Recalls 3 NP 4

Dusty T. Kawi, RN

Situation: Multiple Sclerosis

1. The nurse, Sam, is assessing a 48-year-old client, Antha, diagnosed with multiple sclerosis.
Which clinical manifestation warrants immediate intervention?

A. The client has scanning speech and diplopia.- normal MS

B. The client has dysarthria and scotomas.- N
C. The client has muscle weakness and spasticity.- N
D. The client has a congested cough and dysphagia. - Airway

MS CHarcots Triad
a. S – scanning speech
b. I – intentional tremor
C. N – nystagmus

2. Nicole, 30-year-old female client, is admitted with complaints of numbness, tingling, a

crawling sensation affecting the extremities, and double vision which has occurred two (2) times
in the month. Which question is most important for the nurse to ask the client?

A. "Have you experienced any difficulty with your menstrual cycle?"

B. "Have you noticed a rash across the bridge of your nose?" - SLE
C. "Do you get tired easily and sometimes have problems swallowing?"
D. "Are you taking birth control pills to prevent conception?" - not related

These are clinical manifestation of MS and can go un diagnosed for years

be-cause of the remitting-relapsing nature of the disease. Fatigue and difficulty
swallowing are other symptoms of MS.

3. The 45-year-old client, Ashley, is diagnosed with primary progressive multiple sclerosis and
the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss."
Which intervention should be implemented?

A. Consult the physical therapist for assistive devices for mobility.

B. Determine if the client has a legal power of attorney.
C. Ask if the client would like to talk to the hospital chaplain.
D. Discuss the client's wishes regarding end-of-life care.

The client should make personal choices about end-of-life issues while it is possible to
do so. This client is progressing toward immobility and all the complications related to it.

4. The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose
intravenous injections of corticosteroid medication. Which nursing intervention should be
implemented?

A. Discuss discontinuing the proton pump inhibitor with the HCP. - PPI (Azole)
B. Hold the medication until after all cultures have been obtained. - antibiotics
C. Monitor the client's serum blood glucose levels frequently
D. Provide supplemental dietary sodium with the client's meals. - Na sodium retention

Ans: c. Monitor the client's serum blood glucose levels frequently. Steroids interfere with
glucose metabolism by blocking the action of insulin; therefore, the blood glucose levels
should be monitored.
Situation 2: Guillain-Barre Syndrome

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

A. Seizures or trauma to the brain

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

Patients with Guillain-Barre syndrome often have a preceding respiratory or

gastrointestinal infection. This is because Guillain-Barre syndrome is believed to be an
autoimmune response triggered by an infection. The immune system mistakenly attacks
the peripheral nervous system, leading to inflammation and muscle weakness.
Therefore, it is important for the nurse to ask about any recent respiratory or
gastrointestinal infections in order to assess the potential cause of the client's
Guillain-Barre syndrome.

GBS - ascending paralysis

6. A 25 year-old presents to the ER with unexplained paralysis from the hips downward. The
patient explains that a few days ago her feet were feeling weird and she had trouble walking
and now she is unable to move her lower extremities. The patient reports suffering an illness
about 2 weeks ago, but has no other health history. The physician suspects Guillain-Barré
Syndrome and orders some diagnostic tests. Which finding below during your assessment
requires immediate nursing action?

A. The patient reports a headache.

B. The patient has a weak cough.
C. The patient has absent reflexes in the lower extremities.
D. The patient reports paresthesia in the upper extremities.

Therefore, the nurse should assess for any signs and symptoms that the respiratory
system may be compromised (ex: weak cough, shortness of breath, dyspnea...patient
says it is hard to breath etc.). The nurse should immediately report this to the MD
because the patient may need mechanical ventilation. Absent reflexes is common in
GBS and paresthesia can extend to the upper extremities as the syndrome progresses.
A headache is not common.

7. A patient with Guillain-Barré Syndrome has a feeding tube for nutrition. Before starting the
scheduled feeding, it is essential the nurse? Select all that apply:

A. Assesses for bowel sounds

B. Keeps the head of bed less than 30' degrees
C. Checks for gastric residual
D. Weighs the patient

Some patients may need NGT - for patency = to prevent aspiration

Gastric residual - >100cc - patient may not tolerate the feeding

8. You're about to send a patient for a lumbar puncture to help rule out Guillain-Barré Syndrome.
Before sending the patient you will have the patient?

A. Clean the back with antiseptic

B. Drink contrast dye
C. Void - to prevent bladder being punctured during procedure
D. Lie flat
Situation 3: Myasthenia Gravis

9. A patient with myasthenia Gravis will be eating lunch at 12:00 PM. It is now 10:00 AM and the
patient is scheduled to take Pyridostigmine. At what time should you administer this medication
so the patient will have the maximum benefit of this medication?

A. As soon as possible.
B. 1 hour after the patient has eaten (at 1:00 PM)
C. 1 hour before the patient eats (at 11:00 AM)
D. At 12:00 right before the patient eats.

Ans: c. 1 hour before the patient eats (at 11:00 AM)

Pyridostigmine is an anticholinesterase medication that will help improve muscle

strength. It is important the patient has maximum muscle strength while eating for
the chewing and swallowing process. Therefore, the medication should be given 1
hour before the patient eats because this medication peaks (has the maximum effect) at
approximately 1 hour after administration.

10. The neurologist is conducting a Tensilon test (Edrophonium) at the bedside of a patient who
is experiencing unexplained muscle weakness, double vision, difficulty breathing, and ptosis.
Which findings after the administration of Edrophonium would represent the patient has
myasthenia Gravis?

A. The patient experiences worsening of the muscle weakness

B. The patient experiences wheezing along with facial flushing.
C. The patient reports a tingling sensation in the eyelids and sudden ringing in the ears.
D. The patient experiences improved muscle strength.

During a tensilon test Edrophonium is administered. This medication prevents the

breakdown of acetylcholine, which will allow more of the neurotransmitter acetylcholine
to be present at the neuromuscular junction....hence IMPROVING muscle strength IF
myasthenia Gravis is present. Therefore, if a patient with MG is given this medication
they will have improved muscle strength.

11. Which patient below is MOST at risk for developing a cholinergic crisis?

A. A patient with myasthenia Gravis is who is not receiving sufficient amounts of their
anticholinesterase medication.
B. A patient with myasthenia Gravis who reports not taking the medications
Pyridostigmine for 2 weeks.
C. A patient with myasthenia Gravis who is experiencing a respiratory infection and
recently had left hip surgery.
D. A patient with myasthenia gravis who reports taking too much of their
anticholinesterase medication.

Remember patients who experience a cholinergic crisis are most likely to because
they've received too much of their anticholinesterase medications (example
Pyridostigmine).

However, on the other hand, patients who have received insufficient amount of their
anticholinesterase medication or have experienced an illness/stress/surgery are most
likely to experience a myasthenia crisis. Both conditions will lead to muscle weakness
and respiratory failure but from different causes, which is why a Tensilon test is used to
help differentiate between the two conditions.
 Tensilon test – where they give Edroprhonium
a. Myasthenia Crisis – improves muscle strength
b. Cholinergic Crisis – worsen muscle weakness

ANTIDOTE: atropine sulfate (anti-cholinergic) – inhibits the actions of Ach by partially

blocking cholinergic receptors, decreasing the amount of Ach available at neuromuscular
junction

12. You're a home health nurse providing care to a patient with myasthenia gravis. Today you
plan on helping the patient with bathing and exercising. When would be the best time to visit the
patient to help with these tasks?

A. Mid-Afternoon.
B. Morning. - well rested
C. Evening.
D. Before bedtime

Situation 4: Parkinsons

13. A patient who is diagnosed with Parkinson disease (PD) states, “I can’t tie my shoelaces
anymore.” The healthcare provider recognizes that this patient’s problem is due to a deficiency
in which of these neurotransmitters?

a. Glutamate
b. Norepinephrine
c. Dopamine
d. Serotonin

pD is a progressive neurodegenerative disease that impacts the motor system.

Patients with PD have decreased voluntary motor control.

Dopamine helps our brains control movement and coordination. The cells in the brain
that make dopamine slowly die in patients who have PD, making it increasingly difficult
to control muscles for movement, including fine motor movement needed to tie one’s
shoelaces.

- PD – damage in substantia Nigra (in basal ganglia), which produces Dopamine needed
for movement and msucle tone, caused by Kuri virus, boxers Pugilistica, aluminum
theory, Methyl Phenyl Tetra hydro pyrodine (drug abuse, damage the dopaminergic
neurons in subs nigra)

14. When planning care for a patient diagnosed with Parkinson disease (PD), which of these
patient outcomes should receive priority in the patient’s plan of care?

a. Working on a favorite hobby

b. Taking a vitamin supplement each day
c. Toileting and bathing independently
d. Taking a daily walk around the neighborhood

PD is a progressive neurodegenerative disease which causes impaired motor function.

Being able to perform such tasks as toileting and bathing is important in maintaining
some degree of independence and quality of life, so this is the priority outcome.
15. A patient who has been prescribed the antiparkinsonian medication carbidopa/levodopa,
asks the healthcare provider, “Why am I getting these two medications?” How should the
healthcare provider respond?

A. “This drug combination is composed of two types of the same medication.”

B. “You will experience fewer side effects when you take both medications together.”
C. “The carbidopa prevents the breakdown of the levodopa.”
D. “The levodopa turns the carbidopa into dopamine when it reaches the brain.”

Carbidopa and levodopa have different actions.

Carbidopa cannot cross the blood brain barrier, and has no direct therapeutic effects of
its own.
Levidopa – dopamine precursor that cross blood brain barrier which then converted to
dopamine, if given alone, breaks down in bloodstream before it reaches brain.
Carbidopa prevents the breakdown (decarboxylation) of levodopa in the intestine and
peripheral tissues so more levodopa can travel to the brain, cross the blood brain barrier,
where it is converted into.

16. A patient diagnosed with Parkinson disease (PD) is prescribed levodopa. The medication
therapy can be considered effective when the healthcare provider assesses improvement in
which of the following?

A. Visual acuity
B. Appetite
C. Hearing
D. Urinary frequency

Ans: d. Urinary frequency

Patients who are diagnosed with PD experience both motor and non-motor symptoms.
The non-motor symptoms are caused with autonomic nervous system dysfunction.
Autonomic nervous system dysfunction can cause urinary symptoms in patients, such as
urinary frequency, urgency, and urge incontinence.

PD – bladder issues is due to fluctuations of dopamine levels affecting bladder muscle

and nerves
- Conservative treatment – pelvic floor exercises, bladder diary, bladder training (holding
the urge to urinate for longer time allowing to increase bladder size)

Situation 5: Alzheimer’s Disease

17. When communicating with patients who have dementia, which of the following responses is
most effective?

A. Speak louder to the patient who has delayed response time

B. Utilize visual cues such as pointing or touching items
C. Repeat questions and comments frequently
D. Have the patients begin tasks on their own to promote independence

A situation or task is more easily understood to the patient when the patient can visualize
what is being asked of them. For example, the nurse should guide the patient to the
chair and point to the chair as the patient sits for dinner

Signs and Symptoms

A – Apraxia – unable to do certain movements
A – Aphasia – unable to understand or create speech (Visual imagery)
A – Agnosia – unable to recognize objects, people, and senses (urinary and bowel
incontinence)
A – Amnesia – memory loss
A – Anomia – name of object
18. A 62-year-old patient is brought to the clinic by a family member who is concerned about the
patient's inability to solve common problems. To obtain information about the patient's current
mental status, which question should the nurse ask the patient?

A. "Where were you were born?"

B. "Do you have any feelings of sadness?"
C. "What did you have for breakfast?"
D. "How positive is your self-image?"

This question tests the patient's recent memory, which is decreased early in Alzheimer's
disease (AD) or dementia. Asking the patient about birthplace tests for remote memory,
which is intact in the early stages.
Questions about the patient's emotions and self-image are helpful in assessing
emotional status, but they are not as helpful in assessing mental state.

19. A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3
days after admission. Which information indicates that the patient is experiencing delirium rather
than dementia?

A. The patient was oriented and alert when admitted.

B. The patient's speech is fragmented and incoherent.- both
C. The patient is oriented to person but disoriented to place and time.
D. The patient has a history of increasing confusion over several years.

Dementia - gradual onset

Delirum - sudden/ abrupt

Delirium – acute (sudden), days to weeks, consciousness fluctuates to hyper-vigillance

to drowsiness, hallucinations and illusions present
Dementia – gradual and progressive, years, consciousness often normal, S&Sx are
consistent, hallucination (late stage)

20. For which patient should the nurse prioritize an assessment for depression?

A. A patient in the early stages of Alzheimer's disease

B. A patient who is in the final stages of Alzheimer's disease
C. A patient experiencing delirium secondary to dehydration
D. A patient who has become delirious following an atypical drug response

Patients in the early stages of Alzheimer's disease are particularly susceptible to

depression, since the patient is acutely aware of his or her cognitive changes and the
expected disease trajectory.

Delirium is typically a shorter-term health problem that does not typically pose a
heightened risk of depression.
Sensory/Special Senses

Situation 6: Refractive Errors

21. In the eye clinic, Nurse Leah is discussing various eye conditions with her patient, Mrs.
Peterson, who has been experiencing difficulties with near vision as she’s gotten older. Leah
explains one condition characterized by a reduction in the eye’s power of accommodation.
According to Nurse Leah, what is the term for the eye disorder characterized by a decrease in
the effective powers of accommodation?

A. Presbycusis - hearing loss

B. Hypertropia - strabismus, misalignment of eye
C. Presbyopia - age related condition, lens loses its flexibility - making it difficult
to focus
D. Myopia- nearsightedness

22. Nurse Adrian is assisting Mr. Johnson, a patient who recently learned he has hyperopia or
farsightedness. While discussing options for corrective lenses, Nurse Adrian talks about the
type of lens that would typically be used to help with this condition. According to Nurse Adrian,
what type of lens is typically used to correct hyperopia?

A. Aphakic lens.
B. Bifocal lens.
C. Concave lens.- Myopia
D. Convex lens.

hyperopia, or farsightedness, the eye is shorter than normal or the cornea is too flat,
causing light to focus behind the retina instead of directly on it. This leads to difficulties
seeing objects that are close. Convex lenses are used to correct hyperopia. These
lenses bend the light rays inward, moving the focus forward onto the retina, just like a
magnifying glass.

Aphakic lens: Aphakic lenses are used in individuals who have had their natural lens
removed due to cataract surgery or other reasons and do not have an intraocular lens
replacement. These are not specifically designed for hyperopia correction.

Bifocal lens: Bifocal lenses have two points of focus. The upper part is generally for
distance, and the lower part is for near vision. This type of lens is usually used in
presbyopia, a condition that typically affects older adults and involves difficulty focusing
on near objects.

Concave lens: Concave lenses are used to correct myopia or nearsightedness, not
hyperopia. They spread the light rays out and move the focus back onto the retina.

23. A client has received a diagnosis of hyperopia and is wondering if there is a physical
condition that has caused these vision changes. In explaining hyperopia, what does the nurse
indicate is the cause of this clients vision changes?

A. Eyeballs that are shorter than normal

B. Eyeballs that are longer than normal
C. Unequal curvatures in the corneas
D. Irregularly shaped corneas

Ans: a. Eyeballs that are shorter than normal

24. The client’s vision is tested with a Snellen chart. The results of the tests are documented as
20/100. The nurse interprets this as:

A. The client can read at a distance of 100 feet what a client with normal vision can read
at 20 feet.
B. The client is legally blind.
C. The client’s vision is normal.
D. The client can read only at a distance of 20 feet what a client with normal vision
can read at 100 feet.

Vision that is 20/20 is normal, that is, the client is able to read from 20 feet what a person
with normal vision can read from 20 feet. A client with a visual acuity of 20/100 only can
read at a distance of 20 feet of what a person with normal vision can read at 100 feet.
The results of visual acuity are classically reported using 20/20 (6/6 when using meters)
for standard vision. The numerator describes the distance from the chart, typically
20 ft (6 m). The denominator describes the distance that an individual with normal
vision (20/20 vision) can read the same line on the chart.

Situation 7: Glaucoma

25. A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains
that the chief aim of treatment is to meet which goal?

A. Rest the eye

B. Dilate the pupil
C. Prevent secondary infections
D. Control the intraocular pressure - prevent damage to the optic nerve

26. Nurse Emma is evaluating a patient who has been referred to the clinic due to ocular
hypertension. As she goes over the typical characteristics of this condition, she tries to identify
which feature does not belong. Which is not a feature of ocular hypertension?

A. Normal optic discs.

B. A closed angle.
C. Normal visual fields.
D. Increased intraocular pressure.
 Ocular hypertension refers to a condition in which the intraocular pressure (IOP) is
higher than normal.
This doesn’t necessarily result in vision loss or nerve damage, and in fact, it can occur
even when the optic disc (the place where the optic nerve connects to the retina) looks
normal, and the visual fields (the total area an individual can see without moving their
eyes) remain unaffected. Thus, options (normal optic discs), (normal visual fields), and
(increased intraocular pressure) are all characteristic of ocular hypertension.

27. A nurse is administering eye drops of two different drugs to a patient. How long should the
nurse wait between the instillation of the first medication and the second
Medication?

Q. At least 1 minute - overflow

B. At least 5 minutes _interval of 5 to 10minutes)
C. At least 15 minutes
D. At least 20 minutes

When two or more different eye-drop preparations are used at the same time of day, or
ointment at the same time as drops, the patient should leave an interval of 5 minutes
between preparations to avoid dilution and overflow.

**In what order should I use eye drops?

Ans: There is no strict or recommended order for instilling drops, but the artificial tears
should be used last to minimize the “wash-out” effect.

Situation 8: Cataract

28. John will be undergoing cataract surgery. Nurse Victor is preparing to instill eye drops to a
patient prior to cataract surgery. He is aware that:

A. Mydriatics will be used to dilate the pupil - for making cataract removal easier
B. Miotics will be used to constrict the pupil
C. Miotics will be used to dilate the pupil
D. Mydriatics will be used to constrict the pupil

29. John has recently had cataract surgery. About which symptom does the nurse Victor instruct
the client to notify the health care provider?

A. Increased tearing - expeceted

B. Itching of the eye - expected
C. Reduction in vision - iindicated problem, client should the physician
D. Swollen eyelid - expected

30. Nurse Victor is preparing John for discharge following the removal of a cataract. The nurse
should tell the client to:

A. Take aspirin for discomfort - NSAID - risk bleeding

B. Avoid bending over to put on his shoes - increase IOP
C. Remove the eye shield before going to sleep -
D. Continue showering as usual - infection
31. During the early postoperative period, the client who had a cataract extraction complains of
nausea and severe eye pain over the operative site. The initial nursing action is to:

A. Call the physician.- Indication of increase IOP

B. Administer the ordered main medication and antiemetic. -
C. Reassure the client that this is normal.
D. Turn the client on his or her operative side. Increase IOP

Situation 9: Retinal Detachment

32. A client has been diagnosed with retinal detachment. The nurse knows that which among
the following are the manifestations of retinal detachment (select all that apply):

A. Painless
B. Flashes of Lights
C. Floaters or black spots
D. Sense of a curtain being drawn over the eye
E. Increase in blurred vision

Ans: A, B, C, D, E Sources: American Academy of Ophthalmology; American Academy

of Family Physicians

OLOF

.Because the retina has no pain receptors, neither the tearing nor the physical
detachment of the retina is accompanied by pain.
B. The vitreous gel inside the eye shrinks or changes, pulling on the retina. As this
vitreous shrink it pulls toward the center of the eye causing traction on the retina (the
light sensitive lining of the eye). This force stimulates the retina causing the perception of
flashing lights. Once the gel has completely detached, these flashes of light will subside.
Flashes of light can also happen if you’re hit in the eye or rub your eyes too hard. In both
cases, the flashes are caused by physical force on the retina.
C. Blood and retinal cells freed at the time of the tear cast shadows on the retina as they
drift about the eye…. When the retina tears, blood and retinal pigment epithelium cells
may enter the vitreous cavity and are perceived as floaters
D. And e. (1) When the detachment is extensive and rapid, the client feels as if a curtain
has been pulled over his or her eyes

Situation 10: Macular Degeneration

33. A nurse performs an assessment of a client with a diagnosis of macular degeneration of the
eye. The nurse would expect the client to report which of the following symptoms?

A. Loss of peripheral vision

B. Blurred central vision
C. Increased clarity when looking at objects
D. Clear vision when reading

The most common symptom of macular degeneration is blurred central vision that often
occurs suddenly. Clients complain of difficulty with reading and seeing fine detail.
Formation of a central scotoma (blind spot) occurs in some clients. Clients might
complain of visual distortion, usually described as a bending or irregularity of straight
lines. Peripheral vision is spared, so although affected persons cannot see to read, drive,
watch television clearly, or distinguish faces, they do have the ability to walk.
Macula – part of the retina that controls sharp straight ahead vision (light sensitive tissue)
a. Dry – tiny yellow deposits called drusen forms under macula, deposits dry
and thin your macula
b. Wet (exudative) – abnormal blood vessels form under retina and macula,
leaks blood and fluids a bulge forms in macula, more severe form

34. The 65-year-old client is diagnosed with macular degeneration. Which statement by the
nurse indicates the client needs more discharge teaching?

1. "I should use magnification devices as much as possible."

2. "I will look at my Amsler grid at least twice a week." to assess macular degeneration
3. "I am going to use low-watt light bulbs in my house." - macula light sensitive
part of eye
4. "I am going to contact a low-vision center to evaluate my home." -

A. Magnifying devices used with activities such as threading a needle will help the
client's visual sight; therefore, this statement does not indicate the client needs more
teaching.
B. An Amsler grid is a tool to assess macular degeneration that often provides the
earliest sign of a worsening of the condition. If the lines of the grid become distorted or
faded, the client should call the ophthalmologist.
D. Low-vision centers will send representatives to the client's home or work to make
recommendations about improving lighting, thereby improving the client's vision and
safety.

35. Although all of the following measures might be useful in reducing the visual disability of a
client with adult macular degeneration (AMD), which measure should the nurse teach the client
primarily as a safety precaution?

A. Wear a patch over one eye.

B. Place personal items on the sighted side.
C. Lie in bed with the unaffected side toward the door.
D. Turn the head from side to side when walking. To expand the visual field,
neglecting to so may result in accidents

Situation 11: Hearing Loss

36. The student nurse is performing a Weber tuning fork test. What technique is most
appropriate?

A. Holding the vibrating tuning fork 10 to 12 inches from the clients ear
B. Placing the vibrating fork in the middle of the clients head
C. Starting by placing the vibrating fork on the mastoid process
D. Tapping the vibrating tuning fork against the bridge of the nose

The Weber tuning fork test includes placing the vibrating tuning fork in the middle of the
clients head and asking in which ear the client hears the vibrations louder. The other
techniques are incorrect.
 + rinne test - normal air > bone
- rinne test - conductive hearling loss bone > air

Sensorineural – damage to the inner ear (problems with nerves, ototoxicity, trauma, loud
noises)
Tinnitus – first sign of ototoxicity (ringing ears)
Conductive – outer and middle (otitis media, external otitis, fluids in middle ear, earwax)

37. The clients chart indicates a sensorineural hearing loss. What assessment question does
the nurse ask to determine the possible cause?

A. Do you feel like something is in your ear? - CHL

B. Do you have frequent ear infections? - CHL
C. Have you been exposed to loud noises? - damge cochlea, the eight cranial
nerve
D. Have you been told your ear bones don't move? - CHL

38. The nurse works with clients who have hearing problems. Which action by a client best
indicates goals for an important diagnosis have been met?

A. Babysitting the grandchildren several times a week

B. Having an adaptive hearing device for the television
C. Being active in community events and volunteer work
D. Responding agreeably to suggestions for adaptive devices

Clients with hearing problems can become frustrated and withdrawn. The client who is
actively engaged in the community shows the best evidence of psychosocial
adjustment to hearing loss. Babysitting the grandchildren is a positive sign but does
not indicate involvement outside the home. Having an adaptive device is not the same
as using it, and watching TV without evidence of other activities can also indicate social
isolation. Responding agreeably does not indicate the client will actually follow through.

39. An older adult in the family practice clinic reports a decrease in hearing over a week. What
action by the nurse is most appropriate?

A. Assess for cerumen buildup.

B. Facilitate audiological testing.
C. Perform tuning fork tests.
D. Review the medication list.

ll options are possible actions for the client with hearing loss. The first action the nurse
should take is to look for cerumen buildup, which can decrease hearing in the older
adult. If this is normal, medications should be assessed for ototoxicity. Further auditory
testing may be needed for this client.
40. A client with Meniere's disease is in the hospital when the client has an attack of this
disorder. What action by the nurse takes priority?

A. Assess vital signs every 15 minutes.

B. Dim or turn off lights in the clients room.
C. Place the client in bed with the upper side rails up. - risk for fall
D. Provide a cool, wet cloth for the clients ear.

Clients with Meniere's disease can have vertigo so severe that they can fall. The nurse
should assist the client into bed and put the side rails up to keep the client from falling
out of bed due to the intense whirling feeling. The other actions are not warranted for
clients with Meniere's disease.

Oncology

Situation 12: Breast CA

41. A client has just received a diagnosis of breast cancer from her physician. When the nurse
asks if she would like to talk about the diagnosis, the client replies, “Oh, no, I’m sure they are
wrong—i’ve always had cysts in my breasts.” The nurse recognizes that this may be a grief
response, which probably means that the client is

A. Not ready to accept the diagnosis.

B. In the disbelief stage of the grief process.
C. Not comfortable in discussing the diagnosis with the nurse.
D. Mourning the loss she will have to experience.

7- stages of grief – suggest that if one is in one of the stages there is nothing they can do
but wait until they pass into the next stage

1 Shock or disbelief – first reaction, they may not immediately sense devastated feelings,
numbness
2 Denial – it is related to how one expresses their emotions surrounding grief “Im fine” after
significant loss signifies denying his own feelings
3 Anger – some people become angry at themselves or the person who left them or the
situation they were left alone
4 Bargaining – attempts to make deal, often with God to change situation
5 Guilt – regrets to the things they didn't do or said before, wishing to turn back time
6 Depression – profound sadness
7 Acceptance and Hope – arrives at belief that although life will never be the same after loss,
there is hope that life will go on

42. A client with breast cancer receives diagnostic testing and scan results that indicate a tumor
that is 4.2 cm in size with evidence of metastasis to movable ipsilateral axillary nodes only.
According to the TNM staging​system, how should this​client's breast cancer be​staged?

a. T1 N0 MO b. Tis N1 M0
c. T3 N2 M1 d. T2 N1 M0

T – indicates tumor size

● Tx – not assessable
● T0 – no evidence of primary tumor
● T1 - <= 2cm
● T2 - > 2cm - <=5cm
● T3 - > 5cm
● T4 – any size involving chest wall or skin

N – extent of spread to lymph nodes

 ● Nx – not assessable
● N0 – no spread
● N1 – spread to movable ipsilateral level I & II axillary nodes
● N2 – spread to fixed level I & II ipsilateral axillary nodes
● N3 – metastases to ipsilateral level III axillary nodes with/ out Level I & II
involvement

M – presence of metastasis
● M0 – no distant spread
● M1 – distant spread

43. When teaching a 22-year-old patient when to perform breast self-examination (BSE), the
nurse will instruct the patient that:

A. BSE will be done 7-10 days before menstruation

B. BSE will be done 7-10 days after menstruation
C. BSE will be done 1 day before menstruation
D. BSE will be done 1 day after menstruation

During menstration - elevated estrogen --> makes breast tender and swollen
Irregular mens - same day each month

44. While the nurse is obtaining a nursing history from a 52-year-old patient who has found a
small lump in her breast, which question is most pertinent?

A. "Do you currently smoke cigarettes?"

B. "Have you ever had any breast injuries?" - tra uma
C. "Is there any family history of fibrocystic breast changes?" - no associated
D. "At what age did you start having menstrual periods?"

RISK BREAST - early menarche (<12yrs old and late menopause >60yrs old)

Situation 13: Prostate CA

45. A nurse is providing a program for older men in a senior community about measures that
can be taken to reduce the risk for prostate cancer. Which of the following would the nurse
include in the program?

A. Decrease red meat and fat intake. - some studies increase red and fat meat
intake is risk for developing prostate CA
B. Decrease lycopene intake.
C. Increase fiber intake.
D. Avoid foods high in sodium.

46. A nurse is teaching a 53-year old man about prostate cancer. What information should the
nurse provide to best facilitate the early identification of prostate cancer?

A. Have a digital rectal examination and prostate specific antigen (PSA) test done
yearly.
B. Have a transrectal ultrasound done every 5 years.
C. Perform monthly testicular self-examinations, especially after age 60.
D. Have a complete blood count (CBC), blood urea nitrogen (BUN) and creatinine
assessment performed annually.

B and C- usually after diagnosis to identify extent of disesase

DRE - 40 yrs and above every year

PSA - 50 yrs old and above every year (Prostate CA)
47. The patient who underwent prostate cancer surgery is approaching the time of discharge
from the hospital. What instruction should the nurse provide to this client as part of discharge
teaching? Select all that apply.
A. "Maintain a high fluid intake after you go home." - to reduce risk of clot
formation
B. "Call the healthcare provider immediately if you notice blood in your urine." normal ,
report only if excessive bleeding
C. "You may drive yourself home." (short distance)
D. "Avoid strenuous activity for 4-8 weeks." - healing time (4-8 weeks)
E. "Avoid heavy lifting for 2-4 weeks."

48. A patient has just been diagnosed with prostate cancer and is scheduled for
brachytherapy next week. The patient and his wife are unsure of having the procedure
because their daughter is 3 months pregnant. What is the most appropriate teaching the
nurse should provide to this family?

A. The patient should not be in contact with the baby after delivery.
B. The patients treatment poses no risk to his daughter or her infant.
C. The patients brachytherapy may be contraindicated for safety reasons.
D. The patient should avoid close contact with his daughter for 2 months.

Brachytherapy - implantation of radioactive seeds

Situation 14: Cervical CA

49. A client, age 41, visits the gynecologist. After examining her, the physician suspects cervical
cancer. The nurse reviews the client's history for risk factors for this disease. Which history
finding is a risk factor for cervical cancer?

A) Pregnancy complicated with eclampsia at age 27 - x

B) Spontaneous abortion at age 19 - x
C) Onset of sporadic sexual activity at age 17 - x frequent and multiple partners before
age 16
D) Human papillomavirus infection at age 32 - risk facor

50. A cervical radiation implant is placed in the client for treatment of cervical cancer. The
nurse initiates what most appropriate activity order for this client

A. Out of bed ad lib

B. Ambulation to the bathroom only
C. Bed rest - to prevent dislodgement of implant
D. Out of bed in a chair only

51. The nurse is caring for a female client experiencing neutropenia as a result of chemotherapy
and develops a plan of care for the client. The nurse plans to:

A) Teach the client and family about the need for hand hygiene - preventive
B) Insert an indwelling urinary catheter to prevent skin breakdown - promote infection,
invasive
C) Restrict fluid intake - encourage
D) Restrict all visitors - not all, limit

Neutropenia - decreased neutrophils (type of EBC responsible for bacterial and fungi
infection
52. A 33-yr-old patient has recently been diagnosed with stage II cervical cancer. Which
statement by the nurse best explains the diagnosis?

A. "The cancer is found at the point of origin only."

B. "Tumor cells have been identified in the cervical region."
C. "The cancer has been identified in the cervix and the liver."
D. "Your cancer was identified in the cervix and has limited local spread." - stage 2

Stage 0 – cancer in situ or in point of origin

Stage I – limited to the tissue of origin with localized growth
Stage III – extensive local and regional spread
Stage IV – metastasis to other organs

Situation 15: Testicular CA

53. When obtaining a focused health history for a patient with possible testicular cancer, the
nurse will ask the patient about any history of

A. Testicular torsion.
B. STD infection.
C. Undescended testicles.
D. Testicular trauma.

Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty.
STD infection, testicular torsion, and testicular trauma are risk factors for other testicular
conditions but not for testicular cancer.

54. When planning teaching for a patient who has had a unilateral orchiectomy and
chemotherapy for testicular cancer, the nurse will include information about the need for:

A. Regular follow-up appointments to detect other types of malignancies.

B. Aspiration of sperm from the remaining testis if infertility occurs- infertility
C. Testosterone supplements to help maintain erectile function. - remaining testis will
produce testosterone
D. Application of ice to the scrotum to minimize pain and swelling. - post op orchiectomy

Chemotherapy - may result to secondary malignancies

55. Which information will the nurse plan to include when teaching a young adult who has a
family history of testicular cancer about testicular self-examination?

A. Testicular self-examination should be done at least weekly.

B. Testicular self-examination should be done in a warm room. After bath
C. The only structure normally felt in the scrotal sac is the testis.
D. Call the health care provider if one testis is larger than the other.

The testes will hang lower in the scrotum when the temperature is warm (e.g., during a
Shower), and it will be easier to palpate. The epididymis is also normally palpable in the
Scrotum. One testis is normally larger. Men at high risk should perform testicular
self-examination monthly.
56. A 27-yr-old patient who has testicular cancer is being admitted for a unilateral orchiectomy.
The patient does not talk to his wife and speaks to the nurse only to answer the admission
questions. Which action is appropriate for the nurse to take?

A. Teach the patient and the wife that impotence is unlikely after unilateral Orchiectomy.
B. Ask the patient if he has any questions or concerns about the diagnosis and
treatment.
C. Inform the patient's wife that concerns about sexual function are common with this
diagnosis.
D. Document the patient's lack of communication on the health record and continue
preoperative care.

The initial action by the nurse should be assessment for any anxiety or questions about
the surgery or postoperative care. The nurse should address the patient, not the spouse,
when discussing the diagnosis and any possible concerns. Without further assessment
of patient concerns, the nurse should not offer teaching about complications after
orchiectomy. Documentation of the patient's lack of interaction is not an adequate
nursing action in this situation.

Situation 16: Lymphoma

57. The client asks the nurse, "They say I have cancer. How can they tell if I have Hodgkin's
disease from a biopsy?" The nurse's answer is based on which scientific rationale?

A. Biopsies are nuclear medicine scans that can detect cancer.

B. A biopsy is a laboratory test that detects cancer cells. Pathological exam
Laboratory test bodily fluids
C. It determines which kind of cancer the client has.
D. The HCP takes a small piece out of the tumor and looks at the cells.

Biopsy - removal of cell from a mass, and then examin the tissue inder
microscope
 Reed-Sternberg cells are diagnostic for Hodgkin's disease. If these cells are not found in
the biopsy, the HCP can rebiopsy to make sure the specimen provided the needed
sample or, depending on involvement of the tissue, diagnose a non-Hodgkin's
lymphoma.

58. The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which
assessment data support this diagnosis?

A. Night sweats and fever without "chills."

B. Edematous lymph nodes in the groin. - neck area
C. Malaise and complaints of an upset stomach.
D. Pain in the neck area after a fatty meal.

A. Clients with Hodgkin's disease experience drenching diaphoresis, especially at night;

fever without chills; and unintentional weight loss. Early-stage disease is indicated by a
painless enlargement of a lymph node on one side of the neck (cervical area). Pruritus is
also a common symptom.

B. Lymph node enlargement with Hodgkin's disease is in the neck area.

C. Malaise and stomach complaints are not associated with Hodgkin's disease.
D. Pain in the neck area at the site of the cancer occurs in some clients after the
ingestion of alcohol. The cause for this is unknown.

59. Which information about reproduction should be taught to the 27-year-old female client
diagnosed with Hodgkin's disease?

A. The client's reproductive ability will be the same after treatment is completed. - false,
premature menopause
B. The client should practice birth control for at least two (2) years following
therapy.
C. All clients become sterile from the therapy and should plan to adopt. Some but not all
D. The therapy will temporarily interfere with the client's menstrual cycle. Temporary

B. The client should be taught to practice birth control during treatment and for at least
two (2) years after treatment has ceased. The therapies used to treat the cancer can
cause cancer. Antineoplastic medications are carcinogenic, and radiation therapy has
proved to be a precursor to leukemia. A developing fetus would be subjected to the
internal conditions of the mother.

60. Which clinical manifestation of Stage I non-Hodgkin's lymphoma would the nurse expect to
find when assessing the client?

A. Enlarged lymph tissue anywhere in the body. -> Stage III and IV
B. Tender left upper quadrant.
C. No symptom in this stage. - clients are not usually diagnosed until later stages
D. Elevated B-cell lymphocytes on the CBC. - not seen in CBC, B -cell lymphocytes -
involved in the development of lymphoma
Musculoskeletal, Immune, and Inflammatory

Situation 17: Rheumatoid Arthritis

61. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis.
The nurse should conduct a focused assessment for:

A. Limited motion of joints. - LATE SIGN

B. Deformed joints of the hands. - LATE SIGN
C. Early morning stiffness. - ra occurs at rest
D. Rheumatoid nodules. - LATE SIGN
RA
- Autoimmune , attacks tissue lining of joints on both side of body
- Systemic, Unknown
- Between ages 30 – 60, YORA 16 – 40, LORA - > 60
- Pain at rest/inactivity , Extreme fatigue
- Family history, Sex (woman), smoking, obesity
- Elevated ESR and CRP, Positive RF or CCP (biomarkers)
- NSAIDs, COX2 inhibitors, Corticosteroids, JAK Inhibitors, Biologics, DMARD
- Deformities

62. A client has just recently been diagnosed with rheumatoid arthritis (RA). The client asks the
nurse if RA always causes crippling deformities. The nurse tells the client that to decrease the
likelihood of deformities, it is important to:
Select all that apply.

A. Ignore pain as a warning signal. -

B. Type instead of hand-writing items if possible. - PREFERABLE
C. Use stronger joints for most activity. - CORRECT
D. Avoid stress to any current area of deformity. - TO PREVENT DEFORMITY
E. Stop an activity if it is beyond your ability to perform. - SHOULD NOT PU
STRAIN ON JOINTS

A. A, B, C, D, E C. B, C, D, E
B. C, D, E D. A only

Deformities
● Buotonniere – flexion iin PIP and hyperextension at DIP
● SWAN NECK - FLEXION AT DISTAL IP AND EXTENSION AT PROXIMAL
63. The nurse is collecting a health history for a client being seen in an outpatient clinic. The
client complains of joint pain and swelling that have lasted for about 2 months. The nurse
devises a plan of care based on the nursing diagnosis of Activity Intolerance based on which
client statement?

A. "I seem to get tired early in the day and require a nap." - ONE HALL MARK OF
ra IS FATIGUE, PLAN OF CARE SHOULD INCLUDE FREQUENT REST TO
CONSERVE ENERGY
B. "My joints are stiffest at night before I go to sleep." NOT
C. "I find it difficult to move when I first get up in the morning." - PAIN AT REST
D. "I take ibuprofen for the pain as needed." DOESN’T AFFECT THE ABILITY TO
ACTIVITY

64. The nurse is completing a health screening for a school-age child with rheumatoid arthritis.
The parents ask the nurse to recommend activities that will promote exercise for their child.
Which is an appropriate teaching by the nurse?

A. Swimming - EXERCISES ALL EXTREMITIES WITHOUT PUTTING A LOT OF

STRESS ON JOINTS
B. Football
C. Softball
D. Basketball

Situation 18: Osteoarthritis

65. A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid
arthritis (RA). Which response is correct?

A. "OA and RA are very similar. OA affects the smaller joints and RA affects the larger,
weight-bearing joints."
B. "OA is more common in women. RA is more common in men."
C. "OA affects joints on both sides of the body. RA is usually unilateral."
D. "OA is a noninflammatory joint disease. RA is characterized by inflamed,
swollen joints."

OA - CARTILAGE (WEAR AND TEAR) DEGENERATIVE

RA - LINING OF THE TISSUE JOINTS AUTOIMMUNE

OA
- Degenerative >50s
- wear and tear, cartilage that lines your joint is worn down (cartilage, shock absorbers and
lubricant)
- Primary – most common form, wear and tear over time
- Secondary – traumas or injuries
- Pain during activity
- Obesity, diabetes, hyperlipidemia
- X-rays, MRI, CT
- Pain relievers, therapy, supportive devices, heat and cold, complementary therapies,
arthroplasty
- Nodes
66. The nurse is teaching a class about the joints commonly affected by osteoarthritis​ (OA).
Which joints should the nurse​include?

A. Ankles, feet, and spine

B. Knees, feet, and spine
C. Hands, knees, and hips - OA
D. Neck, shoulders, and ankles

RA - SMALL JOINTS OF HANDS, WRIST AND FEET

67. A nurse is managing the care of a client with osteoarthritis. What is the appropriate
treatment strategy the nurse will teach the about for osteoarthritis?

A. Vigorous physical therapy for the joints. - NORMAL JOINT EXERCISE TO MAINTAIN
MOBILITY
B. Administration of opioids for pain control. - NOT USED IN OA
C. Administration of monthly intra-articular injections of corticosteroids. - PROVIDE
SHORT IMMEDIEATE RELIEF
D. Administration of nonsteroidal anti-inflammatory drugs (nsaids) - REDUCE
INFLAMMATION AND PROVIDE PAIN RELIEVING EFFECT

68. Which is an appropriate nursing intervention in the care of the client with osteoarthritis?

A. Encourage weight loss and an increase in aerobic activity - RISK FACTOR:

OBESITY, AEROBIC - CARDIOVASCULAR EXERCISE (REDUCES FATIGUE AND
INCREASE STAMINA)
B. Avoid the use of topical analgesics - PAIN MANAGEMENT
C. Provide an analgesic after exercise - BEFORE EXERCISE; MAXIMUM FUNCTION
D. Assess for gastrointestinal complications associated with COX-2 inhibitors -
SELECTIVE TYPE NSAIDS - REDUCES THE RISK OF ULCERATION) CELECOXIB

Situation 19: Gouty Arthritis

69. A patient with an acute attack of gout is treated with colchicine. The nurse determines that
the drug is effective upon finding:

A. Relief of joint pain.

B. Increased urine output. - RECOMMENDED 2-3L, NOT INDICATIVE
C. Decreased serum uric acid. - ALLOPURINOL
D. Decreased white blood cells (WBC). - ANTIBIOTIC

COLCHICINE - ANTI MITOTIC --> REDUCING INFLAMMATIO CAUSED BY CRYSTALS OF

URIC ACID

70. When caring for a patient with gout and a red and painful left great toe, which nursing action
will be included in the plan of care?

A. Gently palpate the toe to assess swelling. - PRESSURE --> INDUCE PAIN
B. Use pillows to keep the left foot elevated. - DOESN’T NOT HELOP
C. Use a footboard to hold bedding away from the toe. - ANY TOUCH ON THE SITE
OF INFLAMMATION MAY INCREASE PAIN
D. Teach patient to avoid use of acetaminophen (Tylenol). - PAIN MANAGEMENT
71. Which statement best describes the method of actions of febuxostat (Uloric)?

A. Febuxostat reduces the synthesis of uric acid

B. Febuxostat increases the renal excretion of uric acid
C. Febuxostat reduces inflammation associated with gout
D. Febuxostat increases purine metabolism

FEBUXOSTAT - BLOCKS HYPOXANTHINE AND XANTHINE METABOLISM TO

REDUCE URIC ACID SYNTHESIS

72. What is the most important information for the nurse to include in a teaching plan for the
patient receiving allopurinol?

A. "do not take this medication during an acute attack of gout" - SHOULD NOT
BE TAKEN DURING AN ACUTE ATTACK BECAUSE THE INITIAL RESPONSE TO
ALLOPURINOL IS AN EXACERBATION OF THE SYMPTOMS

B. "include salmon and organ meats in your diet weekly" - WHITE MEATS
C. "take the medication with an antacid to minimize gastrointestinal distress"
D. "this medication may cause your urine to turn orange" - RIFAMPICINE

Situation 20: Osteoporosis and Osteomalacia and Rickets

73. What does the nurse teach a patient with osteomalacia to include in the daily diet?

A. Vitamin A - VISION LOSS AND BLINDNESS

B. Vitamin B Complex - NERVES
C. Vitamin C - IMMUNE SYSTEM
D. Vitamin D - PROMOTES ABSORPTION OF CALCIUM AND PHOSPHORUS

OSTEOMALACIA - IMPAIRED ABSOPRTION --> DEFICIECY VIT D

74. During a health screening event which assessment finding would alert the nurse to the
possible presence of osteoporosis in a white 61-year-old female?

A. The presence of bowed legs - RICKETS

B. A measurable loss of height - GRADUAL BUT MEASURABLE LOSS OG HEIGHT
AND DEVELOPMENT OF KYPHOSIS OR DOWAGERS HUMP
C. Poor appetite and aversion to dairy products - LACK OF Ca and VIT D maybe
present; not indicative
D. Development of unstable, wide-gait ambulation - not indicate

75. The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has
been successful when the patient selects which highest-calcium meal?

A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice
B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an
apple
C. A sardin (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup
of skim milk - high calcium includes Milk and Milk products yogurt and small fish
with bones
D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and
a half grapefruit
Situation 21: Fracture/Amputation/Osteomyelitis

76. The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia.
Which symptom will the nurse most likely find on physical examination of the patient?

A. Nausea and vomiting

B. Localized pain and warmth
C. Paresthesia in the affected extremity
D. Generalized bone pain throughout the leg

Osteomyelitis - infection of the bone

1. Calor - heat
2. Dolor - pain
3. Rubor - redness
4. Tumor - swelling

77. Which statement by the nurse describes a comminuted fracture to the​client?

A. The ends of the broken bones are forced​together." - compression

B. The bone is breaking through the​skin." - open fracture
C. The bone is broken into many​pieces."
D. A fragment of the bone is separated from the rest of the​bone." - avulsion

Greenstick - bending
Transverse - straight line across the bone
Spiral - twisting injury
Oblique - diagonal
Segmental - bone broken into 2 pieces/ segmented

78. A client sustained a radial fracture and a cast was just applied. The client states that there is
unrelieved pain and numbness in the fingers on the affected side. Which intervention should be
a ​priority?

A. Notifying the healthcare provider for cast removal - compartment syndrome

B. Elevating the extremity
C. Preparing for fasciotomy
D. Performing frequent neurovascular checks

Compartment syndrome - increased pressure in the muscle compartment (pain) -->

decreased blood flow ( pulselessness, pallor, and poikilothermia) --> muscle and nerve
damage (paresthesia and paralysis)

6ps
Pain, Pallor, Paresthesia, Paralysis, Poikilothermic, Pulselessness

79. A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom
privileges with the affected foot elevated on two pillows. The nurse would place highest priority
on which intervention?

A. Ambulate the patient to the bathroom every 2 hours. - promte safety,

B. Ask the patient about preferred activities to relieve boredom.
C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. - painful
D. Perform frequent position changes and range-of-motion exercises.

Pro long bedrest --> decreased pulmonary --> stasis of secretions --> medium for
bacterial growth --> pneumonia
80. The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a
day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the
most appropriate statement by the nurse?

A. "This position will help your lungs expand better."

B. "Lying on your stomach will help prevent contractures." - promote hamstring
muscle extension --> prevent contractures leading to problems in fitting
prosthesis
C. "Many times this will help decrease pain in the limb."
D. "The position will take pressure off your backside."

BKA - below knee amputation

81. A person's right thumb was accidentally severed with an axe. The amputated right thumb
was recovered. Which action by the nurse preserves the thumb so it could possibly be
reattached in surgery?

A. Place the right thumb directly on some ice. - vasoconstriction --> necrosis
B. Put the right thumb in a glass of warm water. - disintegrate
C. Wrap the thumb in a clean piece of material. - it will not preserve
D. Secure the thumb in a plastic bag and place on ice.- will help preseve the thumb

82. Which is the correct gait when a patient is ascending stairs on crutches?

A. A two-point gait (The affected leg is advanced between the crutches to the stairs.)
B. A three-point gait (The unaffected leg is advanced between the crutches to the
stairs.)
C. A swing-through gait
D. A four-point gait. (Both legs advance between the crutches to the stairs.)

Heaven - good leg goes first

Hell - bad leg goest first

3 point - gait --> both crutches --> affected --> unaffected

Modified 3 point gate --> both crutches - unaffected --> affected

Axillary pad – 1 – 2 inches away from axilla - brachial nerve plexus paralysis
Hand grip – elbow should be slightly flexed 15 to 30 C

Situation 22: Lupus Erythematosus

83. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE)
involving her joints. In teaching the patient about the disease, the nurse includes the information
that SLE is a(n):

A. Hereditary disorder of women but usually does not show clinical symptoms unless a
woman becomes pregnant. - not confined in women
B. Autoimmune disease of women in which antibodies are formed that destroy all
nucleated cells in the body. - not all nucleacted are destroyed
C. Disorder of immune function, but it is extremely variable in its course, and there
is no way to predict its progression. - unpredictable course
D. Disease that causes production of antibodies that bind with cellular estrogen
receptors, causing an inflammatory response. - not true
84. A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle
pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus
(SLE) is suspected. The nurse further checks for which of the following that is also indicative of
the presence of SLE?

A. Emboli - not related

B. Ascites - not related
C. Two hemoglobin S genes - sickle cell anemia
D. Butterfly rash on cheeks and bridge of nose - hallmark sign

SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on
the cheeks and on the bridge of the nose is a classic sign of SLE.

85. The nurse is caring for a client with systemic lupus erythematosus​ (SLE). Which system
should the nurse consider as being most affected by the formation of immune complexes and
tissue​damage?

A. Cardiac
B. Integumentary
C. Respiratory
D. Renal - kidneys are the frequent site of complexion deposition and damage

Situation 23: Sjogrens Syndrome

86. In an individual with Sjögren's syndrome, nursing care should focus on:

A. Moisture replacement. - progressive loss of lubrication of the skin, autoimmune

that attacks lacrimal and salivary glands
B. Electrolyte balance.
C. Nutritional supplementation.
D. Arrhythmia management.

87. An immune system disorder characterized by dry eyes and dry mouth. With this disorder, the
body's immune system attacks its own healthy cells that produce saliva and tears. The main
symptoms are dry mouth and dry eyes. Treatments include eye drops, medications, and eye
surgery.

A. Sjogren’s syndrome C. Scleroderma - thickening of the skin

B. Rheumatoid arthritis D. Xerostomia - dry mouth, symptoms
Situation 24: Systemic Sclerosis

88. A 40-year-old woman was diagnosed with Raynaud's phenomenon several years earlier and
has sought care because of a progressive worsening of her symptoms. The patient also states
that many of her skin surfaces are stiff, like the skin is being stretched from all directions. The
nurse should recognize the need for medical referral for the assessment of what health
problem?

A. Giant cell arteritis (GCA) - vasculitis

B. Fibromyalgia (FM)
C. Rheumatoid arthritis (RA)
D. Scleroderma

Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands. Later,
the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be
pinched up from the underlying structures. This progression of symptoms is inconsistent with
GCA, FM, or RA.

Reynauds phenomenon --spasm of the small blood vessels in the finger and toes --> skin color
changes, numbness and paresthesia --> later on immune system tricks the tissue into thinking
that they are injured --> inflmmation --> body makes too much collagen leading to
scleroderma

89. A patient has just been told by his physician that he has systemic sclerosis. The physician
tells the patient that he is going to order some tests to assess for systemic involvement. The
nurse knows that priority systems to be assessed include what?

A. Hepatic
B. Gastrointestinal - decreased motility and absorption
Pulmonary --> scarring of lung tissue fibrosis --> pulmonary hypertension --> right
side of the heart --> compensate --> enlargment --> fluid build up and swelling -->
HF
C. Genitourinary
D. Neurologic

Situation 25: Hypersensitivities/Allegies

90. A nurse is teaching a client who has a history of allergic rhinitis about the mechanism of type
I hypersensitivity. Which of the following statements should the nurse include in the teaching?

A. "Type I hypersensitivity is caused by the binding of igg antibodies to antigens on the

surface of target cells."
B. "Type I hypersensitivity is caused by the deposition of immune complexes in the
tissues and blood vessels."
C. "Type I hypersensitivity is caused by the activation of cytotoxic T cells that destroy the
cells expressing foreign antigens."
D. "Type I hypersensitivity is caused by the cross-linking of ige antibodies to mast
cells and basophils that release histamine and other mediators."

Type 1 – IgE mediated, quickly after exposure (bee sting, food allergy)
Type 2 – IgG/IgM antibodies hours to days (acute transfusion reaction, hemolytic)
Type 3 – Antigen-Antibody complex (RA, SLE)
Type 4 – activation of Cytotoxic T cells/ Delayed mediated (tuberculin test, dermatitis)
91. A nurse is administering a blood transfusion to a client who has type AB blood. The nurse
notices that the client develops fever, chills, back pain, and hemoglobinuria after receiving the
blood. The nurse suspects that the client has developed what type of reaction?

A. "A hemolytic transfusion reaction."

B. "An anaphylactic transfusion reaction."
C. "A febrile nonhemolytic transfusion reaction."
D. "A transfusion-related acute lung injury."

TRIAD: FEVER, FLANK PAIN, HEMOGLOBINUIRIA

KIDNEY INJURY --> GLOMERULI FILTER --> CLOGGED WITH PLATELETS AND
DAMAGED RBC

NURSING INTERVENTION - STOP INFUSION, CALL PHYSICAL, MAINTAIN IV

ACCESS, MONITOR, URINE OUTPUT: WOF HYPOTENSION

DIALYSIS

Choice B reason: An anaphylactic transfusion reaction is a type of transfusion reaction that

occurs when the recipient has ige antibodies against plasma proteins in the donor blood and
causes a systemic allergic response. It manifests as urticaria, pruritus, bronchospasm,
laryngeal edema, hypotension, or shock.

Choice C reason: A febrile nonhemolytic transfusion reaction is a type of transfusion reaction

that occurs when the recipient has antibodies against leukocytes or platelets in the donor
blood and causes a mild inflammatory response. It manifests as fever, chills, headache, or
malaise.

Choice D reason: A transfusion-related acute lung injury is a type of transfusion reaction that
occurs when the donor has antibodies against leukocytes in the recipient blood and causes
pulmonary edema and respiratory distress. It manifests as dyspnea, hypoxia, hypotension, or
fever.

92. A nurse is caring for a client who has a history of bee sting allergy. The client reports that he
was stung by a bee while gardening and is feeling dizzy and short of breath. The nurse
observes that the client has urticaria, angioedema, and wheezes. The nurse recognizes that the
client is experiencing what type of reaction?

A. "A type I hypersensitivity reaction."

B. "A type II hypersensitivity reaction."
C. "A type III hypersensitivity reaction."
D. "A type IV hypersensitivity reaction."

93. Which of the following nursing interventions has the highest priority for the client scheduled
for an intravenous pyelogram?

A. Providing the client with a favorite meal for dinner - NPO 4-6 HOURS
B. Asking if the client has allergies to shellfish - CONTRAST (IODINE) -->
ANAPHYLACTIC SHOCK/ REACTIONS
C. Encouraging fluids the evening before the test - AFTER, EXCRETION CONTRAST IS
THROUGH KIDNEYS
D. Telling the client what to expect during the test - NOT PRIORITY
94. James asks Nurse Monty if an anaphylactic reaction can be as simple as developing a rash
after exposure to an allergen. Nurse Monty responds that this is:

A. True
B. False

EXPOSURE TO ALLERGEN --> MAST CELLS AND BASOPHILS RELEASE

HISTAMINES, TRYPTASE, CARBOXY PEPTIDES A AND PROTEOGLYCANS -->
INCREASE VASCULAR PERMEABILITY (PLASMA LEAKAGE) SWELLING AND
VASODILATION --> HYPOTENSION

SMOOTH MUSCLE CONTRACTION --> VOMITING, DIARRHEA AND

BROCHOCONSTRICTION

95. Your patient is having a sudden and severe anaphylactic reaction to a medication. You
immediately stop the medication and call a rapid response. The patient's blood pressure is
80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is noted along with facial
redness and swelling. As the nurse you know that the first initial treatment for this patient's
condition is?

A. IV Diphenhydramine - ANTI HISTAMINE - NO ROLE IN PREVENTING PULMO AND

CARDIO SYMPTOMS
B. IV Normal Saline Bolus - HYPOTENSION (FAST DRIP)
C. IM Epinephrine - FIRST INITIAL
D. Nebulized Albuterol - BRONCHODILATORS

EPI - SYMPATHOMIMETIC - SNS

- VASOCONSTRICTION
- BRONCHODILATION

Situation 26: Human Immunodeficiency Virus

96. Which member of the health care team demonstrates reducing the risk for infection for
the client with acquired immunodeficiency syndrome (AIDS)?

A. The dietary worker hands the disposable meal trays to the LPN assigned to the
client. - LIMIT EXPOSURE
B. The social worker encourages the client to verbalize about stressors at home. -
DOESN’T DECREASE RISK FOR INFECTION
C. Housekeeping thoroughly cleans and disinfects the hallways near the client's room. -
BATHROOM
D. Health care provider orders vital signs including temperature every 8 hours. - EVERY
4 HOURS TO DETECT POTENTIAL RISK FOR INFECITON

97. The nurse is instructing an unlicensed health care worker on the care of the client with
HIV who also has active genital herpes. Which statement by the health care worker indicates
effective teaching of standard precautions?

A. ''I need to know my HIV status, so I must get tested before caring for any clients." -
NOT STANDARD PRECAUTIONS
B. ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''
C. ''Washing my hands and putting on a gown and gloves is what I must do before
starting care.'' STANDARD PRECAUTION
D. ''I will wash my hands before going into the room, and then put on gown and gloves
only for direct contact with the client's genitals." - UHW THEY CANNOT DETERMINE
WHAT IS REQURED FOR STANDARD PRECAUTIONS

STANDARD PRECAUTIONS - HAND HYGEINE, PPE, SAFE US AND DISPOSAL OF

SHARPS
98. Which statement made to the nurse by a health care worker assigned to care for the client
with HIV indicates a breach of confidentiality and requires further education by the nurse?

A. ''I told the family members they needed to wash their hands when they enter and
leave the room.'' - STANDARD PREC

B. ''The other health care worker and I were out in the hallway discussing how we
were concerned about getting HIV from our client, so no one could hear us in the
client's room.'' - DISCUSSING OUTSIDE THE CLIENTS ROOM IS BREACH OF
CONF

B. ''Yes, I understand the reasons why I have to wear gloves when I bathe my
client.''
STANDARD PRECAUTION

D. ''The client's spouse told me she got HIV from a blood transfusion.

99. When preparing the newly diagnosed client with HIV and significant other for discharge,
which explanation by the nurse accurately describes proper condom use?

A. ''Condoms should be used when lesions on the penis are present.'' - ALWAYS
B. ''Always position the condom with a space at the tip of an erect penis.'' -
COLELCTION OF SEMEN
C. ''Make sure it fits loosely to allow for penile erection.'' - SHOULD BE ERECT
D. ''Use adequate lubrication such as petroleum jelly.'' - WATER BASED

100. A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of

breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in
the plan of care to assist the client in performing activities of daily living?

A. Provide supportive care with hygiene needs - REDUCES CLIENTS PHYSICAL

AND EMOTIONAL DEMAND
B. Provide meals and snacks with high-protein, high calorie, and high-nutritional value -
MAINTAINNING NUTRITION
C. Provide small, frequent meals - TOLERATE MEALS BETTER
D. Offer low microbial foods - avoid RAW FOODS