1. A 43-year-old African American male is admitted with sickle cell anemia.

The nurse plans

to assess circulation in the lower extremities every 2 hours. Which of the following outcome
criteria would the nurse use?

A .Body temperature of 99°F or less

B. Toes moved in active range of motion

C. Sensation reported when soles of feet are touched

D. Capillary refill of < 3 seconds

Answer D is correct. It is important to assess the extremities for blood vessel occlusion in
the client with sickle cell anemia because a change in capillary refill would indicate a
change in circulation. Body temperature, motion, and sensation would not give
information regarding peripheral circulation; therefore, answers A, B, and C are incorrect

2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis.
What is the best position for this client?

A .Side-lying with knees flexed

B. Knee-chest

C. High Fowler's with knees flexed

D. Semi-Fowler's with legs extended on the bed

Answer D is correct. Placing the client in semi-Fowler’s position provides the best
oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest
position, impedes circulation and is not correct positioning for this client. Therefore,
answers A, B, and C are incorrect

3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions
would be of highest priority for this client?

A .Taking hourly blood pressures with mechanical cuff

B. Encouraging fluid intake of at least 200mL per hour

C. Position in high Fowler's with knee patch raised

D. Administering Tylenol as ordered

Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to
prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff
places too much pressure on the arm. Answer C is incorrect because raising the knee gatch
impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the
client in crisis.

4. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and
hypoxemia. Which of the following activities would the nurse recommend?

A. A family vacation in the Rocky Mountains

B. Chaperoning the local boys club on a snow-skiing trip

C. Traveling by airplane for business trips

D.A bus trip to the Museum of Natural History

Answer D is correct. Taking a trip to the museum is the only answer that does not pose a
threat

5. A newly admitted client has sickle cell crisis. The nurse is planning care based on
assessment of the client. The client is complaining of severe pain in his feet and hands. The
pulse oximetry is 92. Which of the following interventions would be implemented first?
Assume that there are orders for each intervention.

A .Adjust the room temperature

B. Give a bolus of IV fluids

C. Start O2

D. Administer meperidine (Demerol) 75mg IV push

Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain.
However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes
precedence over pain relief. Answer A is incorrect because although a warm environment
reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect
because although hydration is important, it would not require a bolus. Answer D is
incorrect because Demerol is acidifying to the blood and increases sickling

6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal
plans would the nurse expect the client to select?

A .Roast beef, gelatin salad, green beans, and peach pie

B. Chicken salad sandwich, coleslaw, French fries, ice cream

C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

D. Pork chop, creamed potatoes, corn, and coconut cake

Answer C is correct. Hydration is important in the client with sickle cell disease to prevent
thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The
foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect

7. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency.
Which of the following would the nurse include in the physical assessment?

A. Palpate the spleen

B. Take the blood pressure

C. Examine the feet for petechiae

D. Examine the tongue

Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12
deficiency, so examining the tongue should be included in the physical assessment.
Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B,
and C incorrect.
8. An African American female comes to the outpatient clinic. The physician suspects vitamin
B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of
anemia, what body part would be the best indicator?

A. Conjunctiva of the eye

B. Soles of the feet

C. Roof of the mouth

D. Shins

The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in
dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a
yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are
calloused, making answer B incorrect; the shins would be an area of darker pigment, so
answer D is incorrect

9. The nurse is teaching the client with polycythemia vera about prevention of complications
of the disease. Which of the following statements by the client indicates a need for further
teaching?

A."I will drink 500mL of fluid or less each day."

B. "I will wear support hose when I am up."

C. "I will use an electric razor for shaving."

D."I will eat foods low in iron

Answer A is correct. The client with polycythemia vera is at risk for thrombus formation.
Hydrating the client with at least 3L of fluid per day is important in preventing clot
formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are
incorrect because they all contribute to the prevention of complications. Support hose
promotes venous return, the electric razor prevents bleeding due to injury, and a diet low
in iron is essential to preventing further red cell formation

10. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the
following interventions would be appropriate for this client?

A .Place the client in Trendelenburg position for postural drainage

B. Encourage coughing and deep breathing every 2 hours

C. Elevate the head of the bed 30°

D. Encourage the Valsalva maneuver for bowel movements

Answer C is correct. The client should be positioned upright and leaning forward, to
prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to
the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If
a pack is necessary, the nares are loosely packed.

11. A client who had a Transsphenoidal hypophysectomy should be watched carefully for
hemorrhage, which may be shown by which of the following signs?
a. Bloody drainage from the ears

b. Frequent swallowing

c. Guaiac-positive stools

d. Hematuria

- Frequent swallowing is a sign of bleeding

12. A client with diagnosis of Diabetic ketoacidosis (DKA) is being treated in an emergency
room. Which finding would a nurse EXPECT to not see s confirming this diagnosis?

A. Increased respiration nd increase in pH

B. Comatose state

C. Decreased urine output

D. elevated blood glucose level and low plasma bicarbonate level

Answer: A.

DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in

available insulin results in disorders in the metabolism of carbohydrate, protein and fat.
The three main clinical features of DKA are: Hyperglycemia, dehydration and electrolyte
loss and acidosis. Acidosis causes a decrease in the blood pH, alkalosis causes an increase
in the blood pH.

13. A factor leaned while obtaining the nursing history that probably predisposed a client to
type ll Diabetes would be:

A Being 20 pounds overweight

B. Having diabetes insipidus

C. Eating low cholesterol foods

D. Drinking a daily alcoholic beverage

Answer: A.

Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of

glucose in the blood resulting from defects in insulin secretion, insulin action, or both.
Type II Diabetes is a metabolic disorder characterized by the relative deficiency of insulin
production and a decreased insulin action and increased insulin resistance. Formerly called
noninsulin dependent or adult onset. Patients are usually obese at diagnosis. Causes
include obesity, heredity or environmental factors.

14. A Client is suspected of develop tetany after a subtotal thyroidectomy. Which of the
following symptoms if experienced by the client might indicate tetany?

A. Bleeding on the back of the dressing

B. Tingling of the fingers

C. Pain in hands and feet

D. Tension on the suture lines

Answer: B.

Occasionally in thyroid surgery the parathyroid glands are injured or removed, producing a
disturbance in calcium metabolism. As the blood calcium level falls, hyperirritability of the
nerves occurs, with spasns of the hands and feet and muscle twitching. This group of
symptoms is termed tetany, and the nurse must immediately report its appearance
because laryngospasm, although rare, may occur and obstruct the airway. Tetany of this
type is usually treated with intravenous calcium gluconate. This calcium abnormality is
usually temporary after thyroidectomy

15. A client with hypothyroidism who experiences trauma, emergency surgery or severe
infection is at risk for developing which of the following conditions?

A. Hepatitis B

B. Malignant hyperthermia

C. Myxedema coma

D. Thyroid storm

Answer: C.

Myxedema coma describes the most extreme, severe stage of hypothyroidism, in which
the patient is hypothermic and unconscious. Myxedema coma may follow increasing
lethargy. Progressing to stupor and then coma. Undiagnosed hypothyroidism may be
precipitated by infection or other systematic disease or by use of sedatives or opioid
analgesic agents. The patient's respiratory drive is depressed, resulting in alveolar
hypoventilation, progressive CO2 retention, narcosis and coma. These symptoms along
with Cardiovascular collapse and shock, require intensive therapy if the patient is to
survive vigorous therapy, however, mortality is high.

16. A physician has prescribed propyl thiouracil hyperthyroidism and the nurse assigned to
tis dent plan of care for the client.

A. Relief of pain

B. Signs of renal toxicity

C. Signs and symptoms of hyperglycemia

D. Signs and symptoms of hypothyroidism

Answer: D.

Antithyroid agents block the Utilization iodine by interfering with iodination of thyrosine
the coupling iodothyosines in the synthesis of thyroid hormones. This prevent the
synthesis of thyroid hormone. The medications are propylthoiuracil or methimazole until
the patient is euthyroid. These medications block extrathyriod conversion of T4 to T3. The
objective of pharmacotherapy is to inhibit one or more stages in thyroid hormone
synthesis hormone release; another goal may be fo reduce the of thyroid tissue, with
resulting decreased thyroid hem production.

17. The nurse assesses for the major symptom Associate pheochromocytoma when he:

A. Takes the client's blood pressure

b. Obtains the client's weight

C. Tests the client's urine for glucose

D. Palpates the skin for its temperature

Answer: A.

Pheochromocytoma is a tumor that is usually begins and originates from the chromaffin
cells of the adrenal medulla. The typical triad of symptoms comprises headache, diaphares
and palpitations. Hypertension and other cardiovascular disturbances are common.
Pheochromocytoma is suspected signs of sympathetic nervous system over activity occur
in association with marked elevation of blood pressure. These sign can be associated with
the five Hs: hypertension, headache hyperhidrosis, hypermetabolism and hyperglycemia.

18. Potassium iodide (lugol's solution) is prescribed For a diet thyrotoxic crisis. The client
calls the clinic nurse and complains a brassy taste in the mouth. Which of the following
APPROPRIATE instruction to the client?

A. Continue with the medication

b. Withhold the medication and notify the physician

C. Take half of the prescribed does for the next 24 hours

D. Withhold the medication for the next hours then continue as prescribed

Answer: B. Potassium iodide inhibits thyroid hormone release reduces thyroid vascularity,
and decreases thyroid uptake radioactive iodine after radiation emergencies or
administration of radioactive iodine isotopes. In long term use, checked for sign and
symptoms of iodism (iodine toxicity) which includes metallic taste (brassy taste), sore
teeth and gums, sore throat, burning mouth and throat, cold-like symptoms, severe
headache productive cough. Gl irritation, diarrhea, angioedema, rash, fever and cutaneous
or mucosal hemorrhage. Discontinue drug immediately if these occur.

19. Which of the following lab results would be EXPECTED in a client suspected of having
Cushing disease?

A. Decrease d unitary calcium level

B. Hypoglycemia

C. Hypokalemia

D. Hyponatremia

Answer C.

Cushing's syndrome results from excessive adrenocortical activity. The signs and
symptoms of the disease primarily a result of over secretion of glucocorticoids of
androgens (sex homones). Although mineralocorticoid Secretion also may be affected.
Indicators of Cushing's syndrome include an increase in serum sodium and blood glucose
levels and a decreased serum concentration of potassium, a reduction in the number of
blood eosinophils and disappearance of lymphoid tissue.

20. An order of oral glucocorticoid has been ordered to a client diagnosed with Addison’s
disease. Which of the following statements made by the client does not need further
teaching?

A. "will take the drug after I have eaten something or with an Antacid."

B. " will take the drug at bedtime to increase absorption."

C. "should take the drug on an empty stomach."

D. "must remember to take the drug with a full glass of Water."

Answer: A.

Oral steroids can cause gastric irritation and ulcers and should be administered with
meals, if possible or otherwise with an antacid. Glucocorticoids should be taken in the
morning, not at bedtime.

21. Before the procedure, the nurse is reviewing the potential complications after
hypophysectomy. Which of the following should the nurse teach the client to monitor as a
sign of complication after the procedure?

A. Diabetes mellitus

B. Acromegaly

C. Hypopituitarism

D. Cushing's disease

Answer: C.

Hypophysectomy is the removal of the pituitary gland, may be performed to treat primary
pituitary gland tumors. it is the treatment of choice in patients with Cushing's Syndrome
due to excessive production of ACTH by a tumor of the pituitary gland. The absence of the
pituitary gland alters the function of many body systems. Menstruation ceases and
infertility occurs after total or near-total ablation of the pituitary gland. The client should
be taught to monitor for change in mental status, energy level, muscle strength and
cognitive function. Acromegally and Cushing's disease are conditions of hypersecretion.

22. For a client diagnosed with Diabetes insipidus, which of the following is a priority
outcome?

A. A serum glucose level within the normal range

B. Adequate knowledge regarding dietary restriction

C. Maintains normal fluid and electrolyte balance

D. Practice proper grooming daily

Answer: C. Diabetes insipidus is g disorder of the posterior lobe of the pituitary gland
characterized by a deficiency of antidiuretic hormone (ADH) or vasopressin. Without the
action of ADH on the distal nephron of the kidney, an enormous dally output of very dilute
water-like urine with a specific gravity or 1001 to 1.005 occurs. The objectives of therapy
are (|) to replace ADH (which is usually a long term therapeutic program (2) to ensure
adequate fluid replacement and (3) to identify and correct underlying pathology.

23. among the following. a priority nursing diagnosis for a client experiencing Addisonian
crisis is:

A. Imbalanced Nutrition More than body requirements related to decreased exercise

B. Excess fluid volume relate to reduced urinary excretion of fluid

C. Self-care deficit related weakness and fatigue

D. Imbalanced Nutrition: More than body requirements related to increase in appetite

Answer C: addisonian crisis is an acute insufficiency, characterized by acute hypertension

fever, nausea and vomiting and the classic sign of shock. The patient with addisonian at
risk for circulation collapse and shock; therefore, physical and psychological stress must be
avoided. These include exposure to cold and emotion distress. During acute addisonian
crisis the patient must avoid exertion: therefore the nurse anticipates the patient’s needs
and takes measures to meet them

24. When providing discharge instructions to a client who had a thyroidectomy, the nurse
should teach the client to observe for signs of surgically induced hypothyroidism which
include:

A. Intolerance to heat

b. Dry skin and fatigue

C .Insomnia and excitability

D. Emaciation and weight loss

Answer: B.

Hypothyroidism results from suboptimal thyroid hormones. Early symptoms

hypothyroidism nonspecific, but extreme fatigue makes it difficult the person to complete
a full day’s work or participate In usual activities reports of hair loss, brittle nail and dry
skin are common an and numbness and tingling of the fingers may occur.

25. A nurse provides instructions to a client admitted with type DM. The nurse recognizes
accurate understanding of measures to prevent DKA when the client states which of the
following?

A. I will stop taking my insulin if fm too sick to eat

B. I will decrease my insulin dose curing times of illness

C. I will adjust my insulin dose during times of illness

D. I will notify my physician if my blood glucose level is higher than 300 mg/d.
Answer: D.

PDKA is caused by an absence or markedly inadequate amount of insulin. For prevention

of DKA related illness, patients must be taught 'sick day rules for managing their diabetes
when ill: (0) Take insulin or oral antidiabetic agents as usual (2) Test blood glucose and test
urine ketones every 3-4 hours (3) report elevated glucose levels. greater than 300 mg/dl
urine ketones to the physician (4 Insulin –requiring patient may need supplemental doses
of regular insulin every 34 hours(5) If vomiting, diarrhea, or fever persists, lake liquids
every %to 1hour to prevent dehydration and to provide calories,

26. Which of the following nursing intervention is MOST appropriate for client experiencing
hypercalcemia

A. Ambulate the client as soon as possible

B. Encourage compliance with fluid restrictions

C. Maintain the client on strict bed rest

D. Encourage the consumption of the green leafy vegetables

Answer: A. Hypercalcemia Serum calcium level greater than l0. 5 mg/dL) reduces
neuromuscular excitability because t Suppresses activity at the Myoneural junction.
Interventions such as increasing patient mobility and encouraging fluids can help prevent
hypercalcemia, or at least minimize its severity.

27. Which statement made by the client who is going home after a Trans sphenoid
hypophysectomy indicates to adequate understanding in action to prevent complications
from his treatment?

A. "I will wear dark glasses whenever am outdoors,"

B. ''I will keep the cat food bowl on my table so that I do not have to bend over ''

C. "I will wash the incision line every day with peroxide and to bend over."

D. " I will remember to cough and deep breathe at least every2hrs while I am awake ."

Answer: B.

The head of the bed is raised to decrease pressure on the sella turcica and to promote
normal drainage. The patient is cautioned against blowing the nose or engaging in any
activity that raises ICP, such as bending over or straining during urination or defecation.

28. The nurse is caring for the patient admitted with a diagnosis of close head injury. If the
patient develops diabetes insipidus, the nurse would observe which of the following?

A. Decelerate posturing, BP 160/100, pulse 56

B. Cracked lips, urinary output of 4L 24 h with a specific gravity of 1.004

C. Glucosuria, osmotic diuresis, loss of water and electrolytes

D. Weight gain of 5lb, pulse116, serum sodium 110 mEq/L

Answer: B.

The inability to increase the specific gravity and Osmolality of the urine is characteristic of
Dl. The patient Continues to excrete large volumes of urine with low specific gravity and
experiences weight loss, increasing serum Osmolality, and elevated serum sodium levels.

29. Agnes is diagnosed to have syndrome of inappropriate antidiuretic hormone (SIADH).

The nurse informs Agnes that the physician will prescribe diuretic therapy and restrict fluid
and sodium intake to treat the disorder. If Agnes will not comply with the recommended
treatment, which complication may arise?

A. Cerebral edema

B. Hypovolemic shock

C. Severe hyperkalemia

D. Tetany

Answer: A

(SADH) secretion includes excessive ADH secretion from the pituitary gland even in the
face of subnormal serum osmolality. Patients cannot excrete a dilute urine, retain fiuids,
and develop a sodium deficiency known as delusional hyponatremia.

30. Nurse Terry is caring for a female client with type l diabetes mellitus who exhibits
Confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse
should first administer:

A. IM or subcutaneous glucagon.

B. IV bolus of dextrose 50%

C. 15 to 20 g of a fast-acting carbohydrate such as orange juice.

D. 10 U of fast-acting insulin.

Answer: C.

This client is having a hypoglycemic episode because the client is conscious, the nurse
should first administer a fast-acting carbohydrate, such Orange juice, hard candy or honey.
If the client has lost consciousness, the nurse to administer either I.M. or subcutaneous
glucagon or an l.V. bolus dextrose 50%. The nurse shouldn’t administer insulin to a client
who's hypoglycemic; this action will further Compromise client's condition

31. A male client with type 1 diabetes mellitus has a highly elevated glycosylated
hemoglobin (HbAlc) test result. In discussing the result with the client, nurse Chary would be
MOST accurate in stating:

A.' 'The test needs to be repeated following a 12-hour fast."

B. ''It looks like you aren't following the prescribed diabetic diet"
C. ''It tells us about your sugar control for the last 3 months."

d. ''Your insulin regimen needs to be altered significantly.''

Answer: C. - Glycated Hemoglobin (Glycohermoglobin, HbAic measures glycemic Control

over a 60 to 120-day period by measuring the irreversible reaction of glucose to
hemoglobin through freely permeable erythrocytes during their 120doyte cycle.

32. Capillary glucose monitoring is being performed every 4 hours for a female client
diagnosed with diabetic ketoacidosis. Insulin administered using a scale of regular insulin
according to glucose results. At 2 PM., the client has a capillary glucose level ot 250 mg/dL
for which he receives 8 U of regular insulin.

Nurse Vince should EXPECT the doses:

A Onset to be at 2 PM and its peak to be at 2 PM

B. Onset to be at 2:30 PM and its peak to be at 4:30 PM

C Onset to be at 4 PM and its peak to be at 6 PM

D. onset to be o at 2:30 PM and its peak to be at 3 PM

Answer: B. Regular insulin, which is a short-acting insulin, has onset of 30 to 60 minutes

and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected
onset would be from 2:30 PM to 3:00 PM and the peak from 4 PM to 6PM

33. Ariella with a history of pheochrornocyoma is admitted to the hospital in an acute

hypertensive crisis. To reverse hypertensive crisis by pheochrornocyoma nurse Claudine
EXPECTS to administer

A. Phentolamine (Regtine)

B. Methyldopa (Adomet)

C. Mannitol (Osmitrol

D. Felodipine (Plendil),

Answer: A. Pheochromocytoma causes excessive production epinephrine and

norepinephrine, natural catecholamines he raise the blood pressure. Phentolamine, an
alpha-adrenergic blocking agent given by .V. bolus or drip, antagonizes he body's response
to circulating epinephrine and norepinephrine reducing blood pressure quickly and
effectively

34. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and
mental confusion. The priority intervention for this client is:

A. Measure the urinary output

B. Check the vital signs

C. Encourage increased fluid intake

D. Weigh the client

Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte
imbalance that should be corrected. The loss of electrolytes would be reflected in the vital
signs. Measuring the urinary output is important, but the stem already says that the client
has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the
problem, making answer C incorrect. Answer D is incorrect because weighing the client is
not necessary at this time.

35. A client has had a unilateral adrenalectomy to remove a tumor. To prevent

complications, the most important measurement in the immediate post-operative period for
the nurse to take is:

A. Blood pressure

B. Temperature

C. Output

D. Specific gravity

Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the
client who has had an adrenal gland removed. The remaining gland might have been
suppressed due to the tumor activity. Temperature would be an indicator of infection,
decreased output would be a clinical manifestation but would take longer to occur than
blood pressure changes, and specific gravity changes occur with other disorders; therefore,
answers B, C, and D are incorrect

36. A client with Addison's disease has been admitted with a history of nausea and vomiting
for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol).Which of the
following interventions would the nurse implement?

A. Glucometer readings as ordered

B. Intake/output measurements

C. Sodium and potassium levels monitor

D. Daily weights

Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage
with insulin. Answer B is not necessary at this time, sodium and potassium levels would be
monitored when the client is receiving mineral corticoids, and daily weights is
unnecessary; therefore, answers B, C, and D are incorrect

37.A client had a total thyroidectomy yesterday. The client is complaining of tingling around
the mouth and in the fingers and toes. What would the nurses' next action be?

A. Obtain a crash cart

B. Check the calcium level

C. Assess the dressing for drainage

D. Assess the blood pressure for hypertension

Answer B is correct. The parathyroid glands are responsible for calcium production and can
be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash
cart would be needed in respiratory distress but would not be the next action to take;
thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would
occur in hemorrhage, so answers C and D are incorrect

38. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight
gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is
diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest
priority?

A. Impaired physical mobility related to decreased endurance

B. Hypothermia r/t decreased metabolic rate

C. Disturbed thought processes r/t interstitial edema

D.Decreased cardiac output r/t bradycardia

Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock,
which would take precedence over the other choices; therefore, answers A, B, and C are
incorrect.

39. Which statement is correct about cerebrospinal fluid (CSF)?

A. If CSF contains glucose, the person has a metabolic disorder.

B. CSF circulates through the brain via the meninges.

C. CSF protects the brain and spinal cord from trauma

D. A lumbar puncture is done to withdraw CSF from the brain.

Answer: C

Cerebrospinal fluid (CSF) cushions the brain tissue and spinal cord, protects them from
trauma, provides nourishment to the brain, and removes waste products.

Situation: The right hand of a client with multiple sclerosis trembles severely whenever
she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her
dress fastened securely.

40. Which nursing diagnosis is appropriate for the client with Multiple Sclerosis, regardless
of type or severity?

A. Fatigue

B. Risk for Aspiration

C. Acute Pain

D. Impaired Gas Exchange

Answer: A

Fatigue affects all patients with MS regardless of type or severity.

41. The doctor ordered Baclofen (Lioresal) for the client. Which indicates effectiveness of the
medication?

A. Induces sleep

B. Stimulates client's appetite

C. Relieves muscular spasticity

D. Reduces urine bacterial count

E. Asking the client to speak louder

Answer: C

Baclofen is a centrally acting skeletal muscle relaxant that helps relieve the muscle spasms
Common in MS. Drowsiness is an adverse effect, and driving should be avoided if the
medication produces a sedative effect. Baclofen does not stimulate the appetite or reduce
bacteria in the urine.

41 Which of the following is not a typical clinical manifestation of Multiple Sclerosis?

A. Double vision

B. Sudden burst of energy

C. Weakness in the extremities

D. Muscle tremors

Answer: B

With MS, hyperexcitability and euphoria may occur, but because of muscle weakness,
sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities,
and loss of muscle tone and tremors are common symptoms of MS.

42. The client with multiple sclerosis is starting a bowel retraining program which nursing
action is inappropriate?

A. Eating a diet high in fiber.

B. Setting a regular time for elimination

C. Using an elevated toilet seat

D. Limiting fluid intake to 1,000 mday

Answer: D

Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel
retraining program is being implemented. Furthermore, water imbalance, as well as
electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in
fiber helps keep bowel movements regular. Setting a regular time each day for elimination
helps train the body to maintain a schedule. Using an elevated toilet seat facilitates
transfer of the client from the wheelchair to the toilet or from a standing to a sitting
position.

43. The nurse is talking to the client with multiple sclerosis which nursing action is
contraindicated in talking the client with multiple slurred speech?

A. Encourage the client to speak slowly

B. Encourage the client to speak distinctly

C. Asking the client to repeat indistinguishable Words

D. Asking the client to speak louder

Answer: D

Asking a client to speak louder even when tired may aggravate the problem. Asking the
client to speak slowly and distinctly and to repeat hard-to understand words helps the
client to communicate effectively.

Situation: Angela, a nurse in the medical ward of the Lugo Medical center is reviewing
concepts on how to care for clients with cerebrovascular accident.

44. What is the expected outcome of thrombolytic therapy stroke?

A. Increased vascular permeability

B. Vasoconstriction

C. Dissolved emboli

D. Prevention of hemorrhage

Answer: C

Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve
emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability,
cause vasoconstriction, or prevent further hemorrhage

45. Following stroke, the client has expressive aphasia. The difficulty:

A. Speaking and writing

B. Comprehending spoken words

C. Carrying out purposeful motor activity

D. recognizing and using an object correctly

14. Answer: A

The client with aphasia has trouble and difficulty forming words that ae understandable.
Answer B refers to expressive aphasia. Answer C is apraxia. Answer D is agnosia.

46. In clients with expressive aphasia, which psychosocial problem should be included in the
care plan?
A. Potential for injury

B. Powerless

C. Disturbed thought process

D. Sexual dysfunction

Answer: B

Expressive aphasia means that the client cannot communicate thoughts but understands
what is being communicated; this leads to frustration, anger, depression, and the inability
to verbalize needs, which, in turn, causes the client to have a lack of control and feel
powerless.

47. The client with brain attack (stroke) has residual dysphagia. When a diet order is
initiated, the nurse avoids doing which of the following? (-)

a. Giving the client thin liquids (risk for aspiration, mabilis kasi malulon, pwede din
mapunta sa airway)

b. Thickening liquids to the consistency of oatmeal

c. Placing food on the unaffected side of the mouth

d. Allowing plenty of time for chewing and swallowing

48. The nurse has instructed the family of a client with brain attack (stroke) who has
homonymous hemianopsia about measures to help the client overcome the deficit. The
nurse determines that the family understands the measures to use if they state that they
will:

a. Place objects in the client’s impaired field of vision

b. Discourage the client from wearing eyeglasses

c. Approach the client from the impaired field of vision

d. Remind the client to turn the head to scan the lost visual field

Homonymous hemianopsia - Visual field defect, kapag yung tao naka straight lang hindi
nakikita yung one side of the visual field

49. A nurse obtains a specimen of clear nasal drainage from a client with a head injury.
Which of the following tests differentiates mucus from cerebrospinal fluid?

a. pH

b. Specific gravity

c. Glucose

d. Microorganisms
50.The client has sustained an increase in intracranial pressure of 20 mmHg. Which client
position would be most appropriate?

a. Elevate head of bed 30-45 degrees

b. Trendelenburg’s position

c.Left Sims position

d. Head elevated on 2 pillows

51. The nurse administers mannitol (Osmitrol) to the client with increase intracranial
pressure. Which parameter requires close monitoring?

a. Muscle relaxation

b. Intake and output

c. Widening pulse pressure

d. Pupil dilation

52. Which activity should the nurse encourage the client to avoid when there is a risk for
increased intracranial pressure?

a. Deep breathing

b. Turning

c. Coughing

d. Passive range-of-motion

53. A client has signs of increased ICP. Which of the following is an early indicator of
deterioration in the client’s condition?

a. Widening pulse pressure - late

b. Decrease in the pulse rate - late

c. Dilated, fixed pupil - late

d. Decrease in LOC

54. The client has clear fluid leaking from the nose following a basilar skull fracture. The
nurse assesses that this is cerebrospinal fluid if the fluid:

a. Is clear and tests negative for glucose

b. Is grossly bloody in appearance and has a pH of 6

c. Clumps together on the dressing and has a pH of 7

d. Separates into concentric rings and tests positive for glucose

Rhinorrhea - coming out of the nose Otorrhea - coming out the ear ● to confirm if CSF →
Halo signs and positive for glucose
55. You are providing nursing care for a patient with GBS.

What observation would you report immediately?

a. Complaints of numbness and tingling

b. Facial weakness and difficulty speaking

c. Rapid heart rate of 102 beats per minute

d. Shallow respirations and decreased breath sounds

GBS - demyelination of pns - motor and sensory - ascending paralysis - reversible - airway
number 1

56. The nurse has given suggestions to the client with trigeminal neuralgia about strategies
to minimize episodes of pain. The nurse determines that the client needs reinforcement of
information if the client makes which of the following statements? (-)

a. “I will wash my face with cotton pads.”

b. “I’ll have to start chewing on the unaffected side.”

c. “I’ll try to eat my food either very warm or very cold.”

d. “I should rinse my mouth sometimes if tooth-brushing is painful”

57. The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). the
nurse would gather which of the following items to perform the test?

a. Tuning fork and audiometer – CN8

b. Snellen chart, ophthalmoscope - CN2

c. Flashlight, pupil size chart or millimeter ruler – CN3

d. Safety pin, hot and cold water in test tubes, cotton wisp

CN V – test sensation to the face

58. The nurse has given a client with Bell’s palsy instructions on preserving muscle tone in
the face and preventing denervation. The nurse determines that the client need additional
information if the client states that he or she will:

a. Expose the face to cold and drafts

b. Massage the face with a gentle upward motion ✓

c. Perform facial exercise ✓

d. Wrinkle the forehead, blow out the cheeks, and whistle ✓

Situation: The diagnostic workup of the client hospitalized with complain: progressive
weakness and fatigue confirms a diagnosis of myasthenia gravis.

59. Which of the following assessment finding is associated with Myasthenia Gravis?
A. Visual disturbances including diplopia

B. Ascending paralysis and loss of motor function

C. Cogwheel rigidity and loss of coordination

D. Progressive weakness that is worse as the day's end

Answer: D

The client with Myasthenia Gravis develops progressive weakness that worsens during the
day. Answer A refers to symptoms of multiple sclerosis; B denotes GBS; C is for Parkinson's

60. The medication that is used to treat myasthenia gravis is?

A. Prostigmine (Neostigmine)

B. Atropine (Atropine Sulfate)

C. Didronel (Etidronate)

D. Tensilon (Edrophonium)

Answer: A

Prostigmine is used to treat clients with myasthenia gravis. Atropine is used to reverse the
effects of neostigmine. Tensilon is used to test myasthenia gravis. Didronel is unrelated to
myasthenia gravis.

61. Which response to Tensilon (Edrophonium chloride) test would indicate that the client
has myasthenia gravis?

A. The client has n0 apparent change in the assessment data.

B. There is increased amplitude of electrical stimulation in the muscle.

C. The circulating acetylcholine receptor antibodies are decreased.

D. The client shows a marked improvement of muscle strength.

Answer: D

Clients with MG show a significant improvement of muscle strength lasting approximately

five (5) minutes when Tensilon (Edrophonium chloride) is injected. No change in the
client's muscles strength indicates it is not MG. There is reduced amplitude in an
electromyogram (EMG) in a client with MG The serum assay of circulating acetylcholine
receptor antibodies is increased, not decreased, in MG, and this test is only 80% to 90%
accurate in diagnosing MG.

62. The patient who had a stroke needs to be fed. What instruction should you give to the
nursing assistant who will feed the patient?

a. Position the patient sitting up in bed before you feed her.

b. Check the patient’s vital signs.

c. Feed the patient quickly because there are three more waiting.

d. Suction the patient’s secretions between bites of food.

63. Which assessment finding would warrant immediate intervention to client with
myasthenia gravis who is undergoing plasmapheresis?

A. The client's BP is 90/60 and apical pulse is 112.

B. Negative Chvostek's and Trousseau’s signs.

C. The serum potassium level is 3.5 meal.

D. Ecchymosis at the vascular site access.

Answer: A

Hypovolemia is a complication of plasmapheresis, especially during the procedure, when

up to 15% of the blood volume is in the cell separator. Positive Chvostek's and Trousseau's
signs (not negative signs) warrant intervention and indicate hypocalcemia, which is a
complication of plasmapheresis. The serum potassium level (3.5 to 5.5 mEq/L) is normal,
which does not warrant intervention, but the level should be monitored because
plasmapheresis could cause hypokalemia. Ecchymosis (bruising) does not warrant
immediate intervention. Signs of infiltration or infection warrant immediate intervention.

64. In order to help prevent signs and symptoms of disease process, which surgical
procedure should the nurse anticipate to undergo?

A. Thymectomy

B. Adrenalectomy

C. Transsphenoidal hypophysectomy

D. No surgical procedure

Answer: C

In about 75% of clients with MG, the thymus gland (which is usually inactive after puberty)
continues to produce antibodies, triggering an autoimmune response in MG. After a
Thymectomy, t the production of autoantibodies is reduced or eliminated, and this may
resolve the signs/symptoms of MG. This surgery is performed in clients with pituitary
tumors and is accomplished by going through the client's upper lip though the nasal
passage. An adrenalectomy is the surgery for a client diagnosed with Cushing's disease, a
disease in which there is an increased secretion of Glucocorticoids and mineralocorticoids.

65. An older man develops Myasthenia Gravis. When the nurse reviews the client's medical
history, which sign or symptom is the client most is the client likely to have experienced
when his disease became evident?

A. Sudden hearing loss

B. Drooping eyelids

C. Sensitivity to light

D. Protruding tongue

Answer: D

With a client with known or suspected seizure disorder, the side rails are padded with
bath blankets to prevent injury. Keeping the room brightly lit can be disturbing to the
client and is not necessary. In some people, seizures are precipitated by bright lights and
noise. Although a client may be injured by glass or metal utensils on a tray, they are not
usually restricted. The client is observed more closely by the nurse if near the nursing
station, but room arrangements like this are not always available

66. The basis of the nursing care plan for a client with Myasthenia Gravis is the fact that:

A. Muscle weakness decreases with of baths

B. Muscle weakness decreases with muscle use

C. Muscle strengths improves immediately after meals

D. Muscle strength decreases with repeated muscle use

Answer: D

When a client begins to convulse, the highest priority is establishing a patent airway. This
can be done most easily by turning this client on her side, which allows saliva and vomitus
(if present) to drain from the mouth. Turning also prevents the tongue from blocking the
airway. Oxygen is administered after the airway is open and clear. Vital signs are taken
after the seizure is completed. A client is never restrained while having a seizure because
restraint could cause musculoskeletal injuries

67.. The client has experienced an episode of myasthenic crisis. The nurse would assess
whether the client has precipitating factors such as:

a. Getting too little exercise

b. Taking excess medication - cholinergic crisis

c. Omitting doses of medication

d. Increasing intake of fatty foods

Myasthenic crisis - underdose of medication Cholinergic crisis - overdose both condition

will have muscle weakness because wala sa therapeutic level tensilon test - to determine if
myasthenic crisis or cholinergic if temporary improvement - myasthenic crisis temporary
worsening - cholinergic crisis Antidote / management: myasthenic crisis → Pyridostigmine
cholinergic crisis → atropine sulfite

68. The client with Parkinson’s disease has a nursing diagnosis of Falls, Risk for related to an
abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting
to observe which type of gait?
a. Unsteady and staggering

b. Shuffling and propulsive

c. Broad-based and waddling

d. Accelerating with walking on the toes

69. The nurse has given instructions to the client with Parkinson’s disease about maintaining
mobility. The nurse determines that the client understands the directions if the client states
that he or she will: (+)

a. Sit in soft, deep chair

b. Exercise in the evening to combat fatigue

c. Rock back and forth to start movement with bradykinesia - be-bwelo

d. Buy clothes with many buttons to maintain finger dexterity

70.The nurse observes the client’s upper arm tremors disappear as he unbuttons his shirt.
Which statement best guides the nurse’s analysis of this observation about the client’s
tremors?

a. The tremors are probably psychological and can be controlled at will

b. The tremors sometimes disappear with purposeful and voluntary movements ✓

c. The tremors disappear when the client’s attention is diverted by some activity - dapat may
gagawin siya sa kamay niya

d. There is no explanation for this observation, it is probably a chance occurrence

Velcro - ang concern dito is loss of finger dexterity

71. At what time should the nurse encourage a client with Parkinson’s disease to schedule
the most demanding physical activities to minimize the effects of hypokinesia?

a. Early in the morning when the client’s energy level is high - kahit full energy niya, may
movement problem naman siya

b. To coincide with the peak action of drug therapy - minimize the movement para
magawa yung activity

c. Immediately after a rest period

d. When family members will be available

Goal of management: to relieve the signs and symptoms – palliative

72. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson’s
disease?

a. To cure the disease -

b. To stop progression of the disease

c. To begin preparations for terminal care

d. To maintain optimal body function

73. Which nursing intervention will improve the client's ability to swallow to a client with
Parkinson's disease who complains of "choking"?

A. Withholding liquids until after meals

B. Providing fully liquid diet

C. Provide semiliquid foods as possible

D. Offering small, more frequent meals

Answer: C

Semi-solid foods are more easily swallowed by the client with dysphagia than either
liquids or solids. Answers A, C and D will not improve client’s ability to swallow.

74. An older adult woman with Parkinson's disease is placed in a special unit for
degenerative disorders for basic nursing care. Which clinical manifestation is the initial sign
of F Parkinson's disease?

A. Muscle rigidity

B. Muscle weakness

C. Muscle tremors

D. Muscle deterioration

Answer: C.

The first sign of Parkinson's disease is usually fine motor tremors. The client is often the
first person to notice this sign. Muscle rigidity is the second sign. Due to the tremors and
muscle rigidity, muscle deterioration and muscle weakness may occur if the muscles are
not utilized regularly.

Situation: The client in the early stage of Alzheimer's disease and his adult son attend an
appointment at the community mental health center.

75. Which nursing intervention is most helpful for the client with sexual and vulgar
behaviors?

A. Ignore the behaviors, but try to identify the underlying need for the behaviors.

B. Give feedback on the inappropriateness of the behaviors

C. Employ anger management strategies

D. Administer the prescribed risperidone (Risperdal).

Answer: A
The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs
that can be addressed directly. Therefore, the families should be encouraged to ignore the
behaviors but attempt to identify their purpose. Then the purpose can be addressed,
possibly leading to a decrease in the behaviors, Because of impaired cognitive function the
client is not likely to be able to process the inappropriateness of the behaviors if given
feedback. Likewise, anger management strategies would be ineffective because the client
would probably be unable to process the inappropriateness of the behaviors.

76. What manifestation is usually the first indication of the onset of Alzheimer's disease?

A. Inability to perform activities of daily living

B. Sun downing at night

C. Subtle memory deficits

D. Inability to communicate

. Answer: C

Memory deficits are usually the first indication of AD. They are subtle and may not be
noticed by friends and family until the patient exhibits unsafe behaviors

77. Which of the following is the characteristic sign of stage lll Alzheimer's disease?

A. Memory loss

B. Failure to recognize familiar objects

C. Wandering at night

D. Failing to communicate

. Answer: B

In stage ll of Alzheimer's disease, the client develops agnosia or failure to recognize

familiar objects. Option A appears in stage 1. Option C appears in stage l. Option D appears
in stage IV.

78. Which nursing care should be included in the plan of care for client with Alzheimer’s
disease experiencing moderate impairment?

A. prompting and guiding activities of daily living

B. managing a medication schedule

C. constant supervision and total care

D. supervision of risky activities such as shaving

Answer: A

Considerable assistance is associated with moderate impairment when the client cannot
make decisions but can follow directions. Managing medications is needed even in mild
impairment. Constant care is needed in the terminal phase, when the client cannot follow
directions. Supervision of shaving is appropriate with mild impairment-that is, when the
client still has motor function but lacks judgment about safety issues.

Situation: Meningitis can occur as a complication of other diseases and is an opportunistic

infection seen with greater frequency in patients who are immunocompromised.

79. The mother of the client asks the nurse, "What is septic meningitis? “What is the
appropriate response of the nurse?

A. "There is bleeding into his brain causing irritation of the meninges."

B. ‘’A virus has infected the brain and meninges, causing inflammation.’’

C. "This is a bacterial infection of the tissues that cover the brain and spinal cord."

D. "This is an inflammation of the brain parenchyma caused by a mosquito bite.

Answer: C

Septic meningitis refers to meningitis caused by bacteria, the most Common form of
bacterial meningitis is caused by the Neisseria meningitides bacteria. Answer A & B: refers
to aseptic meningitis, D: refers to encephalitis.

80. Which manifestations support the diagnosis of the client with bacterial meningitis?

A. Positive Babinski's sign and peripheral paresthesia.

B. Negative Chvostek's sign and facial tingling.

C. Positive Kernig's sign and nuchal rigidity.

D. Negative Trousseau's sign and nystagmus.

Answer: C

A positive Kernig's sign (client unable to extend leg when lying flat) and nuchal rigidity
(stiff neck) are signs of bacterial meningitis, occurring because the meninges surrounding
the brain and spinal column are irritated. Babinski's sign is used to assess brainstem
activity, and paresthesia is tingling, which is not a clinical manifestation of bacterial
meningitis. Chvostek's sign is used to assess for hypocalcemia, and facial tingling is a sign
of hypocalcemia. It is not used to assess for bacterial meningitis. Trousseau's sign is used
to assess for hypocalcemia, and nystagmus is abnormal eye movement. Neither of these is
a clinical manifestation of bacterial meningitis.

81. Which collaborative intervention/action should be included in the plan of the care in
clients with meningitis?
A. Administer antibiotics

B. Obtain a sputum culture

C. Monitor the pulse oximeter

D. Assess intake and output

Answer: A

A nurse administering antibiotics is a collaborative intervention because health care

provider must write an order for the intervention; nurses cannot prescribe medications
unless they have additional education and licensure and are nurse practitioners with
prescriptive authority. The nurse needs an order to send culture to laboratory but sputum
culture is not appropriate for meningitis. Pulse oximeter and intake and output are
independent nursing actions.

82. In the care of clients with meningitis, which nursing assessment is the priority?

A. Assess lung sounds

B. Assess the six cardinal fields of gaze

C. Assess apical pulse

D. Assess level of consciousness

Answer: D

Meningitis directly affects the client's brain. Therefore, assessing the neurological status
would have priority for this client.

83. Which precaution is appropriate to be implemented meningitis?

A. Standard Precautions

B. Airborne Precautions

C. Contact Precautions

D. Droplet Precautions

Answer: D

Droplet Precautions are respiratory precautions used for organisms that have a limited
span of transmission. Precautions include staying at least four (4) feet away from the client
or wearing a standard isolation mask and gloves when coming in close contact with the
client. Clients are in isolation for 24 to 48 hours after initiation of antibiotics. Standard
Precautions are mandated for all clients, but a client with septic meningitis will require
more than the Standard Precautions. Airborne Precautions are for contagious organisms
that are spread on air currents and require the hospital personnel to wear an ultra-high
filtration mask, these precautions would be applied for disease such as tuberculosis.
Contact Precautions are for contagious organisms that are spread by blood and body
fluids, such as those that occur with wounds or diarrhea.

84. Which of the following will the nurse observe in the client in the ictal phase of a
generalized tonic-clonic seizure?

a. Jerking in 1 extremity that spreads gradually to adjacent areas

b. Vacant staring and abruptly ceasing all activity

c. Facial grimaces, patting motions, and lip smacking

d. Loss of consciousness, body (tonic) stiffening, and violent (clonic) muscle contractions

85. Which clinical manifestation does the nurse expect in the client in the postictal phase of
generalized tonic-clonic seizure?

a. Drowsiness

b. Inability to move

c. Paresthesia

d. Hypotension

86. For breakfast in the morning a client is to have an electroencephalogram (EEG), the
client is served soft boiled egg, toast with butter and marmalade, orange juice, and coffee.
Which of the following should the nurse do?

a. Remove all the food

b. Remove the coffee

c. Remove the toast

d. Substitute vegetable juice for the orange juice

87. Which of the following is an initial sign of Parkinson’s disease?

a. Rigidity

b. Tremor - earliest

c. Bradykinesia

d. Akinesia

88. The nurse is planning to institute seizure precautions for a client who is being admitted
from the emergency department. Which of the following measures would the nurse avoid in
planning for the client’s safety?

a. Padding the side rails of the bed

b. Putting a padded tongue blade at the head of the bed – not being practice na

c. Placing an airway, oxygen, and suction equipment at the bedside

d. Having intravenous equipment ready for insertion of an intravenous catheter

89. The nurse is caring for the client who begins to experience seizure activity while in bed.
Which of the following actions by the nurse would be contradicted?

a. Loosening restrictive clothing

b. Restraining the client’s limbs

c. Removing the pillow and raising padded side rails

d. Positioning the client to the side, if possible, with the head flexed forward

90. A patient recently started on phenytoin (Dilantin) to control simple complex seizures is
seen in the outpatient clinic. Which information obtained during his chart review and
assessment will be of greatest concern

a. The gums appear enlarged and inflamed. - gingival hyperplasia (expected)

b. The white blood cell count is 2300/mm3.

c. Patient occasionally forgets to take the phenytoin until after lunch. - Not of greatest
concern

d. Patient wants to renew his driver’s license in the next month. - Not of greatest concern

91.While working in the ICU, you are assigned to care for a patient with a seizure disorder.
Which of these nursing actions is most important if the patient is having a seizure?

a. Place the patient on a non-rebreather mask with the oxygen at 15 L/minute.

b. Administer lorazepam (Ativan) 1 mg IV.

c. Turn the patient to the side and protect airway.

d. Assess level of consciousness during and immediately after the seizure.

Ratio: assure safety first

92. When planning care for a client receiving Phenytoin (Dilantin) generalized seizure, the
nurse should:

A. Maintain strict intake and output

B. Check the pulse before giving the medication

C. Administer the medication 30 minutes before meals

D. Provide oral hygiene and gum care every shift

Priority: Protection of airway

93. The client is scheduled for electroencephalography (EEG) What correct preprocedure
teaching to be implemented?

A. Tell the client to take any routine anti-seizure medicates to EEG

B. Tell the client not to eat anything for eight (8) hours prior to EEG

C. Instruct the client to stay awake for 24 hours prior to EEG

Answer: C

The goal is for the client to have a seizure during the EEG. Sleep deprivation,
hyperventilating, or flashing lights may induce a seizure. Meals are not without because
this will alter glucose levels and can alter brain waves of the client

D. Explain to the client that there will be some discomfort during the procedure

94. Which information should be included d in the discharge plan of client with tonic clonic
seizure who is taking Phenytoin (Dilantin)?

A. The medication can cause dental staining.

B. The client will need to avoid high -carbohydrate diet.

C. The client will need regular scheduled blood work.

D. The medication can cause problems like drowsiness.

Answer: C

Adverse effects of Dilantin include agranulocytosis and aplastic anemia so regular blood
wok should be done. Dilantin will not cause dental staining; it does not interfere with
carbohydrate metabolism and it does not cause drowsiness.

95. The nurse who is caring client with absence seizures will expect

A. Short, abrupt muscle contractions

B. Quick, severe, bilateral jerking movements

C. Abrupt loss of muscle tone

D. Brief lapse in consciousness

Answer: D

Absence seizure formerly known as petit mal seizure is characterized by lapses in

consciousness accompanied rapid eye blinking, lip smacking and minor myoclonus of the
upper extremities. Option A: refers clonic seizure formerly known to myoclonic seizure, B:
refers to tonic - as grand mal seizure, C: refers to atonic seizure.

96. A 30-year-old was admitted to the progressive care unit with a C5 fracture from a
motorcycle accident. Which of the following assessments would take priority?

a. Bladder distension
b. Neurological deficit

c. Pulse ox readings

d. The client’s feelings about the injury

To determine the status of airway

97. A client with a C6 spinal injury would most likely have which of the following symptoms?

a. Aphasia

b. Hemiparesis

c. Paraplegia

d. Tetraplegia

Tetraplegia - paralysis of four quadrants

98. A client comes into the ER after hitting his head in an MVA. He’s alert and oriented.
Which of the following nursing interventions should be done first?

a. Assess full ROM to determine extent of injuries

b. Call for an immediate chest x-ray

c. Immobilize the client’s head and neck

C1 to upper C5 - cervical plexus → phrenic nerve = high quadriplegia - paralysis of the neck
below - patient will be hooked to ventilator for lifetime lower

C5 to T1 - brachial plexus → upper extremities = low quadriplegia paralysis from the chest
blow d. Open the airway with the head-tilt chin-lift maneuver L2 - S4 - lumbosacral plexus
→ supply low extremities and pelvis T6 injury - high paraplegia paralysis from the waist L2
- low paraplegia paralysis form the hips below

99. A client with C7 quadriplegia is flushed and anxious and complains of a pounding
headache. Which of the following symptoms would also be anticipated?

a. Decreased urine output or oliguria

b. Hypertension and bradycardia

c. Respiratory depression

d. Symptoms of shock

Autonomic dysreflexia

100. The nurse is evaluating the neurological signs of the male client in spinal shock
following spinal cord injury. Which of the following observations by the nurse indicates that
spinal shock persists?

a. Hyperreflexia – meron pa
b. Positive reflexes – meron pa

c. Reflex emptying of the bladder– meron pa

d. Inability to elicit a Babinski’s reflex ✓

Prepared by:

Fatima Zsat-tria M. Laja RN, LPT, MAN

Clinical Instructor
Checked by:

Lou Norman H. Flores RN, MAN

Bsn Chairperson

Noted by:

Leticia M. Babas RN, MN

College Dean

“You’re braver than you believe, stronger than you seem,

and smarter than you think”