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1.
If a male client experienced a cerebrovascular
accident (CVA) that damaged the hypothalamus, the
nurse would anticipate that the client has problems
with:
a.
body temperature control.
b.
balance and equilibrium.
c.
visual acuity.
d.
thinking and reasoning.
2.
A female client admitted to an acute care facility
after a car accident develops signs and symptoms of
increased intracranial pressure (ICP). The client is
intubated and placed on mechanical ventilation to
help reduce ICP. To prevent a further rise in ICP
caused by suctioning, the nurse anticipates
administering which drug endotracheally before
suctioning?
a.
phenytoin (Dilantin)
b.
mannitol (Osmitrol)
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c.
lidocaine (Xylocaine)
d.
furosemide (Lasix)
3.
After striking his head on a tree while falling from
a ladder, a young man age 18 is admitted to the
emergency department. Hes unconscious and his
pupils are nonreactive. Which intervention would be
the most dangerous for the client?
a.
Give him a barbiturate.
b.
Place him on mechanical ventilation.
c.
Perform a lumbar puncture.
d.
Elevate the head of his bed.
4.
When obtaining the health history from a male
client with retinal detachment, the nurse expects the
client to report:
a.
light flashes and floaters in front of the eye.
b.
a recent driving accident while changing lanes.
c.
headaches, nausea, and redness of the eyes.
d.
frequent episodes of double vision.
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5.
Which nursing diagnosis takes highest priority for
a client with Parkinsons crisis?
a.
Imbalanced nutrition: Less than body
requirements
b.
Ineffective airway clearance
c.
Impaired urinary elimination
d.
Risk for injury
6.
To encourage adequate nutritional intake for a
female client with Alzheimers disease, the nurse
should:
a.
stay with the client and encourage him to eat.
b.
help the client fill out his menu.
c.
give the client privacy during meals.
d.
fill out the menu for the client.
7.
The nurse is performing a mental status
examination on a male client diagnosed with subdural
hematoma. This test assesses which of the following?
a.
Cerebellar function
b.
Intellectual function
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c.
Cerebral function
d.
Sensory function
8.
Shortly after admission to an acute care facility, a
male client with a seizure disorder develops status
epilepticus. The physician orders diazepam (Valium)
10 mg I.V. stat. How soon can the nurse administer a
second dose of diazepam, if needed and prescribed?
a.
In 30 to 45 seconds
b.
In 10 to 15 minutes
c.
In 30 to 45 minutes
d.
In 1 to 2 hours
9.
A female client complains of periorbital aching,
tearing, blurred vision, and photophobia in her right
eye. Ophthalmologic examination reveals a small,
irregular, nonreactive pupil a condition resulting
from acute iris inflammation (iritis). As part of the
clients therapeutic regimen, the physician prescribes
atropine sulfate (Atropisol), two drops of 0.5% solution
in the right eye twice daily. Atropine sulfate belongs to
which drug classification?
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a.
Parasympathomimetic agent
b.
Sympatholytic agent
c.
Adrenergic blocker
d.
Cholinergic blocker
10.
Emergency medical technicians transport a 27-
year-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 a
compound fracture of his left femur and hes
comatose. We intubated him and hes 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 Trendelenburgs position
d.
Assessing level of consciousness
11.
An auto mechanic accidentally has battery acid
splashed in his eyes. His coworkers irrigate his eyes
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with water for 20 minutes, and then take him to the
emergency department of a nearby hospital, where he
receives emergency care for corneal injury. The
physician prescribes dexamethasone (Maxidex
Ophthalmic Suspension), two drops of 0.1% solution
to be instilled initially into the conjunctival sacs of both
eyes every hour; and polymyxin B sulfate (Neosporin
Ophthalmic), 0.5% ointment to be placed in the
conjunctival sacs of both eyes every 3 hours.
Dexamethasone exerts its therapeutic effect by:
a.
increasing the exudative reaction of ocular tissue.
b.
decreasing leukocyte infiltration at the site of
ocular inflammation.
c.
inhibiting the action of carbonic anhydrase.
d.
producing a miotic reaction by stimulating and
contracting the sphincter muscles of the iris.
12.
Nurse April is caring for a client who underwent
a lumbar laminectomy 2 days ago. Which of the
following findings should the nurse consider
abnormal?
a.
More back pain than the first postoperative day
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b.
Paresthesia in the dermatomes near the wounds
c.
Urine retention or incontinence
d.
Temperature of 99.2 F (37.3 C)
13.
After an eye examination, a male client is
diagnosed with open-angle glaucoma. The physician
prescribes pilocarpine ophthalmic solution (Pilocar),
0.25% gtt i, OU q.i.d. Based on this prescription, the
nurse should teach the client or a family member to
administer the drug by:
a.
instilling one drop of pilocarpine 0.25% into both
eyes daily.
b.
instilling one drop of pilocarpine 0.25% into both
eyes four times daily.
c.
instilling one drop of pilocarpine 0.25% into the
right eye daily.
d.
instilling one drop of pilocarpine 0.25% into the
left eye four times daily.
14.
A female client whos paralyzed on the left side
has been receiving physical therapy and attending
teaching sessions about safety. Which behavior
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indicates that the client accurately understands safety
measures related to paralysis?
a.
The client leaves the side rails down.
b.
The client uses a mirror to inspect the skin.
c.
The client repositions only after being reminded to
do so.
d.
The client hangs the left arm over the side of the
wheelchair.
15.
A male client in the emergency department has
a suspected neurologic disorder. To assess gait, the
nurse asks the client to take a few steps; with each
step, the clients feet make a half circle. To document
the clients gait, the nurse should use which term?
a.
Ataxic
b.
Dystrophic
c.
Helicopod
d.
Steppage
16.
A client, age 22, is admitted with bacterial
meningitis. Which hospital room would be the best
choice for this client?
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a.
A private room down the hall from the nurses
station
b.
An isolation room three doors from the nurses
station
c.
A semiprivate room with a 32-year-old client who
has viral meningitis
d.
A two-bed room with a client who previously had
bacterial meningitis
17.
A physician diagnoses a client with myasthenia
gravis, prescribing pyridostigmine (Mestinon), 60 mg
P.O. every 3 hours. Before administering this
anticholinesterase agent, the nurse reviews the
clients history. Which preexisting condition would
contraindicate the use of pyridostigmine?
a.
Ulcerative colitis
b.
Blood dyscrasia
c.
Intestinal obstruction
d.
Spinal cord injury
18.
A female client is admitted to the facility for
investigation of balance and coordination problems,
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including possible Mnires disease. When
assessing this client, the nurse expects to note:
a.
vertigo, tinnitus, and hearing loss.
b.
vertigo, vomiting, and nystagmus
c.
vertigo, pain, and hearing impairment.
d.
vertigo, blurred vision, and fever.
19.
A male client with a conductive hearing disorder
caused by ankylosis of the stapes in the oval window
undergoes a stapedectomy to remove the stapes and
replace the impaired bone with a prosthesis. After the
stapedectomy, the nurse should provide which client
instruction?
a.
Lie in bed with your head elevated, and refrain
from blowing your nose for 24 hours.
b.
Try to ambulate independently after about 24
hours.
c.
Shampoo your hair every day for 10 days to help
prevent ear infection.
d.
Dont fly in an airplane, climb to high altitudes,
make sudden movements, or expose yourself to loud
sounds for 30 days.
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20.
Nurse Oliver is monitoring a client for adverse
reactions to dantrolene (Dantrium). Which adverse
reaction is most common?
a.
Excessive tearing
b.
Urine retention
c.
Muscle weakness
d.
Slurred speech
21.
The nurse is monitoring a male client for
adverse reactions to atropine sulfate (Atropine Care)
eyedrops. Systemic absorption of atropine sulfate
through the conjunctiva can cause which adverse
reaction?
a.
Tachycardia
b.
Increased salivation
c.
Hypotension
d.
Apnea
22.
A male client is admitted with a cervical spine
injury sustained during a diving accident. When
planning this clients care, the nurse should assign
highest priority to which nursing diagnosis?
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a.
Impaired physical mobility
b.
Ineffective breathing pattern
c.
Disturbed sensory perception (tactile)
d.
Self-care deficient: Dressing/grooming
23.
A male client has a history of painful, continuous
muscle spasms. He has taken several skeletal muscle
relaxants without experiencing relief. His physician
prescribes diazepam (Valium), 2 mg P.O. twice daily.
In addition to being used to relieve painful muscle
spasms, diazepam also is recommended for:
a.
long-term treatment of epilepsy.
b.
postoperative pain management of laminectomy
clients.
c.
postoperative pain management of diskectomy
clients
d.
treatment of spasticity associated with spinal cord
lesions.
24.
A female client who was found unconscious at
home is brought to the hospital by a rescue squad. In
the intensive care unit, the nurse checks the clients
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oculocephalic (dolls eye) response by:
a.
introducing ice water into the external auditory
canal.
b.
touching the cornea with a wisp of cotton.
c.
turning the clients head suddenly while holding
the eyelids open.
d.
25.
shining a bright light into the pupil.
While reviewing a clients chart, the nurse
notices that the female client has myasthenia gravis.
Which of the following statements about
neuromuscular blocking agents is true for a client with
this condition?
a.
The client may be less sensitive to the effects of a
neuromuscular blocking agent.
b.
Succinylcholine shouldnt be used; pancuronium
may be used in a lower dosage.
c.
Pancuronium shouldnt be used; succinylcholine
may be used in a lower dosage.
d.
Pancuronium and succinylcholine both require
cautious administration.
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26.
A male client is color blind. The nurse
understands that this client has a problem with:
a.
rods.
b.
cones.
c.
lens.
d.
aqueous humor.
27.
A female client who was trapped inside a car for
hours after a head-on collision is rushed to the
emergency department with multiple injuries. During
the neurologic examination, the client responds to
painful stimuli with decerebrate posturing. This finding
indicates damage to which part of the brain?
a.
Diencephalon
b.
Medulla
c.
Midbrain
d.
Cortex
28.
The nurse is assessing a 37-year-old client
diagnosed with multiple sclerosis. Which of the
following symptoms would the nurse expect to find?
a.
Vision changes
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b.
Absent deep tendon reflexes
c.
Tremors at rest
d.
Flaccid muscles
29.
The nurse is caring for a male client diagnosed
with a cerebral aneurysm who reports a severe
headache. Which action should the nurse perform?
a.
Sit with the client for a few minutes.
b.
Administer an analgesic.
c.
Inform the nurse manager.
d.
Call the physician immediately.
30.
During recovery from a cerebrovascular
accident (CVA), a female client is given nothing by
mouth, to help prevent aspiration. To determine when
the client is ready for a liquid diet, the nurse assesses
the clients swallowing ability once each shift. This
assessment evaluates:
a.
cranial nerves I and II.
b.
cranial nerves III and V.
c.
cranial nerves VI and VIII.
d.
cranial nerves IX and X.
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1.
Answer A. The bodys thermostat is located in the
hypothalamus; therefore, injury to that area can cause
problems of body temperature control. Balance and
equilibrium problems are related to cerebellar
damage. Visual acuity problems would occur following
occipital or optic nerve injury. Thinking and reasoning
problems are the result of injury to the cerebrum.
2.
Answer C. Administering lidocaine via an
endotracheal tube may minimize elevations in ICP
caused by suctioning. Although mannitol and
furosemide may be given to reduce ICP, theyre
administered parenterally, not endotracheally.
Phenytoin doesnt reduce ICP directly but may be
used to abolish seizures, which can increase ICP.
However, phenytoin isnt administered endotracheally.
3.
Answer C. The clients history and assessment
suggest that he may have increased intracranial
pressure (ICP). If this is the case, lumbar puncture
shouldnt be done because it can quickly decompress
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the central nervous system and, thereby, cause
additional damage. After a head injury, barbiturates
may be given to prevent seizures; mechanical
ventilation may be required if breathing deteriorates;
and elevating the head of the bed may be used to
reduce ICP.
4.
Answer A. The sudden appearance of light
flashes and floaters in front of the affected eye is
characteristic of retinal detachment. Difficulty seeing
cars in another driving lane suggests gradual loss of
peripheral vision, which may indicate glaucoma.
Headache, nausea, and redness of the eyes are signs
of acute (angle-closure) glaucoma. Double vision is
common in clients with cataracts.
5.
Answer B. In Parkinsons crisis, dopamine-
related symptoms are severely exacerbated, virtually
immobilizing the client. A client confined to bed during
such a crisis is at risk for aspiration and pneumonia.
Also, excessive drooling increases the risk of airway
obstruction. Because of these concerns, the nursing
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diagnosis of Ineffective airway clearance takes
highest priority. Although the other options also are
appropriate, they arent immediately life-threatening.
6.
Answer A. Staying with the client and
encouraging him to feed himself will ensure adequate
food intake. A client with Alzheimers disease can
forget how to eat. Allowing privacy during meals, filling
out the menu, or helping the client to complete the
menu doesnt ensure adequate nutritional intake.
7.
Answer C. The mental status examination
assesses functions governed by the cerebrum. Some
of these are orientation, attention span, judgment, and
abstract reasoning. Intellectual functioning isnt the
only cerebral activity. Cerebellar function testing
assesses coordination, equilibrium, and fine motor
movement. Sensory function testing involves
assessment of pain, light-touch sensation, and
temperature discrimination.
8.
Answer B. When used to treat status epilepticus,
diazepam may be given every 10 to 15 minutes, as
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needed, to a maximum dose of 30 mg. The nurse can
repeat the regimen in 2 to 4 hours, if necessary, but
the total dose shouldnt exceed 100 mg in 24 hours.
The nurse must not administer I.V. diazepam faster
than 5 mg/minute. Therefore, the dose cant be
repeated in 30 to 45 seconds because the first dose
wouldnt have been administered completely by that
time. Waiting longer than 15 minutes to repeat the
dose would increase the clients risk of complications
associated with status epilepticus.
9.
Answer D. Atropine sulfate is a cholinergic
blocker. It isnt a parasympathomimetic agent, a
sympatholytic agent, or an adrenergic blocker.
10.
Answer A. In the scenario, airway and breathing
are established so the nurses 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
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circulation. The nurse doesnt have enough data to
warrant putting the client in Trendelenburgs position.
11.
Answer B. Dexamethasone exerts its therapeutic
effect by decreasing leukocyte infiltration at the site of
ocular inflammation. This reduces the exudative
reaction of diseased tissue, lessening edema,
redness, and scarring. Dexamethasone and other
anti-inflammatory agents dont inhibit the action of
carbonic anhydrase or produce any type of miotic
reaction.
12.
Answer C. Urine retention or incontinence may
indicate cauda equina syndrome, which requires
immediate surgery. An increase in pain on the second
postoperative day is common because the long-acting
local anesthetic, which may have been injected during
surgery, will wear off. While paresthesia is common
after surgery, progressive weakness or paralysis may
indicate spinal nerve compression. A mild fever is also
common after surgery but is considered significant
only if it reaches 101 F (38.3 C).
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13.
Answer B. The abbreviation "gtt" stands for
drop, "i" is the apothecary symbol for the number 1,
OU signifies both eyes, and "q.i.d." means four times
a day. Therefore, one drop of pilocarpine 0.25%
should be instilled into both eyes four times daily.
14.
Answer B. Using a mirror enables the client to
inspect all areas of the skin for signs of breakdown
without the help of staff or family members. The client
should keep the side rails up to help with repositioning
and to prevent falls. The paralyzed client should take
responsibility for repositioning or for reminding the
staff to assist with it, if needed. A client with left-side
paralysis may not realize that the left arm is hanging
over the side of the wheelchair. However, the nurse
should call this to the clients attention because the
arm can get caught in the wheel spokes or develop
impaired circulation from being in a dependent
position for too long.
15.
Answer C. A helicopod gait is an abnormal gait
in which the clients feet make a half circle with each
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step. An ataxic gait is staggering and unsteady. In a
dystrophic gait, the client waddles with the legs far
apart. In a steppage gait, the feet and toes raise high
off the floor and the heel comes down heavily with
each step.
16.
Answer B. A client with bacterial meningitis
should be kept in isolation for at least 24 hours after
admission and, during the initial acute phase, should
be as close to the nurses station as possible to allow
maximal observation. Placing the client in a room with
a client who has viral meningitis may cause harm to
both clients because the organisms causing viral and
bacterial meningitis differ; either client may contract
the others disease. Immunity to bacterial meningitis
cant be acquired; therefore, a client who previously
had bacterial meningitis shouldnt be put at risk by
rooming with a client who has just been diagnosed
with this disease.
17.
Answer C. Anticholinesterase agents such as
pyridostigmine are contraindicated in a client with a
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mechanical obstruction of the intestines or urinary
tract, peritonitis, or hypersensitivity to
anticholinesterase agents. Ulcerative colitis, blood
dyscrasia, and spinal cord injury dont contraindicate
use of the drug.
18.
Answer A. Mnires disease, an inner ear
disease, is characterized by the symptom triad of
vertigo, tinnitus, and hearing loss. The combination of
vertigo, vomiting, and nystagmus suggests
labyrinthitis. Mnires disease rarely causes pain,
blurred vision, or fever.
19.
Answer D. For 30 days after a stapedectomy,
the client should avoid air travel, sudden movements
that may cause trauma, and exposure to loud sounds
and pressure changes (such as from high altitudes).
Immediately after surgery, the client should lie flat with
the surgical ear facing upward; nose blowing is
permitted but should be done gently and on one side
at a time. The clients first attempt at postoperative
ambulation should be supervised to prevent falls
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caused by vertigo and light-headedness. The client
must avoid shampooing and swimming to keep the
dressing and the ear dry.
20.
Answer C. The most common adverse reaction
to dantrolene is muscle weakness. The drug also may
depress liver function or cause idiosyncratic hepatitis.
Muscle weakness is rarely severe enough to cause
slurring of speech, drooling, and enuresis. Although
excessive tearing and urine retention are adverse
reactions associated with dantrolene use, they arent
as common as muscle weakness
21.
Answer A. Systemic absorption of atropine
sulfate can cause tachycardia, palpitations, flushing,
dry skin, ataxia, and confusion. To minimize systemic
absorption, the client should apply digital pressure
over the punctum at the inner canthus for 2 to 3
minutes after instilling the drops. The drug also may
cause dry mouth. It isnt known to cause hypotension
or apnea.
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22.
Answer B. Because a cervical spine injury can
cause respiratory distress, the nurse should take
immediate action to maintain a patent airway and
provide adequate oxygenation. The other options may
be appropriate for a client with a spinal cord injury
particularly during the course of recovery but dont
take precedence over a diagnosis of Ineffective
breathing pattern.
23.
Answer D. In addition to relieving painful muscle
spasms, diazepam also is recommended for
treatment of spasticity associated with spinal cord
lesions. Diazepams use is limited by its central
nervous system effects and the tolerance that
develops with prolonged use. The parenteral form of
diazepam can treat status epilepticus, but the drugs
sedating properties make it an unsuitable choice for
long-term management of epilepsy. Diazepam isnt an
analgesic agent.
24.
Answer C. To elicit the oculocephalic response,
which detects cranial nerve compression, the nurse
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turns the clients head suddenly while holding the
eyelids open. Normally, the eyes move from side to
side when the head is turned; in an abnormal
response, the eyes remain fixed. The nurse
introduces ice water into the external auditory canal
when testing the oculovestibular response; normally,
the clients eyes deviate to the side of ice water
introduction. The nurse touches the clients cornea
with a wisp of cotton to elicit the corneal reflex
response, which reveals brain stem function; blinking
is the normal response. Shining a bright light into the
clients pupil helps evaluate brain stem and cranial
nerve III functions; normally, the pupil responds by
constricting.
25.
Answer D. The nurse must cautiously administer
pancuronium, succinylcholine, and any other
neuromuscular blocking agent to a client with
myasthenia gravis. Such a client isnt less sensitive to
the effects of a neuromuscular blocking agent. Either
succinylcholine or pancuronium can be administered
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in the usual adult dosage to a client with myasthenia
gravis.
26.
Answer B. Cones provide daylight color vision,
and their stimulation is interpreted as color. If one or
more types of cones are absent or defective, color
blindness occurs. Rods are sensitive to low levels of
illumination but cant discriminate color. The lens is
responsible for focusing images. Aqueous humor is a
clear watery fluid and isnt involved with color
perception.
27.
Answer C. Decerebrate posturing,
characterized by abnormal extension in response to
painful stimuli, indicates damage to the midbrain. With
damage to the diencephalon or cortex, abnormal
flexion (decorticate posturing) occurs when a painful
stimulus is applied. Damage to the medulla results in
flaccidity.
28.
Answer A. Vision changes, such as diplopia,
nystagmus, and blurred vision, are symptoms of
multiple sclerosis. Deep tendon reflexes may be
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increased or hyperactive not absent. Babinskis
sign may be positive. Tremors at rest arent
characteristic of multiple sclerosis; however,
intentional tremors, or those occurring with purposeful
voluntary movement, are common in clients with
multiple sclerosis. Affected muscles are spastic, rather
than flaccid.
29.
Answer D. The headache may be an indication
that the aneurysm is leaking. The nurse should notify
the physician immediately. Sitting with the client is
appropriate but only after the physician has been
notified of the change in the clients condition. The
physician will decide whether or not administration of
an analgesic is indicated. Informing the nurse
manager isnt necessary.
30.
Answer D. Swallowing is a motor function of
cranial nerves IX and X. Cranial nerves I, II, and VIII
dont possess motor functions. The motor functions of
cranial nerve III include extraocular eye movement,
eyelid elevation, and pupil constriction. The motor
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function of cranial nerve V is chewing. Cranial nerve
VI controls lateral eye movement.
