PNLE : Medical Surgical Nursing
Exam 3
Text Mode – Text version of the exam
1. Lisa is newly diagnosed with asthma and is being discharged from
the hospital after an episode of status asthmaticus. Discharge
teaching should include which of the following:
A. Limitations in sports that will be imposed by the illness
B. Specific instructions on staying cal during an attack
C. The relationship of symptoms and a specific trigger such as
physical exercise
D. Incidence of status asthmaticus in children and teens
2. Which of the following symptoms is most characteristic of a client
with a cancer of the lung?
A. air hunger
B. exertional dyspnea
C. cough with night sweats
D. persistent changing cough
3. The client has ST segment depression on his 12-lead ECG. The
nurse determines that this would indicate the following:
A. necrosis
B. injury
C. ischemia
D. nothing significant
4. Red has just returned from the postanesthesia care unit (PACU)
from a hemorrhidectomy. His postoperative orders include sitz baths
every morning. The nurse understands that sitz bath is use for:
A. promote healing
B. relive tension
C. lower body temperature
D. cause swelling
5. Trousseau’s sign is associated with which electrolyte imbalance?
A. hyponatremia
B. hypocalcemia
C. hypernatremia
D. hypercalcemia
6. A 36 year old female complains of headache and neck pain. The
nurse’s assessments reveal painful flexion of the neck to the chest.
The nurse understands that nuchal rigidity is associated with:
A. brain tumor
B. CVA
C. meningitis
D. subdural hematoma
7. The nurse teaching the client about behavioral changes, which
can affect development of atherosclerosis, should discuss which of
the following as a non-modifiable risk factor for atherosclerosis?
A. cigarette smoking
B. hyperlipidemia
C. female over 55 years of age
D. sedentary lifestyle
8. A 76 year old man enters the ER with complaints of back pain and
feeling fatigued. Upon examination, his blood pressure is 190/100,
pulse is 118, and hematocrit and hemoglobin are both low. The
nurse palpates the abdomen which is soft, non-tender and
auscultates an abdominal pulse. The most likely diagnosis is:
A. Buerger’s disease
B. CHF
C. Secondary hypertension
D. Aneurysm
9. Nurse Fiona is caring a patient with Raynaud’s disease. Which of
the following outcomes concerning medication regimen is of highest
priority?
A. Controlling the pain once vasospasm occur
B. Relaxing smooth muscle to avoid vasospasms
C. Preventing major disabilities that may occur
D. Avoiding lesions on the feet
10. Mr. Roberto Robles complains of a severe headache and is
extremely anxious. The nurse checks his vital signs and finds him to
have a heart rate of 57 bpm and a blood pressure of 230/110
mmHg. The nurse should also assess for?
A. presence of bowel sounds
B. presence of babinski reflex
C. fecal incontinence
D. urinary catheter patency
11. A 40n year old male patient is complaining of chronic
progressive and mental deterioration is admitted to the unit. The
nurse recognizes that these characteristics indicate a disease that
results in degeneration of the basal ganglia and cerebral cortex. The
disease is called:
A. multiple sclerosis
B. myasthenia gravis
C. Huntington’s disease
D. Guillain-Barre syndrome
12. Dianne Hizon is a 27 year old woman who has been admitted to
the ER due to severe vomiting. Her ABG values are pH= 7.50,
PaCO2= 85, HCO3= 31, and SaO2= 93%. The nurse interpretation
of this ABG analysis is:
A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis
13. Mr. Perkson has a parkinson’s disease and he finds the resting
tremor he is experiencing in his right hand very frustrating. The
nurse advises him to:
A. take a warm bath
B. hold an object
C. practice deep breathing
D. take diazepam as needed
14. A shuffling gait is typically associated with the patient who has:
A. Parkinson’s disease
B. Multiple sclerosis
C. Raynaud’s disease
D. Myasthenia gravis
15. The priority in preparing the room for a client with a C7 spinal
cord injury is having:
A. the halo brace device
B. a catheterization tray
C. a ventilator on stand by
D. the spinal kinetic bed
16. A 47 year old man with liver failure who has developed ascites.
The nurse understands that ascites is due to:
A. dehydration
B. protein deficiency
C. bleeding disorders
D. vitamin deficiency
17. A client with rheumatoid arthritis may reveal which of the
following assessment data:
A. Heberden’s nodes
B. Morning stiffness no longer than 30 minutes
C. Asymmetric joint swelling
D. Swan neck deformities
18. Elsa Santos is a 18 year old student admitted to the ward with a
diagnosis of epilepsy. She tells the nurse that she is experiencing a
generalized tingling sensation and is “smelling roses”. The nurse
understands that Esla is probably experiencing:
A. an acute alcohol withdrawal
B. an acute CVA
C. an aura
D. an olfactory hallucination
19. Mr. Lucas, a 63 year old, went to the clinic complaining of
hoarseness of voice and a cough. His wife states that his voice has
changed in the last few months. The nurse interprets that Mr.
Lucas’s symptoms are consistent with which of the following
disorders:
A. chronic sinusitis
B. laryngeal cancer
C. gastroesophageal reflux disease
D. coronary artery disease
20. Sarah complains of a nursing sensation, cramping pain in the top
part of her abdomen that becomes worse in the afternoon and
sometimes awakes her at night. She reports that when she eats, it
helps the pain go away but that pain is now becoming more intense.
Which of the following is the best condition for the nurse to draw:
A. these symptoms are consistent with an ulcer
B. The client probably has indigestion
C. A snack before going to bed should be advised
D. The client probably developing cholelithiasis
21. Nurse Cynthia is providing a discharge teaching to a client with
chronic cirrhosis. His wife asks her to explain why there is so much
emphasis on bleeding precautions. Which of the following provides
the most appropriate response?
A. “The low protein diet will result in reduced clotting.”
B. “The increased production of bile decreases clotting factors.”
C. “The liver affected by cirrhosis is unable to produce clotting
factors.”
D. “The required medications reduce clotting factors.”
22. Betty Lee is a 58 year old woman who is being admitted to the
medical ward with trigeminal neuralgia. The nurse anticipates that
Mr. Lee will demonstrate which of the following major complaints?
A. excruciating, intermittent, paroxysmal facial pain
B. unilateral facial droop
C. painless eye spasm
D. mildly painful unilateral eye twitching
23. A 38 year old woman returns from a subtotal thryroidectomy for
the treatment of hyperthyroidism. Upon assessment, the immediate
priority that the nurse would include is:
A. Assess for pain
B. Assess for neurological status
C. Assess fluid volume status
D. Assess for respiratory distress
24. Nurse Shiela is teaching self-care to a client with psoriasis. The
nurse should encourage which of the following for his scaled lesion?
A. Importance of follow-up appointments
B. Emollients and moisturizers to soften scales
C. Keep occlusive dressings on the lesions 24 hours a day
D. Use of a clean razor blade each time he shaves
25. A 48 year old woman presents to the hospital complaining of
chest pain, tachycardia and dyspnea. On exam, heart sounds are
muffled. Which of the following assessment findings would support a
diagnosis of cardiac tamponade?
A. A deviated trachea
B. Absent breath sounds to the lower lobes
C. Pulse 40 with inspiration
D. Blood pressure 140/80
Answers and Rationales
1. C. The relationship of symptoms and a specific trigger such as
physical exercise. COPD clients have low oxygen and high carbon
dioxide levels. Therefore, hypoxia is the main stimulus for
ventilation is persons with chronic hypercapnea. Increasing the
level of oxygen would decrease the stimulus to breathe.
2. D. persistent changing cough. The most common sign of lung
cancer is a persistent cough that changes. Other signs are
dyspnea, bloody sputum and long term pulmonary infection.
Option A is common with asthma, option B is common with COPD
and option C is common with TB.
3. C. ischemia. Depressed ST segment and inverted T-waves
represent myocardial ischemia. Injury has a ST segment
elevation.
4. A. promote healing. Sitz bath provides moist heat to the perineal
and anal area to clean, promote healing and drainage and
reduce soreness to the area. Sitz bath helps healing with
cleaning action and promotion of circulation, thereby reducing
swelling. Sitz bath usually has no therapeutic value in lowering
body temperature. Although relief of tension can occur, this
effect is secondary to the promotion of healing.
5. B. hypocalcemia. Trousseau’s sign is a carpal pedal spasm
elicited when a blood pressure cuff is inflated on the arm of a
patient with hypocalcemia.
6. C. meningitis. A patient with meningitis will exhibit signs that
include photophobia and nuchal rigidity, which is pain on the
flexion of the chin to chest.
7. C. female over 55 years of age. Lifestyle, cigarette smoking and
hyperlipidemia can be changed by changing behaviors.
8. D. Aneurysm. The symptoms exhibited by the client are typical of
an abdominal aortic aneurysm. The most significant sign is the
audible pulse in the abdominal area. If hemorrhage were
present, the abdomen would be tender and firm.
9. B. Relaxing smooth muscle to avoid vasospasms. The major task
of the health care team is to medicate the client drugs that
produce smooth muscle relaxation, which will decrease the
vasospasm and increase the arterial flow to the affected part.
The drugs used are calcium antagonists.
10. D. urinary catheter patency. The patient is complaining of
symptoms of autonomic dysreflexia, which consists of the triad
of hypertension, bradycardia and a headache. Major causes of
autonomic dysreflexia include urinary bladder distention and
fecal impaction. Checking the patency of the urinary catheter will
check for bladder distention.
11. C. Huntington’s disease. Huntington’s disease is a hereditary
disease in which degeneration of the basal ganglia and cerebral
cortex causes chronic progressive chorea (muscle twitching) and
mental deterioration, ending in dementia. Huntington’s disease
usually strikes people ages 25 to 55.
12. D. metabolic alkalosis. Ms. Hizon’s pH is above 7.45, which
makes it alkalatic, and her bicarbonate is high which is also
makes it basic. Thus, the diagnosis is metabolic alkalosis.
13. B. hold an object. The resting or non-intentional tremor may be
controlled with purposeful movement such as holding an object.
A warm bath, deep breathing and diazepam will promote
relaxation but are not specific interventions for tremor.
14. A. Parkinson’s disease. A shuffling gait from the
musculoskeletal rigidity of the patient with Parkinson’s disease is
common. Patients experiencing a stroke usually exhibit loss of
voluntary control over motor movements associated with
generalized weakness; a shuffling gait is usually not observed in
stroke patient.
15. C. a ventilator on stand by. Although a ventilator is not
required for injury below C3, the innervation of intercostal
muscles is affected. Hemorrhage and cord swelling extends the
level of injury making it likely that this client will need a
ventilator.
16. B. protein deficiency. Protein deficiency allows fluid to leak out
of the vascular system and third space into the tissues and
spaces in the body such as the peritoneal space. Bleeding
tendencies, dehydration and vitamin deficiency can occur but
don’t cause ascites.
17. D. Swan neck deformities. Swan neck deformities of the hand
are classic deformities associated with rheumatoid arthritis
secondary to the presence of fibrous connective tissue within the
joint space. Clients with RA do experience morning stiffness, but
it can last from 30 minutes up to several hours. RA is
characterized by symmetrical joint movement, and heberden’s
nodes are characteristic of osteoarthritis.
18. C. an aura. An aura frequently precedes an epileptic seizure
and may manifest as vague physic discomfort or specific aromas.
Patients experiencing auras aren’t having a CVA, substance
withdrawal or hallucination.
19. B. laryngeal cancer. These symptoms, along with dysphagia,
foul-smelling breath, and pain when drinking hot or acidic, are
common signs of laryngeal cancer.
20. A. these symptoms are consistent with an ulcer. The
description of pain is consistent with ulcer pain. The pain is
epigastric and is worse when the stomach is empty and is relived
by food.
21. C. “The liver affected by cirrhosis is unable to produce clotting
factors.” When bile production is reduced, the body has reduced
ability to absorb fat-soluble vitamins. Without adequate Vitamin
K absorption, clotting factors II, VII, IX, and X are not produced in
sufficient amounts.
22. A. excruciating, intermittent, paroxysmal facial
pain. Trigeminal neuralgia is a syndrome of excruciating,
intermittent, paroxysmal facial pain. It manifests as intense,
periodic pain in the lips, gums, teeth or chin. The other
symptoms aren’t characteristic of trigeminal neuralgia.
23. D. Assess for respiratory distress. Though fluid volume status,
neurological status and pain are all important assessment, the
immediate priority for postoperative is the airway management.
Respiratory distress may result from hemorrhage, edema,
laryngeal damage or tetany.
24. B. Emollients and moisturizers to soften scales. Emollients will
ease dry skin that increases pruritus and causes psoriasis to be
worse. Washing and drying the skin with rough linens or pressure
may cause excoriation. Constant occlusion may increase the
effects of the medication and increase the risk of infection.
25. C. Pulse 40 with inspiration. Paradoxical pulse is a hallmark
symptom of cardiac tamponade. As pressure is exerted on the
left ventricle from fluid, the natural increase in pressure from the
right ventricle during inspiration creates even more pressure,
diminishing cardiac output.
