to focus on use of other senseasb.irb.com/test B) Assess and promote the patient's coping skills during interactions with the patient. C) Emphasize that lifestyle will be unchanged once adaptation to vision loss has occurred. D) Promote the patient's hope for recovery.
B) Assess and promote the patient's coping skills during interactions with the patient.
24. The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patient's level of consciousness (LOC)? A) Assess the patient's vital signs and correlate these with the patient's baselines. B) Assess the patient's eye opening and response to stimuli. C) Document that the patient currently lacks a level of a consciousness D) Facilitate diagnostic testing in an effort to obtain objective data.
B) Assess the patient's eye opening and response to stimuli.
17. The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action? A) Placing the patient in a prone position B) Assisting the patient into a sitting position C) Instilling 15 mL of warm normal saline into one of the patient's ears D) Assessing the patient's baseline hearing by performing the whisper test
B) Assisting the patient into a sitting position
3. The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patient's immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years
B) At least once every 2 years
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
B) Atrial Fibrillation
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
B) Bradycardia and hypertension
22. A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A) Risk factors for postoperative cytomegalovirus (CMV) B) Compensating for vision loss for the next several weeks C) Non-pharmacologic pain management strategies D) Signs and symptoms of increased intraocular pressure
B) Compensating for vision loss for the next several weeks
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
B) Confusion
The nurse is planning the care of a patient with Parkinson's Disease The nurse should be aware that treatment will focus on what pathophysiological phenomenon? A) Premature degradation of acetylcholine B) Decreased availability of dopamine C) Insufficient synthesis of epinephrine D) Delayed reuptake of serotonin
B) Decreased availability of dopamine
24. 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
B) Decreased muscle spasms in the lower extremities
The nurse's assessment of a patient with significant visual loss reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patient's visual acuity? A) Assess the patient's vision using a Snellen chart. B) Determine whether the patient is able to see the nurse's hand motion. C) Perform a detailed examination of the patient's external eye structures. D) Palpate the patient's periocular regions.
B) Determine whether the patient is able to see the nurse's hand motion.
A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? A) Magnetic resonance imaging (MRI) B) Electroencephalography (EEG) C) Electromyelography (EMG) D) Computed tomography (CT)
B) Electroencephalography (EEG)
13. 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
B) Elevation of the head of the bed
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 characteristics manifestations of this disease? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia
B) Facial paralysis
17. 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.
B) Have a colleague follow the patient closely with a wheelchair.
10. A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound levaebli?rb.com/test A) Hearing will not be affected by a decibel level in this range. B) Hearing loss may occur with a decibel level in this range. C) Sounds in this decibel level are not perceived to be ahbairrbs.chomto/tetshte ear. D) Ear plugs will have no effect on these decibel levels.
B) Hearing loss may occur with a decibel level in this range.
The nurse has admitted a new patient to the unit. One of the patient's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? A) Thin, watery saliva B) Increased heart rate C) Decreased BP D) Constricted bronchioles
B) Increased heart rate
14. The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement? A) Teach the patient about the risks of ototoxic medications. B) Instruct the patient to protect the ear from water for several weeks. C) Teach the patient to remove cerumen safely at least once a week D) Instruct the patient to protect the ear from temperature extremes until healing is complete.
B) Instruct the patient to protect the ear from water for several weeks.
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)
B) Intravenous diazepam (Valium)
9. The nurse is planning the care of a patient who is adapting o the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time? A) Regulating the tone and volume B) Learning to cope with amplification of background noise C) Constant irritation of the external auditory canal D) Challenges in keeping the hearing aid clean while minimizing exposure to moisture
B) Learning to cope with amplification of background noise
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
B) Level of consciousness
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.
B) Maintain and improve cerebral tissue perfusion.
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
B) Neck flexion produces flexion of knees and hips
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.
B) Notify the neurosurgeon of the occurrence.
1. A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patient's left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? A) Temporal B) Occipital C) Parietal D) Frontal
B) Occipital
he nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit? A) Temporal lobe B) Parietal-occipital area C) Inferior posterior frontal areas D) Posterior frontal area
B) Parietal-occipital area
25. 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.
B) Position the patient upright during feeding.
. 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
B) Positive Kernig's sign
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.
B) Prepare for interventions to increase the patient's BP.
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes. Of what phenomenon should the nurse be aware? A) Hyperactive deep tendon reflexes B) Reduction in cerebral blood flow C) Increased cerebral metabolism D) Hypersensitivity to painful stimuli
B) Reduction in cerebral blood flow
.A patient scheduled for magnetic resonance imaging (MRI) at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions? A) Withholding stimulants 24 to 48 hours prior to exam B) Removing all metal-containing objects C) Instructing the patient to void prior to the MRI D) Initiating an IV line for administration of contrast
B) Removing all metal-containing objects
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
B) Resting in an air-conditioned room whenever possible
. While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patient's health history is most likely to be linked to the patient's hearing deficit? A) Recent completion of radiation therapy for treatment of cancer B) Routine use of quinine for management of leg cramps C) Allergy to hair coloring and hair spray D) Previous perforation of the eardrum
B) Routine use of quinine for management of leg cramps
5. A client has undergone diagnostic testing and has been diagnosed with otosclerosis. What ear structure is primarily affected by this diagnosisa?birb.com/test A) Malleus B) Stapes C) Incus D) Tympanic membrane
B) Stapes
5. A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this patient? A) Generously flush the affected eye with a dilute antibiotic solution. B) Surgical intervention C) Apply a patch to the affected eye. D) Apply direct pressure to the affected eye.
B) Surgical intervention
21. A hospitalized patient with impaired vision must get a piacbtiurbr.ceoi mn/tehsits or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patient's room? A) That a commode is always available at the bedside B) That all furniture remains in the same position C) That visitors do not leave items on the bedside table D) That the patient's slippers stay under the bed
B) That all furniture remains in the same position
2. A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patient's preoperative teaching? A) The procedure is an effective, time-tested treatment for sensory hearing loss. B) The patient is likely to experience resolution of conductive hearing loss after the procedure. C) Several months of post-procedure rehabilitation will be needed to maximize benefits. D) The procedure is experimental, but early indications therapeutic benefits.
B) The patient is likely to experience resolution of conductive hearing loss after the procedure.
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
B) Watchful waiting and close monitoring
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
B) White male, age 60, with history of uncontrolled hypertension
24. A client with hearing loss is scheduled to undergo aural testing. When describing this therapy, the nurse would include which information as the primary purpose? A) increase hearing ability B) maximize ability to communicate C) facilitate use of a hearing aid D) limit extraneous noise
B) maximize ability to communicate
22. A nurse is preparing a presentation for a group of elementary school parents about ways to promote the health of the ears and hearing in their children. When describing the structure and function of the ears, which structure would the nurse most likely include as part of the middle ear? Select all that apply. A) pinna B) tympanic membrane C) oval window D) cochlea E) organ of Corti
B) tympanic membrane C) oval window
22. A client diagnosed with benign paroxysmal positional vertigo is experiencing an acute attack. The client is prescribed a vestibular suppressant. Which would the nurse anticipate being used? A) scopolamine B)Meclizine C) dimenhydrinate D) promethazine
B)Meclizine
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
C
6. A 56-year-old patient has come to the clinic for a routine eye examination and informed bifocals will be prescribed. The patient asks the nurse what change in his eyes has caused a need for bifocals. How should the nurse respond? A) As you age, vision typically deteriorates to a point where many people require bifocals. B) "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry." C) "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." D) "The eye gets shorter, back to front, as we age and it changes how we see things."
C) "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation."
A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test? A) "No metal objects can enter the procedure room." B) "You need to fast for 8 hours prior to the test." C) "You will need to lie still throughout the procedure." D) "There will be a lot of noise during the test."
C) "You will need to lie still throughout the procedure."
22. The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. A) 635241 B) 352416 C) 236145 D) 162534
C) 236145
21. A client is prescribed intravenous antibiotic therapy that requires monitoring of peak and trough drug levels. The client receives the drug at 8:30 am. At which time would the nurse anticipate that the peak level be drawn? A) 8:15 am B) 8:45 am C) 9:00 am D) 9:30 am
C) 9:00 am
The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patient's diminished tactile sensation? A) Damage to cranial nerve VIII B) Adverse medication effects C) Age-related neurologic changes D) An undiagnosed cerebrovascular accident in early adulthood
C) Age-related neurologic changes
5. A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action? A) Reassure the patient that this is an age-related change in vision B) Arrange for the patient to have her visual acuity assessed. C) Arrange for the patient to be assessed for macular degeneration. D) Facilitate tonometry testing.
C) Arrange for the patient to be assessed for macular degeneration.
7. An older adult patient has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the patient for recent changes in visual acuity, the patient states that the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response? A) Ask if the patient has been using OTC vasoconstrictors. B) Instruct the patient to repeat the test at different times of the day when at home. C) Arrange for the patient to visit an ophthalmologist . D) Encourage the patient to adhere to prescribed drug regimen.
C) Arrange for the patient to visit an ophthalmologist .
19. The nurse is reviewing the medication administration 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
C) Aspirin 81 mg PO o.d.
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
C) Bleeding
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
C) Bruising over the mastoid
18. An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B) Cholesteatomas are usually the result of metastasis from a distant tumor site. C) Cholesteatomas are often the result of chronic otitis mediab.dcoiam./test D) Cholesteatomas, if left untreated, result in intractable neuropathic pain. E) Cholesteatomas usually must be removed surgically.
C) Cholesteatomas are often the result of chronic otitis media E) Cholesteatomas usually must be removed surgically.
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" two times before settling into a resting position. How would the nurse document this finding? A) Rigidity B) Flaccidity C) Clonus D) Ataxia
C) Clonus
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 dermatome
C) Close monitoring of fluid balance
A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patients 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
C) Dimming the lights and reducing stimulation
A patient is brought to the ED by her family after falling. 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
C) Emergency craniotomy
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
C) Every 2 hours
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
C) Generalized seizure
15. A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear? A) Yellowish-white B) Pink C) Gray D) Bluish-white
C) Gray
A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? A) Cerebellum B) Thalamus C) Hypothalamus D) Midbrain
C) Hypothalamus
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
C) In the morning, with frequent rest periods
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.
C) Increase the frequency of ROM exercises.
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 diagnosis 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
C) Ineffective breathing patterns related to weakness of the intercostal muscles
. 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 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 accident D) Performing ROM exercises once a day
C) Initiating (ROM) exercises as soon as possible after the accident
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.
C) Monitor the patient's BP before and during position changes
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
C) Monitoring neurologic status closely
13. The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements? A) Vertigo B) Tinnitus C) Nystagmus D) Astigmatism
C) Nystagmus
When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII? A) Palpate trapezius muscle while patient shrugs should against resistance. B) Administer the whisper or watch-tick test. C) Observe for facial movement symmetry, such as a smile. D) Note any hoarseness in the patient's voice
C) Observe for facial movement symmetry, such as a smile.
24. When administering a patient's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A) Ensure that the patient is well hydrated at all times. B) Encourage self-administration of eye drops. C) Occlude the puncta after applying the medication. D) Position the patient supine before administering eye drops.
C) Occlude the puncta after applying the medication.
A patient with Guillain-Barré 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.
C) Prepare to assist with intubation.
22. 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
C) Providing ventilatory assistance
3. Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient? A) Ask the patient to repeat what was said in order to evaluate understanding. B) Stand directly in front of the patient to facilitate lip .test C) Reduce environmental noise and distractions before communicating. D) Raise the voice to project sound at a higher frequency.
C) Reduce environmental noise and distractions before communicating.
10. The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patient's care? A) Risk for disturbed sensory perception B) Risk for unilateral neglect C) Risk for falls D) Risk for ineffective health maintenance
C) Risk for falls
15. A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patient's discharge education? A) Expected changes in facial nerve function B) The need for audiometry testing every 6 months following recovery C) Safe use of analgesics and antivertiginous agents D) Appropriate use of OTC ear drops
C) Safe use of analgesics and antivertiginous agents
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
C) Spinal shock
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.
C) Take antihypertensive medication as ordered.
14. The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patient's health education? A) The need to limit exposure to bright light B) The need to maintain a low Fowler's position when removing the prosthesis C) The need to perform thorough hand hygiene before handling the prosthesis D) The need to apply antiviral ointment to the prosthesis daily
C) The need to perform thorough hand hygiene before handling the prosthesis
19. A patient with low vision has called the clinic and asked the nurse for help with acquiring some low-vision aids. What else can the nurse offer to help this patient manage his low vision? A) The patient uses OTC NSAIDs. B) The patient has a history of stroke. C) The patient has diabetes. D) The patient has Asian ancestry.
C) The patient has diabetes.
. 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 loss 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 action
C) The patient will be encouraged to verbalize concerns related to the disease and its treatment.
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? A) To decrease cerebral edema B) To prevent seizure activity that is common in TIA's C) To remove atherosclerotic plaques blocking cerebral flow D) To determine the cause of the TIA
C) To remove atherosclerotic plaques blocking cerebral flow
A patient had a lumbar puncture performed at the outpatient center the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine? A) What are the patient's and family's expectations of the test B) Whether the patient's family had any questions about why the test was necessary C) Whether the patient has had any complications of the test D) Whether the patient understood accurately why the test was done
C) Whether the patient has had any complications of the test
14. A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? A) Audiometry B) Rinne test C) Whisper test D) Weber test
C) Whisper test
A client is diagnosed with an acoustic neuroma. When assessing the client, which manifestation would the nurse expect to find? Select all that apply. A) tinnitus B) vertigo C) staggering gait D) seizures E) headache
C, D, E
The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques? A) Have the patient identify familiar odors with the eyes closed B) Assess papillary reflex. C) Utilize the Snellen chart. D) Test for air and bone conduction (Rinne test).
D
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.
D
20. The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching? A) "Try to induce a sneeze every 4 hours to equalize pressure." B) "Be sure to exercise to reduce fatigue." C) "Avoid sleeping in a side-lying position." D) "Don't blow your nose for 2 to 3 weeks."
D) "Don't blow your nose for 2 to 3 weeks."
8. The public health nurse is addressing eye health and vision projection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? A) "I'm planning to avoid exposure to direct sunlight on my vacation." B) "I've never exercised regularly, but I'm going to start working out at the gym daily." C) "I'm planning to talk with my pharmacist to review my current medications." D) "I'm certainly going to keep a close eye on my blood pressure from now on."
D) "I'm certainly going to keep a close eye on my blood pressure from now on."
The nurse is admitting a patient to the unit who is diagnosed with lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis? A) "Patient exhibits increased muscle tone." B) "Patient demonstrates normal muscle structure with no evidence of atrophy." C) "Patient demonstrates hyperactive deep tendon reflexes." D) "Patient demonstrates an absence of deep tendon reflexes."
D) "Patient demonstrates an absence of deep tendon reflexes."
6. A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? A) Slight morning discharge from the eye B) Any appearance of redness of the eye C) A "scratchy" feeling in the eye D) A new floater in vision
D) A new floater in vision
8. An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family its essential that the patient have what installed in the home? A) Grab bars B) Nonslip mats C) Baseboard heaters D) A smoke detector
D) A smoke detector
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
D) Assist the family in setting appropriate short-term goals
13. Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A) Ensure that patients understand the differences between sensory hearing loss and conductive hearing loss. B) Educate patients about expected age-related changes in hearing perception. C) Educate patients about the risks associated with prolonged exposure to environmental noise. D) Be aware of patients' medication regimens and collaborate with other professionals accordingly.
D) Be aware of patients' medication regimens and collaborate with other professionals accordingly.
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. .
D) Call the physician immediately.
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A) The malleus can be visualized during otoscopic examination B) The tympanic membrane is pearly gray. C) Tenderness is reported by the patient when the mastoid area is palpated. D) Clear, watery fluid is draining from the patient's ear
D) Clear, watery fluid is draining from the patient's ear
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
D) Difficulty in coordination
23. 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
D) Disturbed sensory perception
15. 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
D) Exercise the affected extremities passively four or five times a day
9. A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine the patient states that her vision is blurred. Which nursing action is most appropriate? A) Holding the next dose and notifying the physician B) Treating the patient for an allergic reaction C) Suggesting that the patient put on her glasses D) Explaining that this is an expected adverse effect
D) Explaining that this is an expected adverse effect
19. On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis? A) Acoustic tumor B) Cholesteatoma C) Facial nerve neuroma D) Glomus tympanicum
D) Glomus tympanicum
The nurse is testing the neurological function of a patient's cerebellum and basal ganglia. What action will most accurately test these structures? A) Have the patient identify the location of a cotton swab on his or her skin with the eyes closed. B) Elicit the patient's response to a hypothetical problem. C) Ask the patient to close his or her eyes and discern between hot and cold stimuli. D) Guide the patient through the performance of rapid extraocular movements.
D) Guide the patient through the performance of rapid extraocular movements.
A nurse is caring for a patient diagnosed with Ménière's disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? A) Movement of the tongue B) Visual acuity C) Sense of smell D) Hearing and equilibrium
D) Hearing and equilibrium
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.
D) Instruct the patient on daily muscle stretching.
13. Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A) Arrange for the administration of prophylactic antibiotics to unaffected residents. B) Instill normal saline into the eyes of affected residents two to three times daily. C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing. D) Isolate affected residents from residents who have not been exposed to conjunctivitis.
D) Isolate affected residents from residents who have not been exposed to conjunctivitis.
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.
D) Loosen the patient's restrictive clothing.
ED nurse has just received a call from EMS that a 17-yearold 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
D) Motor vehicle accidents
16. 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
D) Place the patient's extremities where she can see them
11. A patient with a sudden onset of hearing loss tells the nurse that he would like to begin using hearing aids. The nurse understands that the health professional dispensing hearing aids would have what responsibility? A) Test the patient's hearing promptly. B) Perform an otoscopy. C) Measure the width of the patient's ear canal. D) Refer the patient to his primary care physician.
D) Refer the patient to his primary care physician.
20. 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 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.
D) Report this to the physician as a possible sign of clinical deterioration.
1. The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient? A) Provide instructions in simple, clear terms. B) Introduce herself in a firm, loud voice at the doorway. C) Lightly touch the patient's arm and then introduce herself. D) State her name and role immediately after entering the patient's room.
D) State her name and role immediately after entering the patient's room.
4. A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patient's care? A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B) Eyeglasses or magnifying lenses C) Corticosteroid eye drops D) Surgical intervention
D) Surgical intervention
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.
D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
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
D) The patient's activities immediately prior to the seizure
21. A nurse is assisting the ophthalmologist who is performing direct ophthalmoscopy. When conducting this examination, which structure would the nurse expect to be examined last? A) red reflex B) vasculature C) optic disc D) macula
D) macula
