Ateneo de Zamboanga University

College of Nursing
NURCO-2

Name: _________________________________________________ Score: ________________

Section: ______________________________ Date: ________________

GENERAL INSTRUCTIONS:
1.This exam contains 60 test questions
2.Read INSTRUCTIONS printed on your answer sheet
3.Shade only one (1) box for each question on your answer sheet. Two or more boxes shaded will invalidate
your answer.
4.AVOID ERASURES.
5.Write the subject title “NURCO 2 RESPI & FLUIDS” on the box provided.

SET B

1. The nurse is working on a surgical floor. The nurse must log roll a male client following a:

A. Laminectomy. B. Thoracotomy.
C. Hemorrhoidectomy. D. Cystectomy.

Correct Answer: A. Laminectomy.

The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column
straight when turning. Laminectomy is among the most common procedures performed by spinal surgeons to
decompress the spinal canal in various conditions.

2. Which of the following should the nurse assess when completing the history and physical examination of a client
diagnosed with Osteoarthritis?

A. Anemia B. Osteoporosis
C. Weight loss D. Local joint pain

Correct Answer: D. Local Joint Pain

Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain, unlike rheumatoid
arthritis, which has systemic manifestations such as anemia and osteoporosis. Weight loss occurs in rheumatoid
arthritis, whereas most clients with osteoarthritis are overweight.

3. A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to detect?

A. Internal rotation B. Muscle flaccidity

C. Shortening of the affected leg D. Absence of pain in the fracture area

Correct Answer: C. Shortening of the affected leg

With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle
spasms and external rotation. The client also experiences severe pain in the region of the fracture.

4. When counseling an older patient about ways to prevent fractures, which information will the nurse include?

A. Tacking down scatter rugs in the home is recommended.

B. Occasional weight-bearing exercise will improve muscle and bone strength.
C. Most falls happen outside the home.
 D. Buying shoes that provide good support and are comfortable to wear is recommended.

Correct Answer: D
Rationale: Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs should be
eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but occasional exercise
is not helpful in improving strength. Falls inside the home are responsible for many injuries.

5. A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and
weakness in the left hand and elbow. The nurse identifies these symptoms as related to

A. muscle spasms. B. meniscus injury.

C. repetitive strain injury. D. carpal tunnel syndrome.

Correct Answer: C
Rationale: The patient's occupation and the inflammation, pain, and weakness in the elbow and hand suggest a
repetitive strain injury. Muscle spasms would be characterized by a palpable, firm muscle mass during the
spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is characterized by weakness and
numbness of the hand.

6. A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing
soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first?

A. Administer naproxen (Naprosyn) 500 mg PO.

B. Wrap the ankle and apply an ice pack.
C. Give acetaminophen with codeine (Tylenol #3).
D. Take the patient to the radiology department for x-rays.

Correct Answer: B
Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the
injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression
bandage and ice is applied.

7.Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for
the injury, the nurse tells the patient to

A. apply a heating pad to reduce muscle spasms.

B. wear an elastic compression bandage continuously.
C. use pillows to keep the arm elevated above the heart.
D. gently exercise the joint to prevent muscle shortening.

Correct Answer: C
Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold
packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be
rested and kept immobile to prevent further swelling or injury.

8. A 22-year-old patient started an exercise regimen 2 months ago that includes running 3 to 4 miles a day. The patient
tells the nurse, "I enjoy my daily runs, but now I have shin splints." Which response by the nurse is appropriate?
A. "You may be increasing your running time too quickly and need to cut back a little bit."
B. "You need to have x-rays of your lower legs to be sure you do not have stress fractures."
C. "You should expect some leg pain while running."
D. "You should try speed-walking rather than running."

Correct Answer: A
Rationale: The patient's information about running 3 to 4 miles daily after starting an exercise program only 2
months previously suggests that the shin splints are caused by overuse. Radiographs are not indicated for the
type of injury described by the patient. Shin splints are not a normal or expected response to running. Because
 the patient expresses enjoyment of running, it would not be appropriate for the nurse to suggest a different
sport.

9. A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When
the nurse plans postoperative teaching for the patient, which information will be included?

A. "You have an appointment with a physical therapist for tomorrow."

B. "Leave the shoulder immobilizer on for the first few days to minimize pain."
C. "The doctor will use the drop-arm test to determine the success of the procedure."
D. "You should try to find a different position to play on the baseball team."

Correct Answer: A
Rationale: Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder."
A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would
lead to loss of ROM. The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be
able to return to pitching after rehabilitation.

10. A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the patient that the cast
can be removed only after the bone

A. is strong enough to stand mild stress. B. union is complete on the x-ray.

C. fragments are fully fused. D. healing has started.
Correct Answer: A
Rationale: The cast may be removed when callus ossification has occurred. It is not necessary to wait until
radiologic union or complete bone fusion occurs. Bone healing starts immediately after the injury, but the cast
will need to be worn at least 3 weeks.

11. A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To
assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should

A. have the patient lift the buttocks by bending and pushing with the left leg.
B. turn the patient partially to each side with the assistance of another nurse.
C. place a pillow between the patient's legs and turn gently to each side.
D. loosen the traction and have the patient turn onto the unaffected side.

Correct Answer: A
Rationale: The patient can lift the buttocks off the bed by using the left leg without changing the right-leg
alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will
interrupt the weight needed to immobilize and align the fracture.

12. A patient in the emergency department is diagnosed with a patellar dislocation. The initial patient teaching by the
nurse will focus on the need for
A. conscious sedation. B. a knee immobilizer.
C. gentle knee flexion. D. cast application.

Correct Answer: A
Rationale: The first goal of collaborative management is realignment of the knee to its original anatomic
position, which will require anesthesia or conscious sedation. Immobilization of the joint will be done after
realignment. Later, gentle ROM exercises may be started if the joint is stable. Casting is not usually required for
dislocations.

13. Following a motor-vehicle accident, a patient arrives in the emergency department with massive right lower-leg
swelling. Which action will the nurse take first?

A. Elevate the leg on pillows. B. Apply a compression bandage.

C. Place ice packs on the lower leg. D. Check leg pulses and sensation.
Correct Answer: D
Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for any
evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be
appropriate based on what is observed during the assessment.

14. Following the application of a hip spica cast for a patient with a fracture of the proximal third of the left femur, an
appropriate nursing intervention is to

A. Use the cast support bar to reposition the patient every 2 to 3 hours.
B. Ask the patient about any abdominal discomfort or nausea.
C. Discuss the reasons for remaining on bed rest for several weeks.
D. Promote drying of the cast by placing the patient in a prone position every 4 hours.

Correct Answer: B
Rationale: Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of
cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the
patient can begin ambulating with the assistance of physical therapy personnel. The patient should not be
placed in the prone position until the cast has dried to avoid breaking the cast.

15. A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity.
The initial action by the nurse should be to
A. splint the lower leg.
B. elevate the left leg.
C. check the popliteal, dorsalis pedis, and posterior tibial pulses.
D. obtain information about the patient's tetanus immunization status.

Correct Answer: C
Rationale: The initial nursing action should be assessment of the neurovascular status of the injured leg. After
assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus
immunizations should be done if there is an open wound.

16. In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced
fracture of the tibia, the priority nursing diagnosis is

A. risk for constipation related to prolonged bed rest.

B. activity intolerance related to deconditioning.
C. risk for infection related to disruption of skin integrity.
D. risk for impaired skin integrity related to immobility.

Correct Answer: C
Rationale: A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an
ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are
not as likely.

17. A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured
left radius. Until the cast has completely dried, the nurse should

A. keep the left arm in a dependent position.

B. handle the cast with the palms of the hands.
C. place gauze around the cast edge to pad any roughness.
D. cover the cast with a small blanket to absorb the dampness.

Correct Answer: B
Rationale: Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas
inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The
 edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to
be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

18. A patient has a short-arm plaster cast applied at the outpatient center for a wrist fracture. An understanding of
discharge teaching is apparent when the patient says,

A. "I can get the cast wet as long as I dry it right away with a hair dryer."
B. "I should avoid moving my fingers and elbow until the cast is removed."
C. "I will apply an ice pack to the cast over the fracture site for the next 24 hours."
D. "I can rub lotion on any itching areas under the cast with a cotton-tipped applicator."

Correct Answer: C
Rationale: Ice application for the first 24 hours after a fracture will help to reduce swelling and can be placed
over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and
below the cast. Patients should not insert objects inside the cast.

19. When evaluating the crutch-walking technique of a patient with a right-leg long-leg cast and no weight bearing on
the right leg, the nurse determines that the patient is prepared to ambulate independently with the crutches on
observing that the patient
A. uses the bedside chair to assist in balance as needed when ambulating in the room.
B. keeps the padded area of the crutch firmly in the axillary area when ambulating.
C. advances the right leg and both crutches together and then advances the left leg.
D. moves the left crutch with the left leg and then the right crutch with the right leg.

Correct Answer: C
Rationale: When using crutches, patients are usually taught to move the assistive device and the injured leg
forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to
assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve
damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the
crutch and same-side leg.

20. A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an
external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics.
The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the
nurse is to

A. notify the patient's health care provider.

B. check the patient's blood pressure.
C. assess the external fixator pins for redness or drainage.
D. elevate the extremity and apply ice over the wound site.

Correct Answer: A
Rationale: The patient's clinical manifestations point to compartment syndrome and delay in diagnosis, and
treatment may lead to severe functional impairment. There is no reason to suspect that patient's symptoms are
caused by hypotension or hypertension or by infection at the pin sites. Elevation of or ice application to the leg
will decrease arterial flow and further reduce perfusion.

21. A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The
second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the
patient's symptoms are most likely related to fat embolism when assessment of the patient reveals

A. a blood pressure of 100/65 mm Hg.

B. anxiety, restlessness, and confusion.
C. warm, reddened areas in the calf.
D. pinpoint red areas on the upper chest.

Correct Answer: D
 Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms
might occur with fat embolism but could also occur with other postoperative complications such as bleeding,
myocardial infarction, venous thrombosis, or hypoxemia.

22. The health care provider initially orders bed rest for a patient with an open-book pelvic fracture. Which assessment
data obtained by the nurse are most important to report to the health care provider?

A. The bowel tones are absent.

B. There is an unusual amount of pelvic movement.
C. The patient complains of level 4 abdominal pain on a 10-point pain scale.
D. There is bruising of the abdomen.

Correct Answer: A
Rationale: Absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus,
hemorrhage, or trauma to the bladder, urethra, or colon. Unusual pelvic movement, abdominal pain, and
abdominal bruising would be expected with this type of injury.

23. After falling at home, a patient is admitted to the emergency department, where x-rays confirm the presence of an
extracapsular fracture of the femur. When assessing the patient, the nurse would expect to find

A. bruising of the left hip and thigh.

B. numbness in the left leg and hip.
C. outward pointing toes on the left leg.
D. weak or nonpalpable left leg pulses.

Correct Answer: C
Rationale: External rotation of the leg is a classic sign associated with a hip fracture. Bruising does not always
appear rapidly, and bruising extending to the thigh might indicate hemorrhage. Numbness and decreased pulses
are not typical of a hip fracture unless there is associated tissue swelling and trauma to blood vessels.

24. A patient with an intracapsular fracture of the left femur is placed in Buck's traction before surgery for a hip
replacement. The patient asks why traction is necessary when surgery is planned. The nurse's response to the patient is
based on the knowledge that traction

A. will help prevent flexion contractures of the affected hip.

B. is necessary to prevent displacement of the fracture.
C. will decrease the incidence of painful muscle spasms
D. is used to maintain the leg in the external rotation position.

Correct Answer: C
Rationale: Buck's traction keeps the leg immobilized and reduces muscle spasm. Flexion contractures are not
likely to occur during the short time before surgery. Displacement of the hip is prevented by keeping the patient
on bed rest before surgery. The leg is externally rotated because of the hip fracture, not because of traction.

25. A patient with lower-leg fractures has an external fixation device in place and is scheduled for discharge. Which
information will the nurse include in the discharge teaching?

A. "You will need to remain on bed rest until bone healing is complete."
B. "The external fixator can be removed during the bath or shower."
C. "Prophylactic antibiotics are needed until the external fixator is removed."
D. "You will need to assess and clean the pin insertion sites daily."

Correct Answer: D
Rationale: Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator
allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not
removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

26. When getting a patient from the bed into the chair for the first time since having an ORIF of a hip fracture, the nurse
should

A. use a mechanical lift to transfer the patient from the bed to the chair.
B. assist the patient to use a walker with partial weight bearing to assist in transfer to the chair.
C. have the patient use crutches with a swing-through gait to transfer.
D. ask a nursing assistant to help the patient to stand at the bedside and pivot to the chair.

Correct Answer: B
Rationale: The patient will use an assistive device such as a walker to help with the initial transfers and
ambulation. A mechanical lift is not needed. Crutch walking is taught before discharge but would not be used for
the initial transfer. The RN, not a nursing assistant, should supervise the patient during the initial transfer to
evaluate how well the patient is able to accomplish this skill.

27. A patient is admitted with facial injuries after a bicycle accident and has a repair of a fractured mandible. When
doing postoperative teaching, the nurse will include information about

A. the use of sterile technique for dressing changes.

B. the importance of including high-fiber foods in the diet.
C. when the patient may need to cut the immobilizing wires.
D. self-administration of nasogastric tube feedings.

Correct Answer: C
Rationale: The jaw will be wired for stabilization, and the patient should know what emergency situations
require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is
liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube
feedings, but by discharge the patient will swallow liquid through a straw.

28. A patient who has severe peripheral arterial disease and ischemic foot ulcers is upset with the health care provider's
recommendation to have an above-the-knee amputation. The patient tells the nurse, "If they want to cut off my leg,
they should just shoot me instead." The most appropriate response to the patient's statement is,

A. "Let's talk about how you feel this surgery will affect you."
B. "If you do not want the surgery, you do not have to have it."
C. "I understand why you are upset, but there really is no choice because your leg is so badly diseased."
D. "Many people are able to function normally with a prosthesis after amputation, and you can too."

Correct Answer: A
Rationale: The initial nursing action should be to assess how the patient feels about the amputation and what
the patient knows about the procedure and rehabilitation process. Discussion about the patient's option to not
have the procedure, the reason the procedure is needed, or rehabilitation after the procedure may be
appropriate after the nurse knows more about the patient's current level of knowledge and emotional state.

29. On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated
limb. An appropriate action by the nurse is to

A. administer prescribed opioids to relieve the pain.

B. explain the reasons for phantom limb pain.
C. loosen the compression bandage to decrease incisional pressure.
D. remind the patient that this phantom pain will diminish over time.

Correct Answer: A
 Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations
of the reason for the pain may be given, but the nurse should still medicate the patient. The compression
bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it
still requires treatment now.

30. A patient undergoes a right below-the-knee amputation with an immediate prosthetic fitting. When the patient is
returned to the nursing unit, the nurse should

A. check the surgical site for hemorrhage.

B. take the patient's vital signs frequently.
C. keep the residual leg elevated on a pillow.
D. place the patient in a prone position.

Correct Answer: B
Rationale: The vital signs should be monitored frequently to assess for hemorrhage because the nurse will not
be able to visualize the surgical site. Flexion contracture of the hip would be encouraged by elevating the
residual limb on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but
this would not be done during the immediate postoperative period.

31. The nurse provides discharge instructions to a patient with an above-the-knee amputation who will be fitted with a
prosthesis when healing is complete and the residual limb is well molded. The nurse determines that teaching has been
effective when the patient says,
A. "I should change the limb sock when it becomes soiled or stretched out."
B. "I should use lotion on the stump to prevent drying and cracking of the skin."
C. "I should elevate my residual limb on a pillow 2 or 3 times a day."
D. "I should lay on my abdomen for 30 minutes 3 or 4 times a day."

Correct Answer: D
Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limp
sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because
this would encourage flexion contracture.

32. Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing
measures is inappropriate when providing oral hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client’s mouth with a padded tongue blade.
D. Cleaning the client’s mouth and teeth with a toothbrush.

Correct Answer: A. Placing the client on the back with a small pillow under the head.
A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape
from the throat and mouth, minimizing the risk of aspiration. Observe the patient for paroxysms of coughing,
food dribbling out or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal
regurgitation when swallowing liquids.

33. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and
slurred speech. Which nursing intervention is a priority?

A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation.

Correct Answer: C. Schedule for A STAT computer tomography (CT) scan of the head.
A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder.
This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an
ischemic stroke can use rt-PA. Demonstrates structural abnormalities, edema, hematomas, ischemia, and
infarctions. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions.
34. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-
PA) administration. Which is the priority nursing assessment?

A. Time of onset of current stroke B. Complete physical and history

C. Current medications D. Upcoming surgical procedures

Correct Answer: A. Time of onset of current stroke

The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better
outcomes. Tissue plasminogen activator (tPA) is classified as a serine protease (enzymes that cleave peptide
bonds in proteins). It is thus one of the essential components of the dissolution of blood clots. Its primary
function includes catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in
dissolving blood clots.

35. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:

A. Pulse B. Respirations
C. Blood pressure D. Temperature

Correct Answer: C. Blood pressure

Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of
thrombolytic therapy. Blood pressure should be maintained according to the physician and is specific to the
client’s ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the
priority is blood pressure.

36. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

A. Cholesterol level B. Pupil size and pupillary response

C. Bowel sounds D. Echocardiogram

Correct Answer: B. Pupil size and pupillary response

It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Pupil
reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is
intact. Pupil size and equality is determined by a balance between parasympathetic and sympathetic innervation.
Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.

37. The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the
procedure?

A. Side-lying, with legs pulled up and head bent down onto the chest.
B. Side-lying, with a pillow under the hip.
C. Prone, in a slight Trendelenburg’s position.
D. Prone, with a pillow under the abdomen.

Correct Answer: A. Side-lying, with legs pulled up and head bent down onto the chest
The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen,
and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae. The
positioning of the patient in either a lateral recumbent position or sitting position may be used. The lateral
recumbent position is preferred as it will allow an accurate measurement of opening pressure, and it also
reduces the risk of post-lumbar puncture headache.

38. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected
into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus
toward the right. The nurse understands that this indicates the client has:

A. A cerebral lesion B. A temporal lesion

C. An intact brainstem D. Brain death

Correct Answer: C. An intact brainstem

 Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After
determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response
that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being
irrigated, followed by rapid nystagmus to the opposite side. Absent or deconjugate eye movements indicate
brainstem damage.

39. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following
trends in vital signs if the ICP is rising?

A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

Correct Answer: B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing
temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.
Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign
of impending brain herniation. This occurs when the ICP is too high the elevation of blood pressure is a reflex
mechanism to maintain CPP.

40. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is
developing meningitis as a complication of surgery if the client exhibits:

A. A negative Kernig’s sign. B. A positive Brudzinski’s sign.

C. Absence of nuchal rigidity. D. A Glascow Coma Scale score of 15.

Correct Answer: B. A positive Brudzinski’s sign

Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski’s sign, and
positive Kernig’s sign. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the
nurse gently flexing the head and neck onto the chest. Brudzinski’s sign is characterized by reflexive flexion of
the knees and hips following passive neck flexion. To elicit this sign, the examiner places one hand on the
patient’s chest and the other hand behind the patient’s neck. The examiner then passively flexes the neck
forward and assesses whether the knees and hips flex.

41. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge
that the human body typically and automatically responds to pain first with attempts to:

A. Tolerate the pain. B. Decrease the perception of pain.

C. Escape the source of pain. D. Divert attention from the source of pain.

Correct Answer: C. Escape the source of pain.

The client’s innate responses to pain are directed initially toward escaping from the source of pain. For example,
in sudden strong pain like that generated by pricking the finger, a reflex response occurs within the spinal cord.
Motor neurons are activated and the muscles of the arm contract, moving the hand away from the sharp object.
This occurs in a fraction of a second — before the signal has been relayed on to the brain — so the client will
have pulled his arm away before even becoming conscious of the pain.

42. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most
appropriate to institute?

A. Limiting conversation with the child. B. Allowing the child to play in the bathtub.
C. Keeping extraneous noise to a minimum. D. Performing treatments quickly.

Correct Answer: C. Keeping extraneous noise to a minimum

A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore,
extraneous noise should be minimized and bright lights avoided as much as possible. Maintain a quiet
environment and keep the lights dim. Prevents stimulation that can cause or precipitate an episode of
convulsion.
43. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance

C. Impaired urinary elimination D. Risk for injury

Correct Answer: B. Ineffective airway clearance

In Parkinson’s 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 diagnosis of Ineffective airway
clearance takes highest priority. Although the other options also are appropriate, they aren’t immediately life-
threatening.

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

A. Wrinkle the forehead, blow out the cheeks, and whistle.

B. Massage the face with a gentle upward motion.
C. Perform facial exercises.
D. Exposure to cold and drafts.

Correct Answer: D. Exposure to cold and drafts.

Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide
comfort. Facial pain is controlled with analgesic agents or heat applied to the involved side of the face.

45. A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the
nursing admission interview if the client has a history of:

A. Seizures or trauma to the brain.

B. Meningitis during the last five (5 years).
C. Back injury or trauma to the spinal cord.
D. Respiratory or gastrointestinal infection during the previous month.

Correct Answer: D. Respiratory or gastrointestinal infection during the previous month.

Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves.
Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of
neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.

46. A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical
ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with
this illness?

A. Giving the client full control over care decisions and restricting visitors.
B. Providing positive feedback and encouraging active range of motion.
C. Providing information, giving positive feedback and encouraging relaxation.
D. Providing intravenously administered sedatives, reducing distractions and limiting visitors.

Correct Answer: C. Providing information, giving positive feedback, and encouraging relaxation.
The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden
onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client’s
condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The
family can become involved with selected care activities and provide diversion for the client as well.

47. A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness,
flushed skin above the level of the injury, and headache. The client’s blood pressure is 160/90 mm Hg. Which of the
following is a priority action for the nurse to take?
A. Loosen tight clothing or accessories B. Assess for any bladder distention
C. Raise the head of the bed D. Administer antihypertensive

Correct Answer: C. Raise the head of the bed

The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals
with spinal injuries. Usually, an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above
baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in
high Fowler’s position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke.

48. Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL?

A. Ataxia B. Potassium deficit

C. Neglect syndrome D. Tetraplegia

Correct Answer: A. Ataxia

A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 35 mg/dl signifies toxicity. Symptoms of this level of
concentration include ataxia, tremor, slurred speech, nausea, and vomiting.

49. To encourage adequate nutritional intake for a female client with Alzheimer’s 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.

Correct Answer: A. Stay with the client and encourage him to eat.
Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with
Alzheimer’s disease can forget how to eat. Offer sweet and salt substitutes. Helps satisfy desire for these tastes
as taste buds decrease with aging without compromising diet. Allow for interaction during mealtime to promote
interest in eating.

50. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test
assesses which of the following?

A. Cerebellar function B. Intellectual function

C. Cerebral function D. Sensory function

Correct Answer: C. Cerebral function

The mental status examination assesses functions governed by the cerebrum. Some of these are orientation,
attention span, judgment, and abstract reasoning. Cerebrum is the largest part of the brain and is composed of
right and left hemispheres. It performs higher functions like interpreting touch, vision, and hearing, as well as
speech, reasoning, emotions, learning, and fine control of movement.

51. 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 the 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

Correct Answer: B. In 10 to 15 minutes

When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as 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 shouldn’t
exceed 100 mg in 24 hours. It is crucial to monitor respiratory and cardiovascular status, blood pressure, heart
rate, and symptoms of anxiety in patients taking diazepam.

52. Emergency medical technicians transport a 27-year-old ironworker 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 he’s comatose. We intubated him and he’s maintaining an
arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse
has the highest priority?

A. Assessing the left leg. B. Assessing the pupils.

C. Placing the client in Trendelenburg’s position. D. Assessing level of consciousness.

Correct Answer: A. Assessing the left leg.

In the scenario, airway and breathing are established so the nurse’s next priority should be circulation. With a
compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the
site. Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation. Inadequate
circulating volume compromises systemic tissue perfusion.

53. 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 client’s feet make a half-circle. To document the client’s gait, the nurse
should use which term?

A. Ataxic B. Dystrophic
C. Helicopod D. Steppage

Correct Answer: C. Helicopod

A helicopod gait is an abnormal gait in which the client’s feet make a half circle with each step. A gait seen in
some conversion reactions or hysteric disorders, in which the feet describe half circles.

54. 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 client’s history. Which preexisting
condition would contraindicate the use of pyridostigmine?

A. Ulcerative colitis B. Blood dyscrasia

C. Intestinal obstruction D. Spinal cord injury

Correct Answer: C. Intestinal obstruction

Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction
of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Pyridostigmine
bromide is preferred over neostigmine because of its longer duration of action. In those with bromide
intolerance that leads to gastrointestinal effects, ambenonium chloride can be used. Patients with MuSK MG
respond poorly to these drugs and hence may require higher doses.

55. Nurse Marty 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

Correct Answer: C. Muscle weakness

The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function
or cause idiosyncratic hepatitis. The intravenous administration of dantrolene in healthy volunteers has resulted
in skeletal muscle weakness, dyspnea, respiratory muscle weakness, and decreased inspiratory capacity. These
are expected symptoms given the mechanism of action of the medication.

56. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s
care, the nurse should assign the highest priority to which nursing diagnosis?

A. Impaired physical mobility B. Ineffective breathing pattern

C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming

Correct Answer: B. Ineffective breathing pattern

Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to
maintain a patent airway and provide adequate oxygenation. Maintain patent airway: keep head in neutral
 position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical
injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient
airway.

57. 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), two (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.

Correct Answer: D. Treatment of spasticity associated with spinal cord lesions.

In addition to relieving painful muscle spasms, Diazepam also is recommended for treatment of spasticity
associated with spinal cord lesions. Diazepam’s use is limited by its central nervous system effects and the
tolerance that develops with prolonged use. It is a fast-acting, long-lasting benzodiazepine commonly used in
the treatment of anxiety disorders, as well as alcohol detoxification, acute recurrent seizures, severe muscle
spasm, and spasticity associated with neurologic disorders.

58. 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 client’s 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.

Correct Answer: D. Cranial nerves IX and X.

Swallowing is a motor function of cranial nerves IX and X. Cranial nerve IX (glossopharyngeal nerve), is
responsible for motor (SVE) innervation of the stylopharyngeus and the pharyngeal constrictor muscles by the
nucleus ambiguus. Damage to the recurrent laryngeal branch of the vagus nerve can result in vocal hoarseness
or acute dyspnea with bilateral avulsion.

59. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the
nurse should tell the client to:

A. Take a hot bath. B. Rest in an air-conditioned room.

C. Increase the dose of muscle relaxants. D. Avoid naps during the day.

Correct Answer: B. Rest in an air-conditioned room.

Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an
air-conditioned room may relieve fatigue; however, extreme cold should be avoided. Other measures to reduce
fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn
energy conservation techniques, and reducing spasticity.

60. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical
ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

A. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”
B. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any sensory
loss.”
C. “It must be hard to accept the permanency of your paralysis.”
D. “You’ll first regain use of your legs and then your arms.”

Correct Answer: A. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”
The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only
temporary. Return of motor function begins proximally and extends distally in the legs. Guillain-Barre syndrome
(GBS) patients describe a fulminant course of symptoms that usually include ascending weakness and non-
length dependent sensory symptoms. By definition, the nadir is usually reached within 4 weeks. Symmetric
involvement is a key feature of GBS.