MS LECTURE

NUR 149

1. As a PH nurse, you serve a diverse population . What individual would

likely face the highest risk for patients?

C. cayenne, 63, whose medication regimen includes an

anticholinergic

2. as a nurse assigned for the care of pepper diagnosed with sialadenitis,

you appreciate that she understands her condition by stating which of the
following?

D. the most common cause of the condition in the hospitalized clients

in E.coli.

3. As a student nurse, you understand sleep-up approach in managing

GERD by stating:

D. starring first with antacids, and H2 Blockers, and finally PPI

4. Which statement by the husband of pepper with a percutaneous

gastrostomy tube indicates understanding of your care teaching?

A. I must flush the tube with water after feedings and clamp the tube.
5. Orah has been scheduled for a temporary colostomy due to her colon
cancer. You are knowledgeable that the proximal end of a double barrel
colostomy:

B. is the opening on the distal end on the client left side

6. During the irrigation of a colostomy. Orah complains of abdominal

cramps. What your appropriate nursing actions?

B. stop the irrigation temporarily

7. Being a student nurse, you are knowledgeable about with the most
frequent complication of having an ileostomy. This is

D. fluid and electrolyte imbalance

8. Best understanding of the nature of creating knock pouch if she make

which

9. Orah with acute gastritis asks you about what could have been caused it.
What is your least correct response?

D.

10. Orah has been admitted to health care facility with a diagnosis of
bleeding gastric ulcer. You expect her stools to be:

B.
11. As a student nurse, you are knowledgeable that the pernicious anemia
may accompany gastritis due to:

D. hypochlorhydria resulting from an increase in acid-secreting

parietal cells and degradation of RBCCs.

C. ?

12. On review of the billroth II procedure - postoperative orders, which of

the following, if prescribed, would you question and verify?

A. Irrigating the nasogastric (NG) tube

13. You are doing an admission assessment on pepper with a history of duodenal
ulcer. To determine whether the problem is currently active, you would assess her for
which of the following most frequent symptom?

A. pain that is relieved by food intake

14. Tabasco, 55, has been experiencing severe clostridium difficile-

diarrhea. When reviewing his most recent laboratory tests, you should
prioritize which of the following?

D. Potassium level

15. Orah is diagnosed with celiac disease with the following presenting symptoms:
abdominal distension, severe weight loss, and diarrhea. As her nurse you determine
that the goals of dietary teaching have been met she selects from the menu:

A.
16. Pepper with diverticulosis is prescribed with psyllium ( metamucil). S nurse, you
know that the drug acts as a laxative by:

C.

17. When preparing tabasco, 51, for surgery to treat appendicitis, you as his nurse
formulate a nursing diagnosis of risk for infection r/t inflammation, perforation , and
surgery. What is the rationale for choosing this nursing diagnosis??

B. obstruction of the appendix reduces arterial flow, leading to ischemia,

inflammation, and rupture of the appendix.

18. Pepper is admitted to the hospital after not having has a bowel movement in several
days the nurse observes that she is having small liquid stools, a grossly distended
abdomen, and abdominal cramping. What complication she develops related to this
problem?

B. Bowel perforation

19. In contrast to diverticulitis, cayenne with diverticulosis

B.

20. As a newly-hired nurse in the facility, you are caring for cayenne with complains of
dysphagia, fullness in the neck, and gurgling noises after eating. Diverticulum is
suspected. You understand that diverticulum.

21. You are planning a staff development in-service for health care staff on how to care
for clients with hepatitis A. Which of the following precautions would you indicate as
NOT essential to pepper who has been recently diagnosed with hepatitis A.
A.

22. When developing a plan of care for pepper you should incorporate the primary
treatment for her would be ensuring that she receives

A. adequate bed rest

23. Cayenne, a baby born from a (+) hepatitis B infected mother should be expected by
the nurse to be treated with which of the following?

C.

24. Pepper, diagnosed with severe jaundice, has a nursing diagnosis of altered body
image related to jaundice. When she says . will i always be this horrible color?, the
nurse replies;

B. No, The color will fade gradually as liver inflammation decreases

25. The nurse performs a home care visit on tabasco with a diagnosis of right -sided
cerebrovascular accident. His wife states that she is having frequent loose stools, and
the physician diagnosed viral gastroenteritis. The nurse would be MOST concerned if
which following was observed?

D. The wife is preparing lunch for herself and her husband

26. As the nurse you should recognize that ascites develops from her cirrhosis because
of portal hypertension and

D. a decreased serum albumin level

27. Which of the following positions would be most appropriate for a client with severe
ascites?
A. Fowler's

28. As the nurse you are caring for tabasco with

29. The doctor orders oral neomycin as well as a neomycin enema for a client with
cirrhosis. the nurse understands that the purpose of this therapy is to

C. block ammonia formation

30. Tabasco has been given with lactulose (cephulac) to decrease serum ammonia
level. Which of the following side effects is common?

C.

31. Which of the following instructions should be made by you as her nurse prior to
paracentesis?

B.

32. You help Orah to assume the proper position for a paracentesis, which is:

D.

33. Cayennes initial course of treatment would probably consist of

A.
34. Because her symptoms continue to recur, she is now scheduled for gallbladder
surgery. Cayenne has signed a consent from for removal of her gallbladder ang ligation
of the cystic duct and artery. Post- operative nursing observation includes assessing for:

D.

35. A patient with esophageal varices complicating from portal hypertension would be
at risk for bleeding when there is?

A.

36. As a student nurse who is currently reviewing pharmacology in the ward , you are
knowledgeable that this drug is used as a chelating agent because it helps interfere with
copper absorption in the stomach and intestine. This is:

C.

37. Which of the following reasons why liver recipient are especially susceptible to
infection after transplant?

B.

38. Which of the following clients would most likely be expected by the nurse that the
physician would consider liver transplantation?

C.

39. Orah has a diagnosis of acute cholecystitis with biliary colic. In addition to pain in
the right upper quadrant the nurse should expect her to have?
40. Which of the following statements of Orah would most likely indicate that she is
experiencing steatorrhea?

C.

41. When teaching about diabetes mellitus ( DM) and diet, it is important that both
pepper and family understand that the diet for management of DM.

B.

42. Which of the statement is true about two-hour post-prandial blood test?

D.

43. The prescribed diabetic diet should consist of:

B OR D?

44. In the acute phase of DKA, the priority nursing action to prepare to:

B?

45. Cayenne with type 2 diabetes mellitus has a blood glucose level greater than 700
mg/dl and is complaining of polydipsia, polyuria, and weakness. As her nurse you would
expect to note which of the following diagnoses?

D.
46. Pepper with type 1 diabetes mellitus has an inadequate understanding of the peak
action of neutral protamine hagedorn (NPH) insulin given at 7 am and exercise when
she states that:

B.

47. A blood glucose level reading is obtain on pepper, and the result is 30 mg/dL. Which
of the following medications would you anticipate to be prescribed for her as the nurse
on-duty?

C.

48. The nurse on-duty notifies pepper that which of the following would be noted in
hypoglycemic reaction?

B. tremors

49. Which health education is important to include about insulin administration?

A.

50. As the nurse, you are assessing the learning readiness of pepper with newly
diagnosed diabetes mellitus. Which behavior indicates that there is no readiness to
learn yet?

A. She complains of fatigue whenever the nurse plan a teaching session.

51. The nurse is performing as assessment on orah with a diagnosis of cushing's

syndrome. Which of the following would the nurse expect to note on assessment of the
client?
C. hirsutism

52. A nurse is developing a plan of care for Orah with cushing's syndrome . she has a
nursing diagnosis of excess fluid volume. The nurse understands that which of the
following is unnecessary to indicate in the plan of care?

B. monitor daily weight

53. As the nurse on-duty, you are providing discharge instructions to a tabasco who has
addison's disease. Which statement by him indicates that instructions related to dietary
management are understood?

D. i can eat foods that have lots of potassium in them.

54. In your MS class, you have learned as a student nurse that a pheochromocytoma
causes arterial hypertension by increasing the level of circulating:

C.

55. You are assessing a pepper with hyperthyroidism. What findings should you expect
to document?

56. When instructing cayenne who has been diagnosed with hyperaldosteronism about
her diet, the nurse should stress the importance of which of the following?

57. A newly- hired nurse is caring for orah who has been diagnosed with
hyperaldosteronism ( conn's syndrome). The nurse is correct when she states which of
the following manifestations, but one.
A.

58. Orah has undergone bilateral adrenalectomy, and is having severe hyperkalemia.
The nurse expects this medication to be ordered. This is:

C.

59. Tabasco is to be diagnosed with the presence of pheochromocytoma, and will

undergo vanillylmandelic acid test which of the following should be done?

C.

60. Pepper had undergone bilateral adrenalectomy. As her assigned nurse , which of
the following is expected for her post-operatively?

A.

61. Tabasco , an 85 year old alzheimer's client i being treated for malnutrition and
dehydration. The nurse decides to place him closer to the nurses station because of his
tendency for.

D. roam around

62. Pepper comes to the ER complaining of headache, malaise, chills, fever and stiff
neck. Vital signs assessment reveals a temperature elevation, increased HR & RR, and
normal BP. on physical examination , the nurse notes confusion, a petechial rash,
nuchal rigidity, ( +) brudzinski’s sign & kernig's sign.what does brudzinski's sign
indicate?

D. Meningeal irritation

63. If pepper suddenly has petit mal seizure, the nurse should:
64. Brain abscess may occur as a result of pathogenic invasion to the cranial cavity
which may be caused by the following BUT

B.

65. Cayenne , a 19 year old epileptic hip-hop and cheer dancer, is about to be
discharged from the facility. Which of the following health teachings may NOT be
helpful for her?

A.

66. Tabaso , with a T1 spinal cord injury (SCI) , arrives at the ER with a BP of 82/40, PR
of 34 , dry skin , and flaccid paralysis of the lower extremities . which of the following
conditions would most likely be suspected by nurse on-duty?

C.

67. A neurologic unit nurse is caring for pepper who has been diagnosed of a
degenerative neurologic condition. Which of the following statements by her significant
other will make the nurse suspect Guillain-barre syndrome ( GBS) ?

A.

68. Orah, a client from Batanes with multiple sclerosis is exhibiting linthoff sign. The
nurse caring for her describes this manifestation as:

D.
69. A client was admitted to the neurologic unit due to severe abnormality in muscle
control. As the neurologic nurse , you observe that the client is exhibiting chronic
movements accompanied by facial grimacing and

70. As a student nurse currently taking anatomy and physiology, you are knowledgeable
that the myelin sheaths of the fracture within the peripheral nervous system are formed
by______ whereas those in the central nervous system are formed by _____

D.

71. A seminar is conducted about spinal cord injuries (SCI) which is a prevalent
neurological condition in the clinical settings. Which of the following information shared
in the lecture is questionable?

72. Mr. tabasco pepper was transferred from ICU to the neurologic unit after his GCS
score improved. He is still presenting manifestations of upper body weakness but
normal lower body strength. As his nurse-on-duty, you suspect that mr. pepper has:

C. central cord syndrome

73. A nurse in the intensive care unit is assessing the neurological status of a client with
increased intracranial pressure using the Glasgow coma scale (GCS). The nurse
observes that his client is extremely lethargic, will only open his eyes to painful
mandibular pressure and touching his chin. The nurse asks the client’s name and the
client responded by me? I am at home with my banana “ What is his verbal response
score?

C. 4
74. As the nurse on-duty, you observe that decerebrate posturing is a comatose clients
response to painful stimuli. Mr.pepper exhibits extended and pronated arms, flexed
wrists with palms facing backward, and rigid legs extended with plantar flexion.
Decebrate posturing as a response to pain indicates which of the following?

C. dysfunction in the brain stem.

75. Cayenne is considered in terminal condition after being involved in a motor vehicle
accident in which she sustained massive trauma to the head. As her ICP increase and
condition worsens, the family asks you what indications of approaching death will there
be. What would be your best response?

D. Loss of brainstem reflexes is a sign of approaching death

76. Cayenne has been severely beaten from the accident has been admitted to the
emergency department. The nurse suspects a basilar skull fracture after assessing:

A. raccoon's eyes and Battle sign

77. As a student nurse currently taking MS lecture regarding neurologic disorders,

arrange the following pathophysiologic events of increased intracranial pressure to their
appropriate sequence.

IV. Increased in the volume of cerebrospinal fluid, cerebral blood flow, of CNS tissue
V. Displacement of CSF into spinal cavity
I. Decreased cerebral blood flow
III. Accumulation of acid in the brain causing cerebral injury and swelling
II. Brain herniation

D. IV,V,I,III,II

78. Cayenne is undergoing testing to confirm a diagnosis of myasthenia gravis ( MG).

The nurse explains that a diagnosis of MG is made if muscle function improves after
she receives an IV injection of a medication. What is the medication ordered to be
administered during this test?
B. Edrophonium (Enlon)

79. Pupillary changes may also be noticeable for client with increased intracranial
pressure ( IICP). Which pupillary condition is appropriately matched to its description?

d. Pinpoint pupils – pupillary response to damage of pons

80.
81. B
82.
83. D
84. A
85. A
86.