Practice Questions

A. High risk for injury related to vertigo. Rationale: Meniere's disease is primarily characterized by vertigo. The client is at risk for falls. SAFETY IS A PRIORITY!

The client is experiencing vertigo due to Meniere's disease. Which of the following is the priority nursing diagnosis? A. High risk for injury related to vertigo. B. Alteration in comfort related to tinnitus. C. Altered body image related to hearing loss. D. Altered nutrition related to nausea and vomiting.

D. Destruction of acetylcholine receptors causing muscle weakness.

A client is diagnosed with myasthenia gravis. Which of the following conditions is the cause of this disease? A. A postviral disease characterized by ascending paralysis. B. Loss of myelin sheath surrounding peripheral nerves. C. Inability of the basal ganglia to produce sufficient dopamine. D. Destruction of acetylcholine receptors causing muscle weakness.

D. Hands Rationale: When using crutches, the client bears the eight of the body on the palms of the hands, not on the axillae to prevent CRUTCH PALSY

A client who had an above-the-knee amputation is to use crutches until the prosthesis is properly fitted. When teaching the client about using the crutches the nurse instructs the client to support her weight primarily on which of the following body areas? A. Axillae B. Elbows C. Upper arms D. Hands

C. " Reviewing your losses is a way to help you work through your grief and loss." Rationale: Reassuring the client that verbalizing one's feeling is acceptable, is a therapeutic nursing action.

A client with spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, " Why can't I stop talking about these things? i know those days are gone forever." Which of the following responses by the nurse conveys the best understanding of the client's behavior? A. " Be patient. It takes time to adjust to such massive loss." B. " Talking about the past is a form of denial. We have to help you focus today." C. " Reviewing your losses is a way to help you work through your grief and loss." D. "It's a simple escape mechanism to go back and live again in happier times."

B. Cataract Rationale: Red reflex is absent in opacification of lens (cataract).

Absence of red reflex indicates which of the following eye disorders? A. Presbyopia B. Cataract C. Glaucoma D. Ptyregium

A. Basilar skull fracture Rationale: Basilar skull fracture is characterized by CSF leak from the nose or from the ears. The fuid must be tested for presence of glucose. CSF is positive for glucose. Basilar skull fracture or injury may also be characterized by Battle's sign (hematoma at the mastoid process/ behind the ear).

Clear fluid is draining from the nose of a client who had a head trauma 3 hour ago. This may indicate which of the following? A. Basilar skull fracture B. Cerebral concussion C. Cerebral palsy D. Sinus infection

C. Relief of the muscle spasm Rationale: Robaxin is muscle relaxant, therefore it relieves muscle spasm. It is administered after meals to prevent GI irritation.

The client with a fractured tibia has been taking methocarbamol (Robaxin). When teaching the client about this drug, which of the following would the nurse include as the drug's primary effect? A. Killing the microorganism B. Reduction of itching C. Relief of the muscle spasm D. Decrease in nervousness

A. to reduce the bulk of the feces

The diet of the client who will undergo colonic surgery is low-residue diet. The reason for this is: A. to reduce the bulk of the feces B. to prevent postop infection C. to prevent postop hemorrhage D. to prevent intestinal obstruction

A. The gag reflex returns.

For a client with CVA, which of the following criteria must be fulfilled before the client is fed? A. The gag reflex returns. B. Speech returns to normal. C. The client swallows small sips of water. D. Cranial nerves III, IV and VI are intact.

C. render hot Sitz bath during the first 24 hrs postop

The following are appropriate nursing interventions for the client who have undergone hemorrhoidectomy except: A. place in lateral position B. increase fluid intake C. render hot Sitz bath during the first 24 hrs postop D. administer laxatives as ordered

A. lie supine after eating

The following are appropriate nursing interventions for the client with hiatal hernia except: A. lie supine after eating B. small, frequent feedings C. avoid stimulants like caffeine, alcohol, smoking D. avoid constricting clothing

B. pain that radiates above the umbilicus

The following are characteristics manifestations of left colon and rectal Ca except: A. rectal bleeding B. pain that radiates above the umbilicus C. changed bowel habits D. tenesmus

D. Quadriplegia

A client with a Cs spina cord injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Quadriplegia

A. Crossing the legs while sitting down. Rationale: Crossing the legs causes acute hip flexion. This may cause displacement of the prosthesis. Other activities to be avoided are sitting in low chair; bending and stooping, raising the legs, running, jogging and horseback riding.

A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities would the nurse instruct the client to avoid? A. Crossing the legs while sitting down. B. Sitting on a rise commode seat. C. Using an abductor splint while lying on the side. D. Rising straight from a chair to standing position.

C. Maintaining proper position of the joint on the CPM machine. Rationale: Maintaining the knee joint on the CPM device ensures that ROM exercises are done. To promote circulation and healing of the knee. Initial objective is to promote 10 degree angle extension and 50 degree flexion (partial ROM); then days before discharge until the client is at home, 0 degree extension and 90 degree flexion (full range of motion) should be maintained.

A client with history of severe rheumatoid arthritis undergoes surgery. Postop, the client's right leg is placed in a continuous passive motion (CPM) device. Which of the following would the nurse perform when caring for a client receiving CPM therapy? A. Adjusting the setting as needed to prevent client discomfort. B. Increasing the range-of-motion setting at least every 8 hours. C. Maintaining proper position of the joint on the CPM machine. D. Discontinuing the CPM therapy when range-of-motion increases to 90 degrees.

C. "You seem angry today. Going to rehab may be scary." Rationale: Change of environment may be anxiety provoking for some individuals. Focusing on the client's feelings is therapeutic. This encourages the client to verbalize his fears, feelings, and concerns.

A client with paraplegia from a T10 injury is getting ready to transfer to a rehabilitation hospital. When the nurse offers to assist him, the client throws his suitcase on the floor and says, "you don't want to help me." Which of the suitcase on following responses would be most appropriate for the nurse to give? A. "You know I want to help you, I offered." B "I'll pick these things up for you and come back later" C. "You seem angry today. Going to rehab may be scary." D. "When you get to rehab, they won't let you behave like a spoiled brat."

C. Bradykinesia Explanation: Bradykinesia (slow movement not associated with weakness) is not a manifestation of multiple sclerosis. This is a manifestation of Parkinson's disease.

The following are signs and symptoms of multiple sclerosis EXCEPT: A. Scanning speech B. Intention tremors C. Bradykinesia D. Nystagmus

B. the drug will reduce colonic bacteria

Which of the following is the primary reason for administering neomycin sulfate to a client who will undergo colonic surgery? A. the drug will reduce HCl B. the drug will reduce colonic bacteria C. the drug will reduce peristalsis D. the drug will relieve pain

B. the stool contains blood, pus and mucus

Which of the following is true in ulcerative colitis? A. the stool is acholic B. the stool contains blood, pus and mucus C. the stool is greasy, bulky, foul smelling D. the stool is black and tarry

A. Stress

Which of the following may exacerbate multiple sclerosis? A. Stress B. Swimming C. Urinary retention D. ROM exercises

C. Ticlopidine Rationale: Ticlopidine is platelet aggregation inhibitor. This medication prevent thromboembolic CVA.

Which of the following medications may be prescribed to prevent thromboembolic CVA? A. Acetaminophen B. Dexamethasone C. Ticlopidine D. Mannitol

A. Elevate his head as high as possible. Rationale: The client with autonomic dysreflexia usually experiences very high blood pressure. This may lead to CVA (stroke). Therefore, elevating the head of bed to the sitting position is necessary to lower the blood pressure by gravity and prevent CVA.

A quadriplegic client is experiencing autonomic dysreflexia. The most appropriate first nursing intervention for the client is: A. Elevate his head as high as possible. B. Monitor his bp and pr C. Assist him in emptying his bladder. D. Notify the physician.

A. Impaired physical mobility related to back pain. Rationale: Pain and impaired mobility are the potential initial problems after surgery, like lumbar laminectomy.

After a bilateral lumbar laminectomy at L5-S1, which of the following is a priority nursing diagnosis for the client in immediate postoperative phase? A. Impaired physical mobility related to back pain. B. Imbalanced Nutrition: Less than body requirement related to postoperative status. C. Bowel incontinence related to decreased physical activity. D. Disturbed body image related to fear of disfiguring surgical scars.

D. Sweeping the front porch. Rationale: After laminectomy, bending and stooping should be avoided. Sweeping involves bending and stooping.

After a laminectomy, the client states, " The doctor said that I can do anything I want to." Which of the following activities, if stated by the client indicates the need for further teaching? A. Drying the dishes. B. Sitting on the side of firm cushions. C. Making the bed, walking from side to side. D. Sweeping the front porch.

D. I should wear a thin cotton undershirt under the brace. Rationale: Wearing a thin cotton undershirt under the brace protects the skin from the material of the brace. Choices A and C are incorrect because lotion and powder may cake and will cause skin irritation.

After teaching a client required to wear a back brace after a spinal fusion, which of the following client statements indicates effective teaching about skin protection measure with the brace? A. I will apply lotion before putting on a brace. B. I will be sure to pad the area around my iliac crest. C. I can use baby powder under the brace to absorb perspiration. D. I should wear a thin cotton undershirt under the brace.

B. Homonymous hemianopsia

An elderly client had CVA and can only see the nasal visual field on one side and the temporal portion on the opposite side. Which of the following correctly describes the condition? A. Agnosia B. Homonymous hemianopsia C. Ticlopidine D. Mannitol

C. Immediately after the meal. Rationale: Motrin is an NSAID. It is best given after meal to prevent GI irritation.

At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? A. At bed time. B. On arising. C. Immediately after the meal. D. On an empty stomach

D. taking fluids with meals

Dumping syndrome, a postprandial problem which occurs after gastric resection may be managed by the following measures except: A. small frequent feedings B. Increase protein, decrease carbohydrates C. lying down after meals D. taking fluids with meals

B. Intention tremors Explanation: Parkinson's disease is characterized by resting/ non -intention tremors. The shakings are more severe if the dient is not performing any activities. Multiple sclerosis is characterized by intention tremors. The shakings are more severe when the client attempts to perfom actvities.

Following are signs and symptoms of Parkinson's disease EXCEPT: A. Akinesia B. Intention tremors C. Aspiration D. Drooling

A. Inability to regulate body temperature Rationale: The hypothalamus is the location of the body's heat-regulating center. Therefore, the client with a brain tumor near the hypothalamus should be assessed for inability to regulate body temperature

Following surgery for a brain tumor near the hypothalamus, the nursing assessment should include observing for: A. Inability to regulate body temperature B. Bradycardia C. Visual disturbances D. Inability to perceive sound

C. Flexion of elbows, extension of the knees, plantar flexion of the feet. Rationale: Decorticate postuning is characterized by flexion of the elbows, dension of the knees, plantar flexion of the feet This indicates cerebral cortex function impaiment.

If the client with increased ICP demonstrates decorticate posturing, the nurse will observe: A. Flexion of both upper and lower extremities B. Extension of elbows and knees, plantar flexion of feet, flexion of the wrists C. Flexion of elbows, extension of the knees, plantar flexion of the feet D. Extension of upper extremities, flexion of lower extremities

C. Early morning stiffness. Rationale: Early morning stiffness is an early sign of rheumatoid arthritis (RA). A, B and D are late signs of RA.

On a visit to the clinic, a client reports the onset of early symptom of rheumatoid arthritis. Which of the following would the nurse most likely assess? A. Limited motion of joint. B. Deformed form of the hands. C. Early morning stiffness. D. Rheumatoid arthritis.

B. Atropine sulfate Rationale: After cholinergic therapy, difficulty swallowing and excessive respiratory secretions indicate cholinergic crisis. The client should be given anticholinergic, like Atropine Sulfate.

One hour after receiving Pyridostigmine Bromide (Mestinon), a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the physician and prepares to administer which of the following medications? A. Additional pyridostigmine B. Atropine sulfate C. Edrophonium Chloride (Tension) D. Neostigmine (Prostigmin)

C. " I can pull out cast padding to scratch inside the cast." Rationale: Cast padding protects the skin from the material of the cast. It should not be pulled out.

Regardless of the type of cast material used, the nurse identifies a knowledge deficit when the client makes which of the following statements about the care of his cast? A. "I'll elevate the cast above my heart initially." B. "I'll exercise my joints above and below the cast." C. " I can pull out cast padding to scratch inside the cast." D. "I'll apply ice for 10 minutes to control edema for the first 24 hrs."

A. Patch one eye with eye pad

The client experiences diplopia. Which of the following is appropriate nursing action? A. Patch one eye with eye pad B. Patch both eyes with eye pads C. Advise to turn head from left to right before crossing the street D. Inform that everything will look nearer by 25%

A. administer laxative as ordered

The client had undergone Barium enema. Which of the following is the most important nursing intervention? A. administer laxative as ordered B. promote bed rest C. monitor I & O D. inform that burning sensation is felt on voiding

A. To prevent secondary glaucoma. Rationale: Iridectomy following cataract extraction is done to prevent secondary glaucoma.

The client had undergone cataract extraction. Iridectomy is done for which of the following reasons? A. To prevent secondary glaucoma. B. To prevent color blindness. C. To prevent retinal detachment. D. To prevent color blindness.

A. watery stool

The client had undergone ileostomy. The stoma will drain: A. watery stool B. semi-formed stool C. well-formed stool D. greasy, bulky, foul-smelling stool

C. The client complains of severe pain in the eye Rationale: Severe eye pain after eye surgery may indicate bleeding. This should concern the nurse most. She should notify the physician immediately.

The client had undergone retinal detachment repair. Which of the following should concern the nurse most? A. The client complains of thirst. B. The client complains of nausea C. The client complains of severe pain in the eye D. The client complains of fatigue

A. Alcohol B. High-sodium foods C. Caffeine E. Cigarette smoking

The client has been diagnosed to have Meniere's disease. The client should avoid which of the following to prevent the acute attack of the disease. Select all that apply. A. Alcohol B. High-sodium foods C. Caffeine D. Fruit juices E. Cigarette smoking F. Green salad

D. Assess for claustrophobia. Rationale: EEG is graphical recording of electrical activities of the brain. Electrodes are applied to the scalp. There is no need to assess for claustrophobia (fear of enclosed space) because it is not done in a tunnel like device.

The client is for EEG this moning. Which of the following is not included when preparing him for the procedure? A. Render hair shampoo B. Exclude caffeine from his meal. C. Instruct the client to remain still during the procedure D. Assess for claustrophobia.

C. Lack of weight bearing causes demineralization of the leg bone. Rationale: Lack of weight-bearing causes demineralization of the leg bone, causing increase in blood calcium levels.

The client with a spinal cord injury asks the nurse why the dietician has recommended that she decrease her total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information? A. Excessive intake of dairy products makes constipation more common. B. Immobility increases calcium absorption form the intestine. C. Lack of weight bearing causes demineralization of the leg bone. D. Dairy products likely will contribute to weight gain.

D. Increase the flow rate of the solution when abdominal cramps occur

The following are appropriate nursing actions during colostomy irrigation except: A. place the client in Semi-Fowler's position B. insert 2-4 " of well lubricated catheter into the stoma C. place the solution 18" above the stoma D. Increase the flow rate of the solution when abdominal cramps occur

D. administer laxative as ordered

The following are appropriate nursing interventions for a client with appendicitis except: A. maintain NPO B. apply ice cap over the RLQ of the abdomen C. promote bed rest D. administer laxative as ordered

A. Pilocarpine B. Carbachol D. Humorsol F. Timolol maleate Rationale: Miotics and beta-adrenergic blockers are indicated in a client with glaucoma. These drugs reduce IOP. C & E are anticholinergics. These drugs dilate pupils and will obstruct the outflow of aqueous humor. Mydriatics/ anticholinergic are contraindicated in glaucoma.

The following medications are indicated in a client with glaucoma. Select all that apply. A. Pilocarpine B. Carbachol C. Cogentin D. Humorsol E. Atropine F. Timolol maleate

A, B, D and E Rationale: Snellen's chart assesses visual acuity; one eye is tested at a time , then both eyes are tested together; the client should be 20 ft away from the chart; the test can assess nearsightedness (eg., result of 20/30) and farsightedness (e.g., result of 20/15); result of 20/200 indicates legal blindness. Snellen's test does not assess color blindness. Ishihara plate is used to assess color vision.

The following statements are true about Snellen's test. Select all that apply. A. Visual acuity is tested. B. Right eye is tested first, then the left eye, then both eyes. C. The client should be 30 ft away from the chart. D. It can assess nearsightedness and farsightedness. E. A result of 20/200 indicates legal blindness. F. It can assess color blindness.

D. Tinnitus

The most common complaint of a client with ear disorder is? A. Earache B. Discharge from the ear C. Hearing loss D. Tinnitus

A. With the feet flat on the floor. Rationale: After lumbar laminectomy, maintain 90 degree angle hip flexion when sitting by keeping the feet flat on the floor.

The nurse determines that the client who has had a lumbar laminectomy with a spinal fusion understands his postop instruction when he places himself in which of the following positions when sitting in a chair? A. With the feet flat on the floor. B. On a low footstool. C. In any comfortable position with legs uncrossed. D. On a high footstool so the feet are level with the chair.

D. Obtain equipment for orotracheal suctioning

The nurse enters the room of a client who is in the clonic phase of a tonic clonic seizure. The initial nursing action should be to: A. Insert a padded mouth gag. B. Place some padding under the head. C. Gently restrain the legs. D. Obtain equipment for orotracheal suctioning

D. Personal hygiene with a complete bed bath. Rationale: The client should be allowed to do what he can do for himself. He needs partial assistance with bed bath. The traction is applied on the leg, so he can use his hands.

The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse least likely include in the plan of care? A. Use of fracture bedpan. B. Check for redness over the ischial tuberosity C. Elevation of the head of the bed no more than 25 degrees. D. Personal hygiene with a complete bedbath.

A. "I will need to keep my head elevated for at least 8 hours. " Rationale: After myelogram using water-based dye (Metrizamide) the client the placed in Semi Fowler's position. To prevent meningeal imitation by should be a dye. In e water-based dye myelogram, not all of the dye was removed. Semi-Fowler's position helps keep the dye in the spinal cord and prevents it from reaching the brain.

The nurse is preparing the client for myelogram using Metrizamide (Amipaque), water soluble contrast material. The nurse will know the client understands he postmyelogram care regime when she says: A. "I will need to keep my head elevated for at least 8 hours. B. I will need to lie flat for 12 to 24 hours." C. "I will not be allowed to drink much liquid for 12 hours." D. expect to have some itching and a stiff neck for a few days."

C. Warm solution at 98 degree Fahrenheit. Rationale: C. the solution for ear irrigation should be warmed at body temperature to prevent dizziness. A. The flow of solution should be directed to the lateral walls of the external auditory canal; B. Cold water can cause dizziness; D. The ear to be irrigated should be forward and downward.

The nurse is to administer ear irrigation as prescribed by the physician. Which of the following is appropriate nursing action? A. Direct the flow of solution to the ear drum. B. Use cold water. C. Warm solution at 98 degree Fahrenheit. D. Position the client with the ear to be irrigated facing upward.

C. Ineffective airway clearance Rationale: Airway is a priority. The comatose client is unable to expectorate 3. mucus secretions and the cough reflex is depressed. Therefore, the priority nursing diagnosis is ineffective airway clearance.

The nursing diagnosis that would have the highest priority in the care of the client who has become comatose following cerebral hemorrhage is: A. Impaired physical mobility B. Altered nutrition: less than body requirements C. Ineffective airway clearance D. Constipation

C. liberal bland diet

The prescribes diet for a client with PUD during exacerbation is: A. high fat diet B. high protein diet C. liberal bland diet D. milk or cream every 2 hrs

D. Lessened rigidity and tremors.

To evaluate effectiveness of Levodopa/Carbidopa, a nurse would observe for which of the following results? A. Improved visual acuity. B. Reduction in short-term memory. C. Decreased level of energy. D. Lessened rigidity and tremors.

D. Have orotracheal suction available at all times. Rationale: Having orotracheal suction available at all times is necessary to maintain airway patency. The airway is a priority.

To maintain airway patency during a stroke in evolution, which of the following nursing interventions is appropriate? A. Thicken all dietary liquids. B. Restrict dietary and parenteral liquids. C. Place the client in supine position. D. Have orotracheal suction available at all times.

B. Muscle rigidity Explanation: Parkinson's disease is characterized by rigidity of muscles. This is due to inadequate dopamine production. Dopamine is a neurotransmitter necessary for muscle relaxaton. Deficiency of dopamine results to rigidity.

When evaluating the extent of Parkinson's disease, a nurse observes for which of the following conditions? A. Bulging eyeballs B. Muscle rigidity C. Diplopia D. Hemiparesis

C. Baclofen (Lioresal) Explanation: Baclofen (Lioresal) is an antispasmodic. It is a drug of choice to decrease muscle spasm in the client with multiple sclerosis.

Which of the following medications may be used to decrease spasticity in the client with multiple sclerosis? A. Hydralazine (Apresoline) B. Lidocaine (Xylocaine) C. Baclofen (Lioresal) D. Hydrocortisone (Solu-cortef)

B. Advance the crutch on one side and simultaneously advance and bear weight on the opposite foot, repeat on the opposite side. Rationale: A - 4 point gait C- swing to gait D- swing through gait

When preparing the teaching plan for a client about crutch walking using a two-point gait pattern, which of the following would the nurse include? A. Advance the crutch on one side and then advance the opposite foot, repeat on the opposite side. B. Advance the crutch on one side and simultaneously advance and bear weight on the opposite foot, repeat on the opposite side. C. Advance both crutches together and then follow by lifting both lower extremities to the level of crutches. D. Advance both crutches together and then follow by lifting both lower extremities past the level of crutches.

B. " I can participate in sexual activity but might not experience orgasm." Rationale: A woman with spinal cord injury and quadriplegia can participate in sexual activity but might not experience orgasm due to diminished sensation in the vaginal area.

When teaching a woman with spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates a good understanding of her sexual functioning? A. I won't be able to have sexual intercourse until the urinary catheter is removed." B. " I can participate in sexual activity but might not experience orgasm." C. " I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay." D. " I should be able to participate in sexual activity, but I will be infertile."

D. Drawing a mark around the site Rationale: Do assessment first before implementation. A dime-sized bright red spot on the ace bandage immediately after surgery is normal.

Which of the following actions would be the priority for a client who has been in postanesthesia care unit (PACU) for 45 mins after an above-the-knee amputation and develops a dime-sized bright red spot on the ace bandage above the amputation site? A. Elevating the stump. B. Reinforcing the dressing. C. Calling the surgeon D. Drawing a mark around the site

C. Tooth Brushing Rationale: After cataract extraction, activities that may increase IOP should be avoided, like bending and stooping (tooth brushing).

Which of the following activities is contraindicated immediately after cataract extraction? A. Eating B. Shaving C. Tooth Brushing D. Sleeping

C. Exceeding prescribed exercise program. Rationale: Exceeding prescribed exercise program will further cause strain at the back. This should be avoided by the client with low backpain.

Which of the following activities would the nurse instruct the client with low back pain to avoid? A. Keeping the object below the level of the elbows when lifting. B. Leaning forward while bending the knees. C. Exceeding prescribed exercise program. D. Sleeping on the side with legs flexed.

B. Gingival hyperplasia Rationale: Dilantin (Phenytoin) may cause gingival hyperplasia. This can be avoided or relieved by providing good oral care, massaging the gums using soft bristled toothbrush and having regular dental check up.

Which of the following adverse effects may occur during Phenytoin (Dilantin) therapy? A. Dry mouth B. Gingival hyperplasia C. Urinary incontinence D. Tachycardia

B. The client has difficulty understanding women's voice Rationale: Presbycussis is a sensorineural hearing loss common among elderly males. It is characterized by difficulty understanding high-pitched sounds, like women's voice. Sensorineural hearing loss is characterized by hearing better in a quiet environment; Weber's test reveals that vibration of tuning fork is perceived better in the good ear; the client hears but does not understand telephone conversation.

Which of the following assessment findings indicate presbycussis? A. The client has difficulty hearing in quiet environment. B. The client has difficulty understanding women's voice C. The client's Weber's test indicates that vibration of tuning fork is perceived better in the poor ear. D. The client hears and understands telephone conversation well.

C. Degeneration of the substantia nigra, depleting dopamine.

Which of the following best describes Parkinson's disease? A. An autoimmune response that destroys acetylcholine. B. Bleeding into brainstem. C. Degeneration of the substantia nigra, depleting dopamine. D. Loss of myelin sheath surrounding peripheral nerves.

B. Facial nerve

Which of the following cranial nerves is most frequently affected by acoustic neuroma? A. Olfactory nerve B. Facial nerve C. Oculomotor nerve D. Trochlear nerve

C. gastroscopy

Which of the following diagnostic exam is most conclusive for gastric ulcer? A. ultrasound B. gastric analysis C. gastroscopy D. UGIS

A. Tagamet (Cimetidine)

Which of the following drugs will reduce HCl secretion? A. Tagamet (Cimetidine) B. Maalox (Al-Mg-OH) C. Probanthine (Propantheline Bromide) D. Carafate (Sucralfate)

A. Ptosis Rationale: Ptosis or drooping of the eyelid is an early sign commonly seen in myasthenia gravis. This is a sign of muscle weakness.

Which of the following is an early sign commonly seen in myasthenia gravis? A. Ptosis B. Respiratory distress C. Dysphagia D. Fatigue lessened at the end of the day

C. Teach controlled coughing and deep breathing. Rationale: Coughing should be avoided in a client with increased ICP. This will further increase the ICP. Providing a quiet and darkened room is an appropriate nursing intervention for the client. This measure reduces environmental stimuli and prevents seizures. Elevating the head of the bed (HOB) 15 to 30 degrees reduces ICP by gravity. Limiting fluid intake (1,200 to 1,500 m/day) reduces CSF production and ICP.

Which of the following is inappropriate nursing intervention for the client with increased ICP? A. Provide a quiet and darkened room. B. Elevate the head of bed 15 to 30 degrees. C. Teach controlled coughing and deep breathing. D. Limit fluid intake.

B. High fiber diet

Which of the following is not a risk factor for Ca of the colon? A. high animal fat intake B. High fiber diet C. high protein diet D. High refined carbohydrates intake

C. deep, rapid respirations

Which of the following is not characteristic manifestation of a client with peritonitis? A. board-like rigidity of the abdomen B. remains motionless in bed with knees drawn up over the abdomen C. deep, rapid respirations D. Nausea & vomiting

A. Demyelination of nerve fibers interfering with nerve transmission.

Which of the following pathophysiological processes characterizes multiple sclerosis? A. Demyelination of nerve fibers interfering with nerve transmission. B. Destruction of basal ganglia. C. Degeneration of nucleus pulposus causing pressure on spinal cord. D. Chronic inflammation of the meninges of the brain.

A. Urine output increased

Which of the following results would best show that Mannitol is effective in the client with increased ICP? A. Urine output increased B. Pupils are 8mm and nonreactive C. Systolic BP= 150mmHg D. BUN and creatinine levels return to normal

A. hypersecretion of HCl

Which of the following statements describes duodenal ulcer? A. hypersecretion of HCl B. epigastric pain 1/2 to 1 hour after eating C. normal gastric emptying rate D. usually affects older people

C. Checking for previous complaints of claustrophobia. Rationale: In MRI, the client will be placed in a tunnel-like device. Therefore, it is important to assess for claustrophobia (fear of being in an enclosed space).

Which of the following would be appropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc? A. Informing the client that the procedure is painless. B. Taking a thorough history of past surgeries. C. Checking for previous complaints of claustrophobia. D. Starting an intravenous line at keep-open rate.

B. " Tell me more about how you're feeling." Rationale: Focusing on client's feelings and allowing him to verbalize are therapeutic nursing actions.

While the nurse is providing preop teaching, the client says, "I hate the idea of being an invalid after they cut off my leg". Which of the following would the nurse's most therapeutic response? A. " At least you will have one good leg to use." B. " Tell me more about how you're feeling." C. "Let's finish the preop teaching." D. "You're lucky you have a wife to care for you."