Med Surg Exam 3 Practice Questions Part 5

106. The son of a client diagnosed with ALS asks the nurse, "Is there any chance that I could get this disease?" Which statement by the nurse would be most appropriate? "It must be scary to think you might get this disease." "No, this disease is not genetic or contagious." "ALS does have a genetic factor and runs in families." "If you are exposed to the same virus, you may get the disease."

"ALS does have a genetic factor and runs in families."

93. The wife of the client diagnosed with chronic alcoholism tells the nurse, "I have to call his work just about every Monday to let them know he is ill or he will lose his job." Which would be the nurse's best response? "I am sure that this must be hard for vou. Tell me about your concerns." "You are afraid he will lose his source of income." "Why would you call in for your husband? Can't he do this?" "Are you aware that when you do this, you are enabling him?"

"Are you aware that when you do this, you are enabling him?"

30. The client is diagnosed with an SCI and is scheduled for an MRI scan. Which question would be most appropriate for the nurse to ask before taking the client to the diagnostic test? "Do you have trouble hearing?" "Are you allergic to any type of dairy products?" "Have you eaten anything in the last8 hours?" "Are you uncomfortable in closed spaces?"

"Are you uncomfortable in closed spaces?"

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

"I am going to take a class in stress management."

43. The client is prescribed phenytoin for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 'I will brush my teeth after every meal." "I will check my phenytoin level daily." "My urine will turn orange while on phenytoin." "I won't have any seizures while on this medication."

"I will brush my teeth after every meal."

80. The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? "All of my spouse's emotions will slow down now just like his body movements." "My spouse may experience hallucinations until the medication starts working." "I will schedule appointments late in the morning after his morning bath." "It is fine if we don't follow a strict medication schedule on weekends."

"I will schedule appointments late in the morning after his morning bath."

61. The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? "There is bleeding into his brain, causing irritation of the meninges." "A virus has infected the brain and meninges, causing inflammation." "It is a bacterial infection of the tissues that cover the brain and spinal cord." "It is an inflammation of the brain parenchyma caused by a mosquito bite."

"It is a bacterial infection of the tissues that cover the brain and spinal cord."

95. The client diagnosed with substance abuse is being discharged from a drug and alcohol rehabilitation facility. Which information should the nurse teach the client? Select all that apply. "Do not go anyplace where you can be tempted to use again." "It is important that you attend a 12-step meeting regularly." "Now that you are clean, your family will be willing to see you again." "You should explain to all your coworkers what has happened." "Practice breathing and relaxation techniques to manage stress."

"It is important that you attend a 12-step meeting regularly." "Practice breathing and relaxation techniques to manage stress."

100. The client diagnosed with ALS asks the nurse, "I know this disease is going to kill me. What will happen to me in the end?" Which statement by the nurse would be most appropriate? "You are afraid of how you will die?" "Most people with ALS die of respiratory failure." "Don't talk like that. You have to stay positive." "ALS is not a killer. You can live a long life."

"Most people with ALS die of respiratory failure."

47. The nurse asks the male client diagnosed with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? "Some people have a warning that the seizure is about to start." "Auras occur when you are physically and psychologically exhausted." "You're concerned that you do not have auras before your seizures?" "Auras usually cause you to be sleepy after you have a seizure."

"Some people have a warning that the seizure is about to start."

124. The client newly diagnosed with Parkinson's disease asks the nurse, "Why can't I control these tremors?" Which is the nurse's best response? "You can control the tremors when you learn to concentrate and focus on the cause." "The tremors are caused by a lack of the chemical dopamine in the brain; medication may help." "You have too much acetylcholine in your brain, causing the tremors, but they will get better with time." "You are concerned about the tremors? If you want to talk, I would like to hear how you feel."

"The tremors are caused by a lack of the chemical dopamine in the brain; medication may help."

29. The home health nurse is caring for a 28-year-old client diagnosed with a T10 SCI saying, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? "This must be very hard for you. You're feeling worthless?" "You shouldn't feel worthless-_-you are still alive." "Why do you feel worthless? You still have the use of your arms." "If you attended a work rehab program, you wouldn't feel worthless.'

"This must be very hard for you. You're feeling worthless?"

51. The male client diagnosed with a brain tumor is scheduled for an MRI scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response? "MRIs are loud, but there will not be any invasive procedure done." "You're scared. Tell me about what is scaring you" "This is the last thing to be scared about-there will be worse." "I can call the MRI tech to come and talk to you about the scan."

"You're scared. Tell me about what is scaring you"

The client is to receive a 100-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump?

200 mL/hr

134. The client diagnosed with a brain abscess is experiencing a tonic-clonic seizure. Which interventions should the nurse implement?Rank in order of performance. Assess the client's mouth. Loosen restrictive clothing. Administer phenytoin IVP. Turn the client to the side. Protect the client's head from injury

4, 5, 2, 3, 1

8. The client has been diagnosed with a CVA (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife before discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Obtain a raised toilet seat for the client's bathroom.

3. Which client would the nurse identify as being most at risk for experiencing a CVA? A 65-year-old African American male. An 84-year-old Japanese female. A 57-year-old white male. A 25-year-old pregnant Hispanic female.

A 65-year-old African American male.

10. Which assessment data would indicate to the nurse that the client is at risk for a hemorrhagic stroke? Select all that apply. A blood glucose level of 480 mg/dL. A right-sided carotid bruit. A blood pressure (BP) of 220/120 mmHg. The presence of bronchogenic carcinoma. A lithium level of 0.8 mE/L.

A blood glucose level of 480 mg/dL. A blood pressure (BP) of 220/120 mmHg.

107. The client diagnosed with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding? A residual of 125 mL. The abdomen is soft. Three episodes of diarrhea. The potassium level is 3.4 mEq/L.

A residual of 125 mL

14. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with wound closure strips. Which clinical manifestations would warrant transferring the resident to the ED? A 4-cm area of bright red drainage on the dressing. A weak pulse, shallow respirations, and cool pale skin. Pupils that are equal, react to light, and accommodate. Reports of a headache that resolves with medication

A weak pulse, shallow respirations, and cool pale skin.

12. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for the repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? Administer a stool softener bid. Encourage the client to cough hourly. Monitor neurological status every shift. Maintain the dopamine drip to keep BP at160/90

Administer a stool softener bid.

44. The client is admitted to the intensive care unit(CU) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? Assess the client's neurological status every hour. Monitor the client's heart rhythm via telemetry. Administer an anticonvulsant medication by intravenous push. Prepare to administer a glucocorticosteroid orally.

Administer an anticonvulsant medication by intravenous push.

71. The client diagnosed with acute bacterial meningitis is admitted to the medical floor at noon. Which HCP's order would have the highest priority? Administer an intravenous antibiotic. Obtain the client's lunch tray. Provide a quiet, calm, and dark room. Weigh the client in hospital attire.

Administer an intravenous antibiotic.

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

Administer antibiotics.

118. Which collaborative intervention should the nurse implement when caring for the client diagnosed with West Nile virus? Complete neurovascular examinations every8 hours. Maintain accurate intake and output at the end of each shift. Assess the client's symptoms to determine if there is an improvement. Administer intravenous fluids while assessing for overload.

Administer intravenous fluids while assessing for overload.

27. The rehabilitation nurse caring for the client diagnosed with a lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? Keep oxygen via nasal cannula on at all times. Administer low-dose subcutaneous anticoagulants. Perform active lower extremity ROM exercises. Refer to a speech therapist for ventilator-assisted speech.

Administer low-dose subcutaneous anticoagulants.

101. The client diagnosed with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? Elevate the head of the bed 30 degrees. Administer oxygen via nasal cannula. Assess the client's lung sounds. Obtain a pulse oximeter reading.

Administer oxygen via nasal cannula.

20. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. Maintain the head of the bed at 60 degrees of elevation. Administer stool softeners daily. Ensure the pulse oximeter reading is higher than 93%. Perform deep nasal suction every 2 hours. Assess neurological status every 1 to 2 hours.

Administer stool softeners daily. Ensure the pulse oximeter reading is higher than 93%. Assess neurological status every 1 to 2 hours.

116. Which problem is the highest priority for the client diagnosed with West Nile virus? Alteration in body temperature. Altered tissue perfusion. Fluid volume excess. Altered skin integrity.

Altered tissue perfusion.

48. The nurse educator is presenting an in-service on seizures. Which diseases or conditions can cause seizures in older people? Select all that apply. Alzheimer's disease. Cervical spondylosis. Head injuries. CVA. Brain tumors.

Alzheimer's disease. Head injuries. CVA. Brain tumors.

18. The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? A subcutaneous anticoagulant. An intravenous osmotic diuretic. An oral anticonvulsant. An oral proton pump inhibitor.

An intravenous osmotic diuretic.

7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? An oral anticoagulant medication. A beta blocker medication. An antihyperuricemic medication. A thrombolytic medication.

An oral anticoagulant medication.

69. The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the HCP to order for the significant others in the home? The Haemophilus influenzae vaccine. Antimicrobial chemoprophylaxis. A 10-day dose pack of corticosteroids. A gamma globulin injection.

Antimicrobial chemoprophylaxis.

85. The friend of an 18-year-old male client brings the client to the ED. The client is unconscious, and his breathing is slow and shallow. Which action should the nurse implement first? Ask the friend what drugs the client has been taking. Initiate an IV infusion at a keep-open rate. Call for a ventilator to be brought to the ED. Apply oxygen at 100% via nasal cannula.

Apply oxygen at 100% via nasal cannula.

126. The 80-year-old male client on an Alzheimer's unit is agitated and asking the nurse to get his father to come and see him. Which is the nurse's best response? Tell the client his father is dead and cannot come to see him. Give the client the phone and have him attempt to call his father. Ask the client to talk about his father with the nurse. Call the family so they can tell the client why his father cannot come to see him.

Ask the client to talk about his father with the nurse.

31. The client diagnosed with a C6 SCI is admitted to the ED reporting a severe pounding headache and has a BP of 180/110. Which intervention should the ED nurse implement? Keep the client flat in bed. Dim the lights in the room. Assess for bladder distention. Administer a narcotic analgesic.

Assess for bladder distention.

114. The nurse is caring for the client diagnosed with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication? Examine pupil reactions to light. Assess level of consciousness. Observe for seizure activitv. Monitor vital signs every shift.

Assess level of consciousness.

25. The nurse arrives at the site of a one-car motor vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? Carefully remove the driver from the car. Assess the client's pupils for a reaction. Assess the client's airway. Attempt to wake the client up by shaking him

Assess the client's airway.

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

Assess the level of consciousness.

104. The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? Discuss the need to be placed in a long-term care facility. Explain how to care for a sigmoid colostomy. Assist the client to prepare an advance directive. Teach the client how to use a motorized wheelchair.

Assist the client to prepare an advance directive.

35. Which nursing task would be most appropriate for the RN to delegate to the UAP? Teach Credé's maneuver to the client needing to void. Administer the tube feeding to the client diagnosed with quadriplegia. Assist with bowel training by placing the client on the bedside commode. Observe the client demonstrating the self-catheterization technique.

Assist with bowel training by placing the client on the bedside commode.

90. The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. Which symptoms would the nurse assess in the client? Insomnia and anxiety. Visual or auditory hallucinations. Extreme tremors and agitation. Ataxia and confabulation.

Ataxia and confabulation.

13. The client diagnosed with a mild concussion is being discharged from the ED. Which discharge instruction should the nurse teach the client's significant other? Awaken the client every 2 hours. Monitor for increased intracranial pressure(ICP). Observe frequently for hypervigilance. Offer the client food every 3 to 4 hours.

Awaken the client every 2 hours.

122. The client diagnosed with atrial fibrillation reports numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? Schedule a STAT MRI of the brain. Call a code STROKE. Notify the HCP. Have the client swallow a glass of water.

Call a code STROKE.

74. The client diagnosed with Parkinson's disease is being discharged on carbidopa and levodopa.Which statement is the scientific rationale for combining these medications? There will be fewer side effects with this combination than with carbidopa alone. Dopamine D requires the presence of both of these medications to work. Carbidopa makes more levodopa available to the brain. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

Carbidopa makes more levodopa available to the brain.

115. The public health department nurse is preparing a lecture on the prevention of West Nile virus.Which information should the nurse include?Select all that apply. Change water frequently in pet dishes and birdbaths. Wear thick, dark clothing when outside to avoid bites. Apply insect repellent over face and arms only. Explain that mosquitoes are more prevalent from dusk to dawn. Get the West Nile virus vaccination yearly.

Change water frequently in pet dishes and birdbaths. Explain that mosquitoes are more prevalent from dusk to dawn.

96. The nurse is working with clients and their families regarding substance abuse. Which statement is the scientific rationale for teaching the children new coping mechanisms? The child needs to realize that the parent will be changing behaviors. The child will need to point out to the parent when the parent is not coping. Children tend to mimic the behaviors of parents when faced with similar situations. Children need to feel like they are a part of the parent's recovery.

Children tend to mimic the behaviors of parents when faced with similar situations.

11. The 85-year-old client diagnosed with a stroke is reporting a severe headache. Which intervention should the nurse implement first? Administer a nonnarcotic analgesic. Prepare for STAT magnetic resonance imaging (MRI). Start an intravenous infusion with D,W at100 mL/hr. Complete a neurological assessment.

Complete a neurological assessment.

109. The nurse is admitting the client to rule out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply. Determine if the client has recently received any immunizations. Ask if the client has had a cold in the last week. Check to see if the client has active herpes simplex 1. Find out if the client has traveled to the Great Lakes region. Assess for recent insect or mosquito bites.

Determine if the client has recently received any immunizations. Ask if the client has had a cold in the last week. Check to see if the client has active herpes simplex 1. Assess for recent insect or mosquito bites.

73. The client diagnosed with Parkinson's disease is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations would explain these assessment data? Masklike face and shuffling gait. Difficulty swallowing and immobility. Pill rolling of fingers and flat affect. Lack of arm swing and bradykinesia

Difficulty swallowing and immobility.

98. The client is diagnosed with ALS. Which client problem would be most appropriate for this client? Disuse syndrome. Altered body image. Fluid and electrolyte imbalance. Alteration in pain.

Disuse syndrome.

65. Which type of precautions should the nurse implement for the client diagnosed with meningococcal meningitis? Standard precautions. Airborne precautions. Contact precautions. Droplet precautions.

Droplet precautions.

37. The male client is sitting in the chair, and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds.Which action should the nurse implement first? Push aside any furniture. Place the client on his side. Assess the client's vital signs. Ease the client to the floor.

Ease the client to the floor.

97. Which diagnostic tests are used to confirm the diagnosis of ALS? Select all that apply. Electromyogram (EMG). Nerve conduction study (NCS). Serum creatine kinase (CK). Pulmonary function test. Magnetic resonance imaging.

Electromyogram (EMG). Nerve conduction study (NCS). Serum creatine kinase (CK). Magnetic resonance imaging.

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

Ensure that helmets are worn in appropriate areas

76. The RN and the UAP are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? Feed the 69-year-old client diagnosed with Parkinson's disease having difficulty swallowing. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

Feed the 69-year-old client diagnosed with Parkinson's disease having difficulty swallowing.

79. The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? Stereotactic pallidotomy. Dopamine receptor agonist medication. Deep brain stimulation. Fetal tissue transplantation.

Fetal tissue transplantation.

49. The client is being admitted to rule out a brain tumor. Which symptoms support a diagnosis of a brain tumor? Select all that apply. Nervousness, cough, and frequent eye movements. Headache, vomiting, and papilledema. Hypotension, tachycardia, and tachypnea. Abrupt loss of motor function, diarrhea, and changes in taste. Mood changes, blurred vision, and seizures.

Headache, vomiting, and papilledema. Mood changes, blurred vision, and seizures.

50. The client has been diagnosed with a brain tumor.Which presenting clinical manifestations help to localize the tumor position? Widening pulse pressure and bounding pulse. Diplopia and decreased visual acuity. Bradykinesia and scanning speech. Hemiparesis and personality changes

Hemiparesis and personality changes

52. The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement? Institute aspiration precautions. Refer the client to Reach to Recovery. Initiate seizure precautions. Teach the client about mastectomy care

Initiate seizure precautions.

111. The client admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. Which instructions should the nurse teach the client? Select all that apply. Instruct that all invasive procedures require written permission. Explain this test allows for the analysis of a sample of the cerebrospinal fluid. Tell the client to increase fluid intake for the next 48 hours. Discuss that lying supine with the head flat will prevent all hematomas. Teach the client about the spinal anesthesia used for the test.

Instruct that all invasive procedures require written permission. Explain this test allows for the analysis of a sample of the cerebrospinal fluid. Tell the client to increase fluid intake for the next 48 hours.

32. The client diagnosed with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? Select all that apply. Discuss how to remove the insertion pins correctly. Instruct the client to report reddened or irritated skin areas. Inform the client that the vest liner cannot be changed. Encourage the client to remain in the recliner as much as possible. Teach the client to notify the HCP of difficulty swallowing

Instruct the client to report reddened or irritated skin areas. Teach the client to notify the HCP of difficulty swallowing

39. The client is scheduled for an EEG to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? Select all that apply. Tell the client to take any routine antiseizure medication before the EEG. Tell the client not to eat anything for 8 hours before the procedure. Instruct the client to sleep only 4 or 5 hours before the EEG. Explain to the client that there will be some discomfort during the procedure. Tell the client to avoid hair products, such as hairspray and gels, before the EEG.

Instruct the client to sleep only 4 or 5 hours before the EEG. Tell the client to avoid hair products, such as hairspray and gels, before the EEG.

45. The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply. Keep a record of seizure activity. Take tub baths only; do not take showers. Avoid over-the-counter medications. Have anticonvulsant medication serum levels checked regularly. Do not drive alone; have someone in the car.

Keep a record of seizure activity. Avoid over-the-counter medications. Have anticonvulsant medication serum levels checked regularly.

123. The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson's disease. Which priority intervention should the nurse implement? Keep the bed low and call light in reach. Provide a regular diet of three meals per day. Obtain an order for home health to see the client. Perform the Braden scale skin assessment.

Keep the bed low and call light in reach.

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

Maintain an adequate airway.

81. The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? Crackles in the upper lung fields and jugular vein distention. Muscle weakness in the upper extremities and ptosis. Exaggerated arm swinging and scanning speech. Mask like face and a shuffling gait.

Masklike face and a shuffling gait.

82. Which is a common cognitive problem associated with Parkinson's disease? Emotional lability. Depression. Memory deficits. Paranoia.

Memory deficits.

28. The nurse in the neuro-intensive care unit is caring for a client diagnosed with a new cervical (C7) SCI and breathing independently. Which nursing interventions should be implemented? Select all that apply. Monitor pulse oximetry reading. Provide pureed foods six times a day. Encourage coughing and deep breathing. Assess for autonomic dysreflexia. Administer intravenous corticosteroids.

Monitor pulse oximetry reading. Encourage coughing and deep breathing. Administer intravenous corticosteroids.

117. The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan? Monitor the client's respirations frequently. Refer to a dermatologist for the treatment of maculopapular rash. Treat hypothermia by using ice packs under the client's arms. Teach the client to report any swollen lymph glands.

Monitor the client's respirations frequently.

94. The nurse caring for a client abusing amphetamines writes a problem of "cardiovascular com-promise." Which nursing interventions should be implemented? Monitor the telemetry and vital signs every4 hours. Encourage the client to verbalize the reason for using drugs. Provide a quiet, calm atmosphere for the client to rest. Place the client on bedrest and a low-sodium diet.

Monitor the telemetry and vital signs every 4 hours.

16. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data supports that the client is brain dead? When the client's head is turned to the right, the eyes turn to the right. The electroencephalogram (EEG) has identifiable waveforms. No eye activity is observed when the cold caloric test is performed. The client assumes decorticate posturing when painful stimuli are applied.

No eye activity is observed when the cold caloric test is performed.

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

Note the first thing the client does in the seizure.

67. The nurse is preparing a client diagnosed with possible meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply. Obtain an informed consent from the client or significant other. Have the client empty the bladder before the procedure. Place the client in a side-lying position with the back arched. Instruct the client to breathe rapidly and deeply during the procedure. Explain to the client what to expect during the procedure.

Obtain an informed consent from the client or significant other. Have the client empty the bladder before the procedure. Place the client in a side-lying position with the back arched. Explain to the client what to expect during the procedure.

127. The 28-year-old client is on the rehabilitation unit post SCI at level T10. Which collaborative team members should participate with the RN at the case conference? Select all that apply. Occupational therapist (OT). Physical therapist (PT). Registered dietitian (RD). Rehabilitation physician. Social worker. Patient care tech (PCT).

Occupational therapist (OT). Physical therapist (PT). Registered dietitian (RD). Rehabilitation physician. Social worker.

75. The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? Request the physical therapist to consult for equipment needed. Request a low-fat, low-sodium diet from the dietary department. Provide three meals per day that include nuts and whole-grain breads. Offer six meals per day with a soft consistency.

Offer six meals per day with a soft consistency.

2. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? Hemiparesis of the client's left arm and apraxia. Paralysis of the right side of the body and ataxia. Homonymous hemianopsia and diplopia. Impulsive behavior and hostility toward family.

Paralysis of the right side of the body and ataxia.

105. The client is in the terminal stage of ALS. Which intervention should the nurse implement? Perform passive ROM every 2 hours. Maintain a negative nitrogen balance. Encourage a low-protein, soft-mechanical diet. Turn the client and have him cough and deep breathe every shift.

Perform passive ROM every 2 hours.

92. The client is withdrawing from a heroin addiction. Which interventions should the nurse implement? Select all that apply. Initiate seizure precautions. Check vital signs every 8 hours. Place the client in a quiet, calm atmosphere. Have a consent form signed for HIV testing. Administer buprenorphine

Place the client in a quiet, calm atmosphere. Have a consent form signed for HIV testing. Administer buprenorphine

125. The concept of intracranial regulation is identified for a client diagnosed with a brain tumor.Which intervention should the nurse include in the client's plan of care? Tell the client to remain on bedrest. Maintain the intravenous rate at 150 mL/ hour. Provide a soft, bland diet with three snacks per day. Place the client on seizure precautions.

Place the client on seizure precautions.

4. The client diagnosed with a right-sided CVA is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. Position the client to prevent shoulder adduction. Turn and reposition the client every shift. Encourage the client to move the affected side. Perform quadriceps exercises three times a day. Instruct the client to hold the fingers in a fist.

Position the client to prevent shoulder adduction. Encourage the client to move the affected side.

23. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? Position the client with the head of the bed elevated at intervals. Perform active range-of-motion (ROM) exercises every 4 hours. Turn the client every shift and massage bony prominences. Explain all procedures to the client before performing them.

Position the client with the head of the bed elevated at intervals.

135. Which intervention should the nurse implement to decrease increased ICP for a client on a ventilator? Select all that apply. Position the client with the head of the bed up 30 degrees. Cluster activities of care. Suction the client every 3 hours. Administer soapsuds enemas until clear. Place the client in the Trendelenburg position.

Position the client with the head of the bed up 30 degrees. Cluster activities of care.

63. The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? Positive Babinski's sign and peripheral paresthesia.Negative Chvostek's sign and facial tingling. Positive Kernig's sign and nuchal rigidity. Negative Trousseau's sign and nystagmus.

Positive Kernig's sign and nuchal rigidity.

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

Powerlessness.

86. The chief executive officer (CEO) of a large manufacturing plant presents to the occupational health clinic with chronic rhinitis and requesting medication. On inspection, the nurse notices holes in the septum that separates the nasal pas-sages. The nurse also notes dilated pupils and tachycardia. The facility has a "No Drug" policy.Which intervention should the nurse implement? Prepare to complete a drug screen urine test. Discuss the client's use of illegal drugs. Notify the client's supervisor about the situation. Give the client an antihistamine and say nothing.

Prepare to complete a drug screen urine test.

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

Purposeless movement in response to painful stimuli.

64. The RN is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP? Purpuric lesions on the face. Reports of light hurting the eyes. Dull, aching, frontal headache. Not remembering the day of the week.

Purpuric lesions on the face.

5. The nurse is planning care for a client experiencing agnosia secondary to a CVA. Which collaborative intervention will be included in the plan of care? Observe the client swallowing for possible aspiration. Position the client in a semi-Fowler's position when sleeping. Place a suction set up at the client's bedside during meals. Refer the client to an occupational therapist(OT) for an evaluation.

Refer the client to an occupational therapist(OT) for an evaluation.

36. The 34-year-old male client diagnosed with anSCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? Refer the client to the American Spinal Cord Injury Association (ASIA). Refer the client to the state vocational rehabilitation agency. Ask the social worker (SW) about applying for disability. Suggest the client talk with his significant other about this concern.

Refer the client to the state vocational rehabilitation agency

108. The client diagnosed with ALS is prescribed riluzole. Which instructions should the nurse discuss with the client? Select all that apply. Take the medication with food. Do not eat green, leafy vegetables. Use SPF 30 when going out in the sun. Report any febrile illness. Throw away unused medication after 15 days.

Report any febrile illness. Throw away unused medication after 15 days.

89. The nurse observes a coworker acting erratically.The clients assigned to this coworker don't seem to get relief when pain medications are administered. Which action should the nurse implement? Try to help the coworker by confronting the coworker with the nurse's suspicions. Tell the coworker that the nurse will give all narcotic medications from now on. Report the nurse's suspicions to the nurse's supervisor or the facility's peer review. Do nothing until the nurse can prove the coworker has been using drugs.

Report the nurse's suspicions to the nurse's supervisor or the facility's peer review.

62. The public health nurse is giving a lecture on potential outbreaks of infectious meningitis.Which population is most at risk for an outbreak? Clients recently discharged from the hospital. Residents of a college dormitory. Individuals visiting a developing country. Employees in a high-rise office building.

Residents of a college dormitory.

1. A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? Prepare to administer recombinant tissue plasminogen activator (rtPA). Discuss the precipitating factors that caused the symptoms. Schedule for a STAT computed tomography(CT) scan of the head Notify the speech pathologist for an emergency consult.

Schedule for a STAT computed tomography(CT) scan of the head

60. The client is being discharged following a trans-sphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client?Select all that apply. Sleep with the head of the bed elevated. Keep a humidifier in the room. Use caution when performing oral care. Stay on a full liquid diet until seen by the HCP. Notify the HCP if developing a cold or fever.

Sleep with the head of the bed elevated. Keep a humidifier in the room. Use caution when performing oral care. Notify the HCP if developing a cold or fever.

53. The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make? Social worker. Chaplain. Health-care provider. Occupational therapist.

Social worker.

22. The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water, not responding to verbal stimuli. The nurse is the first HCP to respond to the accident. Which intervention should be implemented first? Assess the client's level of consciousness. Organize onlookers to remove the client from the lake. Perform a head-to-toe assessment to determine injuries. Stabilize the client's cervical spine.

Stabilize the client's cervical spine.

121. The male client is admitted to the ED following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the ED nurse implement in the first 5 minutes? Select all that apply. Stabilize the client's neck and spine. Contact the organ procurement organization to speak with the family. Elevate the head of the bed to 70 degrees. Perform a Glasgow Coma Scale assessment. Ensure the client has a patent peripheral venous catheter in place. Check the client's driver's license to see if he will accept blood.

Stabilize the client's neck and spine. Perform a Glasgow Coma Scale assessment. Ensure the client has a patent peripheral venous catheter in place.

58. The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement? Make the client NPO until seen by the HCP. Position the client in low Fowler's position for all meals. Place the client on a mechanically ground diet. Teach the client to direct food and fluid toward the right side.

Teach the client to direct food and fluid toward the right side

87. The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse that another client, Client B, has "started using again." Which action should the nurse implement? Tell Client A the nurse cannot discuss ClientB with him. Find out how Client A got this information. Inform the HCP that Client B is using again. Get in touch with Client B and have the client come to the clinic.

Tell Client A the nurse cannot discuss Client B with him.

42. The UAP is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure.Which action should the RN primary nurse take? Help the UAP to insert the oral airway in the mouth. Tell the UAP to stop trying to insert anything in the mouth. Take no action because the UAP is handling the situation. Notify the charge nurse of the situation immediately.

Tell the UAP to stop trying to insert anything in the mouth.

21. The client diagnosed with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? Notify the HCP immediately. Prepare to administer an antihistamine. Test the drainage for the presence of glucose. Place a 2 x 2 gauze under the nose to collect drainage.

Test the drainage for the presence of glucose.

15. The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? The 22-year-old male client diagnosed with a concussion is reporting someone is waking him up every 2 hours. The 36-year-old female client admitted with reports of left-sided weakness scheduled for an MRI scan. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident with a Glasgow Coma Scale (GCS) score of 6. The 62-year-old client diagnosed with a CVA with expressive aphasia.

The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident with a Glasgow Coma Scale (GCS) score of 6.

84. The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first? The 65-year-old client diagnosed with seizures reporting a headache that is a "2" on a 0 to-10 scale. The 24-year-old client diagnosed with a T10 SCI and cannot move his toes. The 58-year-old client diagnosed with Parkinson's disease is crying and worried about her facial appearance. The 62-year-old client diagnosed with a CVA and a resolving left hemiparesis.

The 58-year-old client diagnosed with Parkinson's disease is crying and worried about her facial appearance.

128. Which diagnostic evaluation tool would the nurse use to assess the client's cognitive func-tioning? Select all that apply. The Geriatric Depression Scale (GDS). The St. Louis University Mental Status(SLUMS) scale. The Mini-Mental Status Examination(MIMSE) scale. The Manic Depression vs Elderly Depression (MDED) scale. 5. The Functional Independence MeasurementScale (FIMS).

The St. Louis University Mental Status(SLUMS) scale. The Mini-Mental Status Examination(MIMSE) scale.

6. The nurse and an unlicensed assistive personnel (UAP) are caring for a client diagnosed with right-sided paralysis. Which action by the UAP requires the RN to intervene? The assistant places a gait belt around the client's waist before ambulating. The assistant places the client on the back with the client's head to the side. The assistant places a hand under the client's right axilla to move up in bed. The assistant praises the client for attempting to perform ADL independently.

The assistant places a hand under the client's right axilla to move up in bed.

59. The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, "Why not try chemotherapy first? It has helped my other tumors." The nurse's response is based on which scientific rationale? Chemotherapy is only used as a last resort in caring for clients diagnosed with brain tumors. The blood-brain barrier prevents medications from reaching the brain. Radiation therapy will have fewer side effects than chemotherapy. Metastatic tumors become resistant to chemotherapy and it becomes useless.

The blood-brain barrier prevents medications from reaching the brain.

119. The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse? The vital signs are documented as T100.2°F, P 80, R 18, and BP 136/78. The client reports generalized body aches and pains. Positive results are reported from the enzvme-linked immunosorbent assay (ELISA. The client becomes lethargic and is difficult to arouse using verbal stimuli.

The client becomes lethargic and is difficult to arouse using verbal stimuli.

110. The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies. The client has a recurrent temperature of100.6°F. The client has a decreased report of headaches. The client comments that the meal has no taste.

The client comments that the meal has no taste.

34. The nurse is caring for clients in the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report? The client diagnosed with a C6 SCI reporting dyspnea and has crackles in the lungs. The client diagnosed with an L4 SCI crying and very upset about being discharged home. The client diagnosed with an L2 SCI reporting a headache and feeling very hot. The client diagnosed with a T4 SCI unable to move the lower extremities.

The client diagnosed with a C6 SCI reporting dyspnea and has crackles in the lungs.

77. The RN charge nurse is making assignments.Which client should be assigned to the new graduate nurse? The client diagnosed with aseptic meningitis reporting a headache and the light bothering his eyes. The client diagnosed with Parkinson's disease after falling during the night and is reporting difficulty walking. The client diagnosed with a CVA with vital signs P 60, R 14, and BP 198/68. The client diagnosed with a brain tumor, reporting seeing spots before the eyes.

The client diagnosed with aseptic meningitis reporting a headache and the light bothering his eyes.

The nurse is caring for several clients in a medical unit. Which client should the nurse assess first? The client diagnosed with ALS refusing to turn every 2 hours. The client diagnosed with abdominal pain reporting nausea. The client diagnosed with pneumonia and a pulse oximeter reading of 90%. The client reporting not receiving any pain medication.

The client diagnosed with pneumonia and a pulse oximeter reading of 90%.

57. The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery? The client reports a headache at "3" to "4" on a 1-to-10 scale. The client has an intake of 1,000 mL and an output of 3,500 mL. The client reports a raspy, sore throat. The client experiences dizziness when trying to get up too quickly.

The client has an intake of 1,000 mL and an output of 3,500 mL.

55. The client diagnosed with a brain tumor was admitted to the ICU with decorticate posturing. Which indicates that the client's condition is becoming worse? The client has purposeful movements with painful stimuli. The client has assumed adduction of the upper extremities The client is aimlessly thrashing in the bed. The client has become flaccid and does not respond to stimuli.

The client has become flaccid and does not respond to stimuli.

24. The 29-year-old client, employed as a forklift operator, sustains a traumatic brain injury (TBI secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after 3 months and has cognitive deficits. Which goal would be most realistic for this client? The client will return to work within 6 months. The client is able to focus and stay on task for 10 minutes. The client will be able to dress without assistance. The client will regain bowel and bladder control.

The client is able to focus and stay on task for 10 minutes.

83. The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? The client should discuss feelings about being placed on a ventilator. The client may have rapid mood swings and become easily upset. Pill-rolling tremors will become worse when the medication is wearing off. The client may automatically start to repeat what another person says.

The client may have rapid mood swings and become easily upset.

56. The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach? There will be a large turban dressing around the skull after surgery. The client will not be able to eat for 4 or5 days postop. The client should not blow the nose for 2 weeks after surgery. The client will have to lie flat for 24 hours following the surgery.

The client should not blow the nose for 2 weeks after surgery.

78. The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? The client will experience periods of akinesia throughout the day. The client will take the prescribed medications correctly. The client will be able to enjoy a family outing with the spouse. The client will be able to carry out ADL.

The client will be able to carry out ADL.

129. Which priority goal would the nurse identify for a client diagnosed with Parkinson's disease? The client will be able to maintain mobility and swallow without aspiration. The client will verbalize feelings about the diagnosis of Parkinson's disease. The client will understand the purpose of medications administered for the disease. The client will have a home health agency for monitoring at home.

The client will be able to maintain mobility and swallow without aspiration.

54. The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit? The client will maintain body weight within 2 pounds. The client will execute an advance directive. The client will be able to perform three ADL with assistance The client will verbalize a feeling of loss by the end of the shift.

The client will be able to perform three ADL with assistance

66. The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem "altered cerebral tissue perfusion"? The client will be able to complete ADL. The client will be protected from injury if seizure activity occurs. The client will be afebrile for 48 hours before discharge. The client will have elastic tissue turgor with ready recoil.

The client will be protected from injury if seizure activity occurs.

112. The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client? The client will regain as much neurological function as possible. The client will have no short-term memory loss. The client will have improved renal function. The client will apply hydrocortisone cream daily.

The client will regain as much neurological function as possible.

88. A 20-year-old female client having tried lysergic acid diethylamide (LSD) as a teen tells the nurse that she has bad dreams that make her want to kill herself. Which is the explanation for this occurrence? These occurrences are referred to as "hold-over reactions" to the drug. These are flashbacks to a time when the client had a "bad trip." The drug is still in the client's body and causing these reactions. The client is suicidal and should be on one-to-one precautions.

These are flashbacks to a time when the client had a "bad trip."

70. Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and an NSAID every 2 hours to a female client diagnosed with bacterial meningitis? This regimen helps to decrease the purulent exudate surrounding the meninges. These medications will decrease ICP and brain metabolism. These medications will increase the client's memory and orientation. This will help prevent a yeast infection secondary to antibiotic therapy.

These medications will decrease ICP and brain metabolism.

91. The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering? Thiamine and chlordiazepoxide. Phenytoin and ferrous sulfate. Methadone and divalproex sodium. Mannitol and methylphenidate.

Thiamine and chlordiazepoxide.

120. Which rationale explains the transmission of theWest Nile virus? Transmission occurs through exchange of body fluids when sneezing and coughing. Transmission occurs only through mosquito bites and not between humans. Transmission can occur from human to human in blood products and breast milk. Transmission occurs with direct contact from the maculopapular rash drainage.

Transmission can occur from human to human in blood products and breast milk.

113. Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply. Turn the client every 2 hours. Encourage the client to increase fluids. Keep the client in the supine position. Assess for deep vein thrombosis (DVT). Assess for any alterations in elimination.

Turn the client every 2 hours. Encourage the client to increase fluids. Assess for deep vein thrombosis (DVT). Assess for any alterations in elimination.

41. The client, after a 3-minute seizure, has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep.Which intervention should the nurse implement? Perform a complete neurological assessment. Awaken the client every 30 minutes. Turn the client to the side and allow the client to sleep. Interview the client to find out what caused the seizure.

Turn the client to the side and allow the client to sleep.

132. The nurse is caring for a client diagnosed with ICP and secretions pooled in the throat. Which intervention should the nurse implement first? Set the ventilator to hyperventilate the client in preparation for suctioning. Assess the client's lung sounds and check for peripheral cyanosis. Turn the client to the side to allow the secretions to drain from the mouth. Suction the client using the in-line suction, wait 30 seconds, and repeat.

Turn the client to the side to allow the secretions to drain from the mouth.

26. In assessing a client diagnosed with a thoracicSCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock? Select all that apply. Warm lower extremities. Inability to move upper extremities. Reports of a pounding headache. Hypotension Tachycardia.

Warm lower extremities. Hypotension

99. The client is being evaluated to rule out ALS. Which clinical manifestations would the nurse note to confirm the diagnosis? Muscle atrophy and flaccidity. Fatigue and malnutrition. Slurred speech and dysphagia. Weakness and paralysis.

Weakness and paralysis.