Philippine Nursing Board Exam Results | Practice Nursing Questions | Medical Surgical Nursing | Psychiatric Nursing | OB Nursing

MEDICAL SURGICAL NURSING 52 Items

51. Because diet and exercise have failed to control a 63 yr-old client’s blood glucose level, the client is prescribed glipizide (Glucotrol). After oral administration, the onset of action is:
A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
D. 2 to 3 hours

ANS: A
Glipizide begins to act in 15 to 30 minutes. The other options are incorrect.

52. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis

ANS: A
Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don’t cause metabolic acidosis.

53. A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He’s being converted to continuous subcutaneous insulin therapy. While teaching the client bout continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:
A. intermediate and long-acting insulins
B. short and long-acting insulins
C. short-acting only
D. short and intermediate-acting insulins

ANS: C
Continuous subcutaneous insulin regimen uses a basal rate and boluses of short-acting insulin. Multiple daily injection therapy uses a combination of short-acting and intermediate or long-acting insulins.
54. a client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:
A. prevent leaning
B. distribute weight away from the involved side
C. maintain stride length
D. prevent edema

ANS: B
Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Use of a cane won’t maintain stride length or prevent edema.

55. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:
A. hypertension
B. high urine output
C. dry mucous membranes
D. pulmonary crackles

ANS: D
High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren’t directly associated with elevated pulmonary artery wedge pressures.
56. The nurse is caring for a client with a fractures hip. The client is combative, confused, and trying to get out of bed. The nurse should:
A. leave the client and get help
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints
D. order soft restraints from the storeroom

ANS: B
It’s mandatory in most settings to have a physician’s order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility’s policy.

57. For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?
A. hypocalcemia
B. hypercalcemia
C. hypokalemia
D. Hyperkalemia

ANS: A
The client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek’s sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau’s sign (carpal spasm when a blood pressure cuff is inflated for few minutes). These signs aren’t present with hypercalcemia, hypokalemia, or Hyperkalemia.

58. In a client with enteritis and frequent diarrhea, the nurse should anticipate an acid-base imbalance of:
A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

ANS: C
Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates leading to metabolic acidosis. Diarrhea doesn’t lead to respiratory acid-base imbalances, such as respiratory acidosis and respiratory alkalosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis.

59. When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
A. position the client in a supine position
B. elevate the head of the bed 90 degrees during meals
C. encourage the client to remove dentures
D. encourage thin liquids for dietary intake

ANS: B
The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position—not a supine position—when lying down to reduce the risk of aspiration. Encourage the client to wear properly fitted dentures to enhance his chewing ability. Thickened liquids, not thin liquids, decrease aspiration risk.

60. A nurse is caring for a client who has a tracheostomy and temperature of 39º C. which intervention will most likely lower the client’s arterial blood oxygen saturation?
A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of cooling blanket
D. Incentive spirometry

ANS: A
Endotracheal suctioning secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn’t be affected.

61. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:
A. fluid resuscitation
B. infection
C. body image
D. pain management

ANS: D
With a superficial partial thickness burn such as a solar burn (sunburn), the nurse’s main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has a lower priority than pain management.

62. Which statement is true about crackles?
A. They’re grating sounds.
B. They’re high-pitched, musical squeaks.
C. They’re low-pitched noises that sound like snoring.
D. They may be fine, medium, or course.

ANS: D
Crackles result from air moving through airways that contain fluid. Heard during inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They’re classified as fine, medium, or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed pleurae rub together. Continuous, high-pitched, musical squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like gurgles, occur on expiration and sometimes on inspiration. Loud, coarse, low-pitched sounds resembling snoring are called gurgles. These sounds develop when thick secretions partially obstruct airflow through the large upper airways.

63. A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include:
A. scheduling her for annual tuberculin skin testing
B. placing her in quarantine until sputum cultures are negative
C. gathering a list of persons with whom she has had recent contact
D. advising her to begin prophylactic therapy with isoniazid (INH)

Individuals who are tuberculin skin test converters should begin a 6-month regimen of an antitubercular drug such as INH, and they should never have another skin test. After an individual has a positive tuberculin skin test, subsequent skin tests will cause severe skin reactions but won’t provide new information about the client’s TB status. The client doesn’t have active TB, so can’t transmit, or spread, the bacteria. Therefore, she shouldn’t be quarantined or asked for information about recent contacts.

64. The nurse is caring for a client who has had an above the knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that he doesn’t wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client’s problem is:
A. Hopelessness
B. Powerlessness
C. Disturbed body image
D. Fear

ANS: C
Disturbed body image is a negative perception of the self that makes healthful functioning more difficult. The defining characteristics for this nursing diagnosis include undergoing a change in body structure or function, hiding or overexposing a body part, not looking at a body part, and responding verbally or nonverbally to the actual or perceived change in structure or function. This client may have any of the other diagnoses, but the signs and symptoms described in the case most closely match the defining characteristics for disturbed body image.

65. A client with three children who is still I the child bearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon’s preoperative teaching when the client states:
A. “If I should become pregnant again, the child would be delivered by cesarean delivery.”
B. “If I have another child, the procedure may need to be repeated.”
C. “This surgery may render me incapable of conceiving another child.”
D. “This procedure is accomplished in two separate surgeries.”

ANS: B
Because the pregnant uterus exerts a lot of pressure on the urinary bladder, the bladder repair may need to be repeated. These clients don’t necessarily have to have a cesarean delivery if they become pregnant, and this procedure doesn’t render them sterile. This procedure is completed in one surgery.

66. A client experiences problems in body temperature regulation associated with skin impairment. Which gland is most likely involved?
A. Eccrine
B. Sebaceous
C. Apocrine
D. Endocrine

ANS: A
Eccrine glands are associated with body temperature regulation. Sebaceous glands lubricate the skin and hairs, and apocrine glands are involved in bacteria decomposition. Endocrine glands secrete hormones responsible for the regulation of body processes, such as metabolism and glucose regulation.

67. A school cafeteria worker comes to the physician’s office complaining of severe scalp itching. On inspection, the nurse finds nail marks on the scalp and small light-colored round specks attached to the hair shafts close to the scalp. These findings suggest that the client suffers from:
A. scabies
B. head lice
C. tinea capitis
D. impetigo

ANS: B
The light-colored spots attached to the hair shafts are nits, which are the eggs of head lice. They can’t be brushed off the hair shaft like dandruff. Scabies is a contagious dermatitis caused by the itch mite, Sacoptes scabiei, which lives just beneath the skin. Tinea capitis, or ringworm, causes patchy hair loss and circular lesions with healing centers. Impetigo is an infection caused by Staphylococcus or Streptococcus, manifested by vesicles or pustules that form a thick, honey-colored crust.

68. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
A. erythema
B. leukocytosis
C. pressure-like pain
D. swelling

ANS: C
Severe pressure-like pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulites. Erythema, leukocytosis, and swelling are present in both cellulites and necrotizing fasciitis.

69. A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is confirmed if the rash appears:
A. erythematous with raised papules
B. dry and scaly with flaking skin
C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures

ANS: A
Contact dermatitis is caused by exposure to a physical or chemical allergen, such as cleaning products, skin care products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of the exposure and can begin within 1 hour of exposure. Allergic reactions tend to be red and not scaly or flaky. Weeping, crusting lesions are also uncommon unless the reaction is quite severe or has been present for a long time. Excoriation is more common in skin disorders associated with a moist environment.

70. When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?
A. Complaints of intense thirst
B. Moderate to severe pain
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice

ANS: D
Hoarseness indicate injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client’s output is adequate.

71. A client is admitted to the hospital following a burn injury to the left hand and arm. The client’s burn is described as white and leathery with no blisters. Which degree of severity is this burn?
A. first-degree burn
B. second-degree burn
C. third-degree burn
D. fourth-degree burn

ANS: C
Third-degree burn may appear white, red, or black and are dry and leathery with no blisters. There may be little pain because nerve endings have been destroyed. First-degree burns are superficial and involve the epidermis only. There is local pain and redness but no blistering. Second-degree burn appear red and moist with blister formation and are painful. Fourth-degree burns involve underlying muscle and bone tissue.

72. The nurse is caring for client with a new donor site that was harvested to treat a new burn. The nurse position the client to:
A. allow ventilation of the site
B. make the site dependent
C. avoid pressure on the site
D. keep the site fully covered

ANS: C
A universal concern I the care of donor sites for burn care is to keep the site away from sources of pressure. Ventilation of the site and keeping the site fully covered are practices in some institutions but aren’t hallmarks of donor site care. Placing the site in a position of dependence isn’t a justified aspect of donor site care.

73. a 45-yr-old auto mechanic comes to the physician’s office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by:
A. Inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris
B. Suggesting he take aspirin for relief because it’s probably early rheumatoid arthritis
C. Validating his complaint but assuming it’s an adverse effect of his vocation
D. Asking him if he has been diagnosed or treated for carpal tunnel syndrome

ANS: A
Anyone with psoriasis vulgaris who reports joint pain should be evaluated for psoriatic arthritis. Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis, which can be painful and cause deformity. It would be incorrect to assume that his pain is caused by early rheumatoid arthritis or his vocation without asking more questions or performing diagnostic studies. Carpal tunnel syndrome causes sensory and motor changes in the fingers rather than localized pain in the joints.

74. The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember?
A. Use cosmetic camouflage techniques.
B. Protect the graft from direct sunlight.
C. Continue physical therapy.
D. Apply lubricating lotion to the graft site.

ANS: B
To avoid burning and sloughing, the client must protect the graft from sunlight. The other three interventions are all helpful to the client and his recovery but are less important.

75. a 28 yr-old female nurse is seen in the employee health department for mild itching and rash of both hands. Which of the following could be causing this reaction?
A. possible medication allergies
B. current life stressors she may be experiencing
C. chemicals she may be using and use of latex gloves
D. recent changes made in laundry detergent or bath soap.

ANS: C
Because the itching and rash are localized, an environmental cause in the workplace should be suspected. With the advent of universal precautions, many nurses are experiencing allergies to latex gloves. Allergies to medications, laundry detergents, or bath soaps or a dermatologic reaction to stress usually elicit a more generalized or widespread rash.

76. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for:
A. hives
B. a toxin
C. a tubercle
D. a virus

ANS: A
Hives and urticaria are two names for the same skin lesion. Toxin is a poison. A tubercle is a tiny round nodule produced by the tuberculosis bacillus. A virus is an infectious parasite.

77. A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
A. scale
B. crust
C. ulcer
D. scar

ANS: A
A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don’t accompany psoriasis.

78. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?
A. Turn and reposition the client a minimum of every 8 hours.
B. Vigorously massage lotion into bony prominences.
C. Post a turning schedule at the client’s bedside.
D. Slide the client, rather than lifting when turning.

ANS: C
A turning schedule with a signing sheet will help ensure that the client gets turned and thus, help prevent pressure ulcers. Turning should occur every 1-2 hours—not every 8 hours—for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift rather than slide the client to void shearing.

79. Following a full-thickness (3rd degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of the artificial skin when he states that during the first 7 days after the procedure, he’ll restrict:
A. range of motion
B. protein intake
C. going outdoors
D. fluid ingestion

ANS: A
To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

80. A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
A. 9%
B. 18%
C. 27%
D. 36%

ANS: C
According to the Rule of Nines, the posterior and anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27%.

81. The nurse is providing care for a client who has a sacral pressure ulcer with wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?
A. The wound should remain moist form the dressing.
B. The wet-to-dry dressing should be tightly packed into the wound.
C. The dressing should be allowed to dry out before removal.
D. A plastic sheet-type dressing should cover the wet dressing.

ANS: A
A wet-to-dry saline dressing should always keep the wound moist. Tight packing or dry packing can cause tissue damage and pain. A dry gauze—not a plastic-sheet-type dressing—should cover the wet dressing.

82. While in skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home with six other persons. During her visit to the clinic, she asks a staff nurse, “What should my family do?” the most accurate response from the nurse is:
A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to see a physician right away.”
C. “Just be careful not to share linens and towels with family members.”
D. “After you’re treated, family members won’t be at risk for contracting scabies.”

ANS: A
When someone in a group of persons sharing a home contracts scabies, each individual in the same home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop

83. In an industrial accident, client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?
A. A urine output consistently above 100 ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24 hours.
C. Body temperature readings all within normal limits
D. An electrocardiogram (ECG) showing no arrhythmias.

ANS: A
In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn’t a goal. In fact, a 4 lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.

84. The nurse is reviewing the laboratory results of a client with rheumatoid arthritis. Which of the following laboratory results should the nurse expect to find?
A. Increased platelet count
B. Elevated erythrocyte sedimentation rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN) and creatinine levels

ANS: B
The ESR test is performed to detect inflammatory processes in the body. It’s a nonspecific test, so the health care professional must view results in conjunction with physical signs and symptoms. Platelet count, electrolytes, BUN, and creatinine levels aren’t usually affected by the inflammatory process.

85. Which nursing diagnosis takes the highest priority for a client with Parkinson’s crisis?
A. Imbalanced nutrition: less than body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury

ANS: B
In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client who is confined to bed during a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, ineffective airway clearance is the priority diagnosis for this client. Although imbalanced nutrition:less than body requirements, impaired urinary elimination and risk for injury also are appropriate diagnoses for this client, they aren’t immediately life-threatening and thus are less urgent.

86. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
A. Increase the frequency of the catheterizations.
B. Insert an indwelling urinary catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of an invasive one.

ANS: A
As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren’t indicated for this case; the problem isn’t overhydration, rather its urine retention. A condom catheter doesn’t help empty the bladder of a client with urine retention.

87.The nurse is caring for a client who is to undergo a lumbar puncture to assess for the presence of blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which result would indicate n abnormality?
A. The presence of glucose in the CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells (RBCs) in the first specimen tube
D. A pressure of 00 to 250 mmH2O

ANS: D
The normal pressure is 70 to 200 mm H2O are considered abnormal. The presence of glucose is an expected finding in CSF, and RBCs typically occur in the first specimen tube from the trauma caused by the procedure.

88. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:
A. conjunctival sac
B. pupil
C. sclera
D. vitreous humor

ANS: A
The nurse should instill the eyedrop into the conjunctival sac where absorption can best take place. The pupil permits light to enter the eye. The sclera maintains the eye’s shape and size. The vitreous humor maintains the retina’s placement and the shape of the eye.

89. A 52 yr-old married man with two adolescent children is beginning rehabilitation following a cerebrovascular accident. As the nurse is planning the client’s care, the nurse should recognize that his condition will affect:
A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete recovery

ANS: C
According to family theory, any change in a family member, such as illness, produces role changes in all family members and affects the entire family, even if the client eventually recovers completely.

90. Which action should take the highest priority when caring for a client with hemiparesis caused by a cerebrovascular accident (CVA)?
A. Perform passive range-of-motion (ROM) exercises.
B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
D. Apply antiembolism stockings

ANS: B
To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis on the affected side. Although performing ROM exercises, providing pillows for support, and applying antiembolism stockings can be appropriate for a client with CVA, the first concern is to maintain a patent airway.

91. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which fact should the nurse include in the teaching plan?
A. TIA symptoms may last 24 to 48 hours.
B. Most clients have residual effects after having a TIA.
C. TIA may be a warning that the client may have cerebrovascular accident (CVA)
D. The most common symptom of TIA is the inability to speak.

ANS: C
TIA may be a warning that the client will experience a CVA, or stroke, in the near future. TIA symptoms last no longer than 24 hours and clients usually have complete recovery after TIA. The most common symptom of TIA is sudden, painless loss of vision lasting up to 24 hours.

92. The nurse has just completed teaching about postoperative activity to a client who is going to have a cataract surgery. The nurse knows the teaching has been effective if the client:
A. coughs and deep breathes postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt from the floor after he drops it.
D. States that he doesn’t need to wear an eye patch or guard to bed

ANS: C
Bending to pick up something from the floor would increase intraocular pressure, as would bending to tie his shoes. The client needs to wear eye protection to bed to prevent accidental injury during sleep.

93. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called:
A. contusion
B. concussion
C. coup
D. contrecoup

ANS: B
Concussions are considered minor with no structural signs of injury. A contusion is bruising of the brain tissue with small hemorrhages in the tissue. Coup and contrecoup are type of injuries in which the damaged area on the brain forms directly below that site of impact (coup) or at the site opposite the injury (contrecoup) due to movement of the brain within the skull.

94. When the nurse performs a neurologic assessment on Anne Jones, her pupils are dilated and don’t respond to light.
A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell’s palsy

ANS: B
The third cranial nerve (oculomotor) is responsible for pupil constriction. When there is damage to the nerve, the pupils remain dilated and don’t respond to light. Glaucoma, lumbar spine injury, and Bell’s palsy won’t affect pupil constriction.

95. A 70 yr-old client with a diagnosis of left-sided cerebrovascular accident is admitted to the facility. To prevent the development of diffuse osteoporosis, which of the following objectives is most appropriate?
A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises

ANS: C
When the mechanical stressors of weight bearing are absent, diffuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures.

96. A client is admitted with a diagnosis of meningitis caused by Neisseria meningitides. The nurse should institute which type of isolation precautions?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions

ANS: B
This client requires droplet precautions because the organism can be transmitted through airborne droplets when the client coughs, sneezes, or doesn’t cover his mouth. Airborne precautions would be instituted for a client infected with tuberculosis. Standard precautions would be instituted for a client when contact with body substances is likely. Contact precautions would be instituted for a client infected with an organism that is transmitted through skin-to-skin contact.

97. A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, “He was unconscious briefly and then became alert and behaved as though nothing had happened.” Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client’s intracranial pressure (ICP) is increasing, the nurse would expect to observe which of the following signs first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness

ANS: D
With a brain injury such as an epidural hematoma (a diagnosis that is most likely based on this client’s symptoms), the initial sign of increasing ICP is a change in the level of consciousness. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

98. Emergency medical technicians transport a 28 yr-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the highest priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness

ANS: A
In the scenario, airway and breathing are established so the nurse’s next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic assessment is a secondary concern to airway, breathing and circulation. The nurse doesn’t have enough data to warrant putting the client in Trendelenburg’s position.

99. Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client’s plan of care?
A. Perform activities of daily living for the client to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as possible.

ANS: C
Establishing and maintaining a routine is essential to decreasing extraneous stimuli. The client should participate in daily care as much as possible. Attempting to reason with such clients isn’t successful, because they can’t participate in abstract thinking.

100. For a client with a head injury whose neck has been stabilized, the preferred bed position is:
A. Trendelenburg’s
B. 30-degree head elevation
C. flat
D. side-lying

ANS: B
For clients with increased intracranial pressure (ICP), the head of the bed is elevated to promote venous outflow. Trendelenburg’s position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. Side-lying isn’t specifically a therapeutic treatment for increased ICP.

101. In a comatose client, hearing is the last sense to be lost. Therefore, the nurse should always:
A. talk loudly in case the client can hear
B. speak softly before touching the client
C. tell others in the room not to talk to the client
D. tell family members that the client probably can’t hear

ANS: B
Many clients have reported being able to hear when being in a comatose state. Therefore, the nurse should converse as if the client was alert and oriented. Talking loudly is only appropriate if the client is hard of hearing, and family members should be encouraged to talk with the client unless contraindicated.

102. When a client experiences loss of vibratory sense on examination, this indicates:
A. injury to the cranial nerves
B. injury to the peripheral nerves
C. intact cranial nerves
D. intact peripheral nerves

ANS: B
Appropriate perception of vibration indicates intact dorsal column tracts and peripheral nerves. If there’s a loss of vibratory sense, an injury to the peripheral nerves is probable.

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