1.

In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced
oxygenation?

1. Decreased heart rate

2. Increased restlessness

3. Increased blood pressure

4. Decreased level of consciousness (LOC)

RATIONALES: An early sign of respiratory distress is increased restlessness, which results from inadequate oxygen
flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood
pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

2. A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks
frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm
or occlusion of a cerebral vessel by a clot?

1. Nausea, vomiting, and profuse sweating

2. Hemiplegia, seizures, and decreased level of consciousness (LOC)

3. Difficulty breathing or swallowing

4. Tachycardia, tachypnea, and

hypotension

RATIONALES:

Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of
a stroke hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms. Nausea,
vomiting, and profuse sweating suggest a delayed reaction to the contrast material used in cerebral angiography.
Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension
suggest internal hemorrhage

3. The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions
should be included in the client's care plan?

Select all that apply:

 1. Make frequent changes in the client's routine.

2. Engage the client in complex discussions to help improve his memory.

3. Furnish the client's environment with familiar possessions.

4. Assist the client with activities of daily living (ADLs) as necessary.

5. Assign tasks in simple steps.

Correct Answer: 3,4,5 Your Answer: 3,4,5

RATIONALES: A client with Alzheimer's disease experiences progressive deterioration in cognitive functioning.
Familiar possessions may help to orient the client. The client should be encouraged to perform ADLs as much as
possible but may need assistance with certain activities. Using a step-by-step approach helps the client complete
tasks independently. A client with Alzheimer's disease functions best with consistent routines. Complex
discussions don't improve the memory of a client with Alzheimer's disease.

4. How should the nurse position a client for a lumbar puncture?

1. Laterally, with knees drawn up to the abdomen and chin touching the chest

2. Prone, with arms and legs straight and arms aligned next to the body

3. Laterally, with legs straight and arms folded across the chest

4. Sitting in a chair, with arms held out horizontally

Correct Answer: 1 Your Answer: 1

RATIONALES: For a lumbar puncture, the nurse should position the client laterally, with knees drawn up to the
abdomen and the chin touching the chest. This position curves the spine, increasing the space between the
vertebrae and allowing easier needle insertion. The other positions don't cause spinal curvature and therefore
aren't beneficial.

5.

A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development
of disuse osteoporosis, which of the following objectives is appropriate?
 1. Maintaining protein levels

2. Maintaining vitamin levels

3. Promoting weight-bearing exercises

4. Promoting range-of-motion (ROM) exercises

Correct Answer: 3

RATIONALES: When the mechanical stressors of weight bearing are absent, disuse osteoporosis can occur.
Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein
and vitamins levels is important, but neither will prevent osteoporosis. Doing ROM exercises will help prevent
muscle atrophy and contractures.

6.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is
confirmed by:

1. a positive edrophonium (Tensilon) test.

2. Kernig's sign.

3. a positive sweat chloride test.

4. Brudzinski's sign.

Correct Answer: 1

RATIONALES: A positive edrophonium (Tensilon) test confirms the diagnosis of myasthenia gravis. After
edrophonium administration, most clients with myasthenia gravis show markedly improved muscle tone. Kernig's
sign and Brudzinski's sign indicate meningitis. The sweat chloride test is used to confirm cystic fibrosis.

A client with hypertension comes to the clinic for a routine checkup. Because hypertension is a risk factor for
cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage.
Which complaint is a possible indicator of cerebral hemorrhage in this client?

1. Vertigo

2. Tinnitus
 3. Frontal headache

4. Nausea

Correct Answer: 1 Your Answer: 1

RATIONALES: Vertigo is a warning sign of cerebral hemorrhage in a hypertensive client. Other warning signs and
symptoms include severe occipital or nuchal headache, syncope, motor or sensory disturbances, nosebleed, and
visual disturbances (caused by retinal hemorrhages). Tinnitus, frontal headache, and nausea aren't associated
with cerebral hemorrhage in hypertensive clients

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain
tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding
the most significant?

1. Decreased level of consciousness (LOC)

2. Elevated blood pressure

3. Increased urine output

4. Decreased heart rate

Correct Answer: 3 Your Answer: 3

RATIONALES: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A
decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart
rate doesn't indicate that mannitol is effective.

A client is hospitalized with Guillain-Barr syndrome. Which data collection finding is most significant?

1. Warm, dry skin

2. Urine output of 40 ml/hour

3. Soft, nondistended abdomen

4. Even, unlabored respirations

Correct Answer: 4 Your Answer: 4

RATIONALES: A characteristic feature of Guillain-Barr syndrome is ascending weakness, which usually begins
in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness is a particularly
dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore,
although all of the options are pertinent assessment data, those related to respiratory function and status are most
significant.

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the
client indicate that he understands the instructions?

Select all that apply:

1. "I'll eat food that is very hot."

2. "I'll try to chew my food on the unaffected side."

3. "I can wash my face with cold water."

4. "Drinking fluids at room temperature should reduce pain."

5. "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

Correct Answer: 2,4,5

RATIONALES: The facial pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli. Chewing food
on the unaffected side and rinsing the mouth rather than brushing teeth reduce mechanical stimulation. Drinking
fluids at room temperature reduces thermal stimulation. Eating hot food and washing the face with cold water are
likely to trigger pain

When caring for a client with a head injury, the nurse must stay alert for signs and symptoms of
increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

1. Rising blood pressure and bradycardia

2. Hypotension and bradycardia

3. Hypotension and tachycardia

4. Hypertension and narrowing pulse pressure

Correct Answer: 1
RATIONALES: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and
widening pulse pressure known collectively as Cushing's triad. Increased ICP usually causes a bounding
pulse; as death approaches, the pulse becomes irregular and thready.

The nurse observes that a comatose client's response to painful stimuli is decerebrate posturing. The client
exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with
plantar flexion. Decerebrate posturing as a response to pain indicates:

1. dysfunction in the cerebrum.

2. risk for increased intracranial pressure.

3. dysfunction in the brain stem.

4. dysfunction in the spinal column.

Correct Answer: 3 Your Answer: 3

RATIONALES: Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates
cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in
sensation or paralysis indicate dysfunction in the spinal column.

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

1. Impaired physical mobility

2. Ineffective breathing pattern

3. Disturbed sensory perception (tactile)

4. Dressing or grooming self-care deficit

Correct Answer: 2

RATIONALES: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate
action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a
client with a spinal cord injury particularly during the course of recovery but they don't take precedence over
a diagnosis of Ineffective breathing pattern.
When self-administering atropine (Atropisol), the nurse should instruct the client to wait how long between instilling
the first drop and instilling the second drop?

1. 30 seconds

2. 1 minute

3. 2 to 3 minutes

4. 5 minutes

Correct Answer: 3

RATIONALES: The client should wait 2 to 3 minutes before instilling a second drop of atropine to avoid losing a
drop from tearing or blinking. Waiting 5 minutes isn't necessary.

A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes." The client
wears corrective glasses. The nurse would suspect that the client is experiencing a deficiency in which of the
following vitamins?

1. Vitamin A

2. Vitamin B complex

3. Vitamin E

4. Vitamin C

Correct Answer: 1

RATIONALES: Vitamin A is important for the eye's ability to see color. The B complex vitamins play a role in many
functions, including nerve conduction. Vitamins E and C have antioxidant properties and aid in wound healing.

A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants
without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice daily. In addition to
being used to relieve painful muscle spasms, diazepam also is recommended for:

1. long-term treatment of epilepsy.

 2. postoperative pain management of laminectomy clients.

3. postoperative pain management of diskectomy clients.

4. treatment of spasticity associated with spinal cord lesions.

Correct Answer: 4

RATIONALES: 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. The parenteral form of diazepam can treat status epilepticus, but
the drug's sedating properties make it an unsuitable choice for long-term management of epilepsy. Diazepam isn't
an analgesic agent.

A quadriplegic client is prescribed baclofen (Lioresal), 5 mg by mouth three times daily. What is the principal
indication for baclofen?

1. Acute, painful musculoskeletal conditions

2. Skeletal muscle hyperactivity secondary to cerebral palsy

3. Spasticity related to stroke

4. Muscle spasms with paraplegia or quadriplegia from spinal cord lesions

Correct Answer: 4 Your Answer: 4

RATIONALES: Baclofen's principal clinical indication is for the paraplegic or quadriplegic client with spinal cord
lesions, most commonly caused by multiple sclerosis or trauma. For these clients, baclofen significantly reduces
the number and severity of painful flexor spasms.

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions
about safety. Which behavior indicates that the client accurately understands safety measures related
to paralysis?

1. The client leaves the side rails down.

2. The client uses a mirror to inspect his skin.

 3. The client repositions only after being reminded to do so.

4. The client hangs his left arm over the side of the wheelchair.

Correct Answer: 2 Your Answer: 2

RATIONALES: Using a mirror enables the client to inspect all areas of his skin for signs of breakdown without the
help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent
falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if
needed. A client with left-side paralysis may not realize that his left arm is hanging over the side of the wheelchair.
However, the nurse should call this to the client's attention because his arm can get caught in the wheel spokes or
develop impaired circulation from being in a dependent position too long.

A client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic
examination reveals a small, irregular, nonreactive pupil a condition resulting from acute iris inflammation (iritis).
As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5%
solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?

1. Parasympathomimetic agent

2. Sympatholytic agent

3. Adrenergic blocker

4. Cholinergic blocker

Correct Answer: 4 Your Answer: 4

RATIONALES: Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a sympatholytic
agent, or an adrenergic blocker.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which
equipment is most important for the nurse to keep at the client's bedside?

1. Sphygmomanometer

2. Padded tongue blade

3. Nasal cannula and oxygen

 4. Suction machine with catheters

Correct Answer: 4

RATIONALES: The client's MS weakens the respiratory muscles and impairs swallowing, which puts him at risk
for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at
the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade
could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen
delivery; this client would require mechanical ventilation in a critical care setting.

A client is experiencing problems with balance and fine and gross motor function. Identify that area of the client's
brain that's malfunctioning.

The green rectangle shows the correct answer.

RATIONALES: The cerebellum is the portion of the brain that controls balance and fine and gross motor function.

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client
teaching about this drug should include which instruction?

1. "Discontinue this medication after you've been seizure-free for 2 weeks."

2. "Don't drive a car or operate machinery while taking this medication."

 3. "Schedule follow-up visits with your physician for blood tests."

4. "Be aware that this drug may make your heart beat faster."

Correct Answer: 3

RATIONALES: A client taking phenytoin to control seizures must undergo routine blood testing to monitor for
therapeutic serum phenytoin levels. Typically, the client takes the medication for 1 year after the original seizure,
and is then reevaluated for continued therapy. During phenytoin therapy, the client may drive and operate
machinery. This drug may cause a decreased heart rate and hypotension.

The physician orders measurement of the serum acetaminophen level of a client admitted with a suspected
overdose of this drug. To ensure an accurate result, the nurse should wait how long after acetaminophen (Tylenol)
ingestion before drawing the blood sample?

1. 1 hour

2. 2 hours

3. 3 hours

4. 4 hours

Correct Answer: 4

RATIONALES: Because acetaminophen has a duration of action ranging from 3 to 5 hours and a half-life ranging
from 1 to 3 hours, the nurse should wait at least 4 hours after acetaminophen ingestion before drawing a blood
sample to measure the client's serum acetaminophen level. Waiting less than 4 hours could yield inaccurate
results

A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which
nursing diagnosis takes highest priority in this client's plan of care?

1. Disturbed sensory perception (visual)

2. Dressing or grooming self-care deficit

3. Impaired verbal communication

 4. Risk for injury

Correct Answer: 4 Your Answer: 4

RATIONALES: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for
injury. Although the other options may be appropriate, they're secondary because they don't immediately affect
the client's health or safety.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital
sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood
pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign,
and Kernig's sign. What does Brudzinski's sign indicate?

1. Increased intracranial pressure (ICP)

2. Cerebral edema

3. Low cerebrospinal fluid (CSF) pressure

4. Meningeal irritation

Correct Answer: 4

RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation
include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low
CSF pressure.

On the 5th postoperative day, a client who underwent spinal fusion begins to complain of nausea and has an
episode of vomiting. How should a nurse intervene?

1. Auscultate the abdomen for bowel sounds.

2. Administer an antiemetic as prescribed.

3. Notify a physician immediately.

4. Insert a nasogastric tube and set it to low, intermittent suction.

Correct Answer: 1
RATIONALES: The nurse should first auscultate the client's abdomen for bowel sounds. Absence of bowel
sounds might indicate that the client is experiencing paralytic ileus, a complication that can occur after surgery.
The nurse shouldn't administer an antiemetic or notify the physician without first assessing the client. The nurse
shouldn't insert a nasogastric tube without a physician's order to do so.

The nurse on the neurologic unit must provide care for four clients who require different levels of care. Which client
should the nurse assist first with morning care?

1. A client who requires a complete bed bath and must be transported to physical therapy on a stretcher

2. A client who requires minimal bathing assistance and ambulates with a walker independently

3. A client who is confused since suffering a stroke 1 week ago

4. A client who suffered a stroke and is paralyzed of the left side of his body

Correct Answer: 2

RATIONALES: The nurse should determine which client requires minimal assistance and then attend to that client
first. The client who ambulates with a walker requires the least assistance. After attending to him, the nurse
should distribute her time among those who require more care.

A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough
violently. What should the nurse do?

1. Avoid providing mouth care.

2. Maintain the client on nothing-by-mouth status.

3. Make sure a tonsil suction device is readily available while providing mouth care.

4. Continue providing mouth care because the client's gag reflex is intact.

Correct Answer: 3 Your Answer: 3

RATIONALES: The client with facial droop has difficulty swallowing secretions during mouth care. Therefore, the
nurse should have a tonsil suction device available to suction the client's mouth to avoid further coughing
episodes and prevent aspiration. The client should undergo swallowing studies before a decision is made on
whether to maintain nothing-by-mouth status. Continuing mouth care without the tonsil suction device places the
client at risk for aspiration.
Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The
physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of
diazepam, if needed and prescribed?

1. In 30 to 45 seconds

2. In 10 to 15 minutes

3. In 30 to 45 minutes

4. In 1 to 2 hours

Correct Answer: 2

RATIONALES: 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. The nurse must not administer I.V. diazepam faster than 5 mg/minute.
Therefore, the dose can't be repeated in 30 to 45 seconds because the first dose wouldn't have been
administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the
client's risk of complications associated with status epilepticus

The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia
gravis. The nurse should teach the client that myasthenia gravis is caused by:

1. genetic dysfunction.

2. upper and lower motor neuron lesions.

3. decreased conduction of impulses in an upper motor neuron lesion.

4. destruction of acetylcholine receptors.

Correct Answer: 4 Your Answer: 4

RATIONALES: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat,
caused by the destruction of acetylcholine receptors at the postsynaptic membrane of the neuromuscular junction.
It isn't a genetic disorder. A combined upper and lower motor neuron lesion generally occurs as a result of spinal
injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of
impulses at an upper motor neuron.
The nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to
experience?

Select all that apply:

1. Visual disturbances

2. Coagulation abnormalities

3. Balance problems

4. Immunity compromise

5. Mood disorders

Correct Answer: 1,3,5 Your Answer: 1,3,5

RATIONALES: Multiple sclerosis, a neuromuscular disorder, may cause visual disturbances, balance problems,
and mood disorders. Multiple sclerosis doesn't cause coagulation abnormalities or immunity problems.

A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes
phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction?

1. Excessive gum tissue growth

2. Drowsiness

3. Hypertension

4. Tinnitus

Correct Answer: 1 Your Answer: 1

RATIONALES: Phenytoin can lead to excessive gum tissue growth. However, brushing the teeth two or three
times daily helps retard such growth. Some clients may require excision of excessive gum tissue every 6 to 12
months. Phenytoin may cause central nervous system stimulation, leading to insomnia, nervousness, and
twitching; it doesn't cause drowsiness. Other adverse reactions to phenytoin include hypotension, not
hypertension; and visual disturbances, not tinnitus.

A client is having a tonic-clonic seizure. What should the nurse do first?

 1. Elevate the head of the bed.

2. Restrain the client's arms and legs.

3. Place a tongue blade in the client's mouth.

4. Take measures to prevent injury.

Correct Answer: 4 Your Answer: 4

RATIONALES: Protecting the client from injury is the immediate priority during a seizure. Elevating the head of
the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause
injury. Placing a tongue blade or other object in the client's mouth could damage the teeth and should be avoided.

A 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place
him closer to the nurses' station because of his tendency to:

1. forget to eat.

2. not change his position often.

3. exhibit acquiescent behavior.

4. wander.

Correct Answer: 4 Your Answer: 4

RATIONALES: A client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing
him closer to the nurses' station makes it easier to monitor him and better ensures his safety if he begins to
wander. Placing the client closer to the nurses' station won't help the client remember to eat, change his position
often, or modify his behavior.

A client is color blind. The nurse understands that this client has a problem with:

1. rods.

2. cones.
 3. lens.

4. aqueous humor.

Correct Answer: 2

RATIONALES: Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more
types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but
can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid that
isn't involved with color perception.

After a motor vehicle accident, a client is admitted to the medical-surgical unit with a cervical collar in place. The
cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury.
Until such an injury is ruled out, the nurse should restrict this client to which position?

1. Flat

2. Supine, with the head of the bed elevated 30 degrees

3. Flat, except for logrolling as needed

4. A head elevation of 90 degrees to prevent cerebral swelling

Correct Answer: 3

RATIONALES: When caring for a client with a possible cervical spinal injury who's wearing a cervical collar, the
nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client
can be logrolled, if necessary, with the cervical collar on.

A client with quadriplegia is in spinal shock. What should the nurse expect?

1. Absence of reflexes along with flaccid extremities

2. Positive Babinski's reflex along with spastic extremities

3. Hyperreflexia along with spastic extremities

4. Spasticity of all four extremities

Correct Answer: 1

RATIONALES: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock,
all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate
positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

A client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do
when preparing the client for this test?

1. Immobilize the neck before the client is moved onto a stretcher.

2. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

3. Place a cap over the client's head.

4. Insert an indwelling urinary catheter.

Correct Answer: 2

RATIONALES: Because CT commonly involves use of a contrast agent, the nurse should determine whether the
client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a
suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results;
instead, the hair should be combed smoothly. An indwelling urinary catheter isn't indicated for a CT scan.

The nurse receives a physician's order to administer 1,000 ml of normal saline solution I.V. over 8 hours to a client
who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/ml?

Answer:

31

Correct Answer: 31

RATIONALES: The drip rate is calculated using the following formula:

Volume of infusion (in milliliters)/Time of infusion (in minutes) drip factor (in drops/milliliter) = drops/minute.
Therefore, 1,000 ml/480 minutes 15 drops/ml = 31 gtt/minute

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

1. Putting slippers on the client's feet

 2. Crossing the client's ankles every 2 hours

3. Placing hand rolls on the balls of each foot

4. Attaching braces or splints to each foot and leg

Correct Answer: 4 Your Answer: 4

RATIONALES: Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by
supporting the feet in proper alignment. Slippers can't prevent footdrop because they're too soft to support the
ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and
damage veins, which promotes thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent
contractures because they're too soft to support and hold the feet in proper alignment.

The parents of a client who sustained a closed head injury in a motor vehicle accident voice their concerns about
the distance and cost of the rehabilitation center chosen for their son. Which health care team member can help
the parents with their questions and concerns?

1. Physician

2. Primary nurse

3. Physical therapist

4. Social worker

Correct Answer: 4 Your Answer: 4

RATIONALES: The social worker is best equipped to address the parents' questions and concerns about the
arrangements made for their son's rehabilitation. The physician, primary nurse, and physical therapist can all
address other aspects of the client's recovery. The physician can address questions concerning the client's long-
term outcome. The primary nurse can address care issues during hospitalization. The physical therapist can help
address the actual rehabilitation process.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis
takes highest priority?

1. Disturbed sensory perception (visual) related to neurologic trauma

2. Feeding self care deficit: related to neurologic trauma

 3. Impaired verbal communication related to confusion

4. Risk for injury related to neurologic deficit

Correct Answer: 4 Your Answer: 4

RATIONALES: Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury as
the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. The
other options are pertinent, but they don't take precedence over client safety.

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes
that the client's pilocarpine solution is cloudy. What should the nurse do first?

1. Advise the client to discard the drug because it may have undergone chemical changes or become
contaminated.

2. Advise the client to obtain a fresh container of pilocarpine solution to avoid omitting prescribed doses.

3. Observe the client or a family member administer the drug to determine possible contamination sources.

4. Advise the client to keep the container closed tightly and protected from light.

Correct Answer: 1 Your Answer: 1

RATIONALES: A cloudy solution indicates that the drug has been changed chemically or has become
contaminated. Therefore, the nurse first should advise the client to discard the drug. The other options are
appropriate actions to take later.

The physician prescribes diazepam (Valium), 10 mg I.V., for a client experiencing status epilepticus. Which
statement about I.V. diazepam is true?

1. It may be mixed with other drugs in an infusion.

2. It should be administered in a small vein to minimize irritation.

3. It rarely causes adverse reactions.

4. It should be administered no faster than 5 mg/minute in an adult.

Correct Answer: 4 Your Answer: 4
RATIONALES: To prevent adverse reactions, which are common, I.V. diazepam should be administered no faster
than 5 mg/minute in an adult and should be given over at least 3 minutes in children. Diazepam shouldn't be
mixed with other drugs in an infusion because of the high risk of incompatibility. To help prevent extravasation, the
nurse should avoid administering diazepam in a small vein. I.V. diazepam may cause cardiorespiratory
depression; to detect this problem, the nurse should monitor the client's vital signs carefully during administration.

A 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?

1. Ataxic

2. Dystrophic

3. Helicopod

4. Steppage

Correct Answer: 3

RATIONALES: A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An
ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a
steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

1. Administering chloral hydrate (Noctec)

2. Assessing laboratory test results as ordered

3. Placing the client in Trendelenburg's position

4. Monitoring the patency of an indwelling urinary catheter

Correct Answer: 4

RATIONALES: Because a full bladder can precipitate autonomic dysreflexia, the nurse should monitor the
patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder.
Administering chloral hydrate, assessing laboratory values, and placing the client in Trendelenburg's position can't
prevent autonomic dysreflexia.
A client is thrown from an automobile during a collision. The nurse knows that the client will be able
to maintain gross arm movements and diaphragmatic breathing if the injury occurs at what vertebral level?

1. C4

2. C5

3. C3

4. C7

Correct Answer: 2 Your Answer: 2

RATIONALES: A client with a spinal cord injury at or above the level of the fourth cervical vertebra (C4) can't
breathe spontaneously. With an injury below this level, diaphragmatic breathing occurs. An injury from C5 to C6
results in quadriplegia, with diaphragmatic breathing and gross arm movements.

The physician prescribes mannitol (Osmitrol) I.V. stat for a client who develops increased intracranial
pressure after a head injury. While preparing to administer mannitol, the nurse notices crystals in the solution.
What should the nurse do?

1. Administer the solution as is.

2. Warm the solution in hot water to dissolve the crystals.

3. Send the crystallized solution back to the pharmacy.

4. Add a filter to the infusion set and administer the solution.

Correct Answer: 2

RATIONALES: The nurse must dissolve crystallized mannitol before administering it. This is best done by
warming it in hot water and shaking the container vigorously, then allowing the solution to return to room
temperature before administering it. Sending the crystallized solution back to the pharmacy isn't necessary
because the nurse can resolve the problem. Administering crystallized mannitol with or without a filter can
seriously harm the client.

A client with Guillain-Barr syndrome has paralysis affecting the respiratory muscles and requires mechanical
ventilation. What should the nurse tell the client about the paralysis?
 1. "The paralysis caused by this disease is temporary."

2. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory
loss."

3. "It must be hard to accept the permanency of your paralysis."

4. "You'll first regain use of your legs and then your arms."

Correct Answer: 1

RATIONALES: The nurse should inform the client that the paralysis that accompanies Guillain-Barr syndrome is
only temporary. Return of motor function begins proximally and extends distally in the legs.

A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the
left cerebral hemisphere. Which nursing interventions are appropriate for the client's postoperative care?

Select all that apply:

1. Place a pillow under the client's head so that his neck is flexed.

2. Turn the client on his right side.

3. Place pillows under the client's legs to promote hip flexion and venous return.

4. Maintain the client in the supine position.

5. Apply a soft collar to keep the client's neck in a neutral position.

Correct Answer: 2,5

RATIONALES: The client should be turned on his right side because lying on the left side would cause the brain
to shift into the space previously occupied by the tumor. A soft collar keeps the neck in a neutral position, allowing
for adequate perfusion and venous drainage of the brain. Placing a pillow under the head flexes the neck and
impairs circulation to the brain. Flexion of the hip increases intracranial pressure and, therefore, is
contraindicated. Exclusive use of the supine position isn't indicated.

A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and
heaviness. During the admission process, the client presents her advance directive, which states that she doesn't
want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse
respond?

1. "Thank you for providing this document; I'll include it in your permanent record."

2. "Advance directives aren't necessary for clients your age."

3. "It's important for us to have this information. You should review the document with your physician at
every admission."

4. "Your disease hasn't progressed enough to institute an advance directive."

Correct Answer: 3

RATIONALES: An advance directive should be part of the client's medical record. The client should review the
document with the physician at every admission because portions of the advance directive may be inappropriate if
a particular condition is reversible and temporary. Option 1 doesn't address the need to review the directive with
the physician. Advance directives are appropriate for clients of all ages.

After a stroke, a 75-year-old client is admitted to a health care facility. The client has left-sided weakness and an
absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin
is 10 g. Which action is a priority for this client?

1. Checking stools for occult blood

2. Performing range-of-motion (ROM) exercises to the left side

3. Keeping skin clean and dry

4. Elevating the head of the bed to 30 degrees

Correct Answer: 4 Your Answer: 4

RATIONALES: Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps
minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin
clean and dry are important, but preventing aspiration through positioning is the priority.

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours.
The average catheterized urine volume has been 550 ml. The nurse should plan to:
 1. increase the frequency of the catheterizations.

2. insert an indwelling urinary catheter.

3. place the client on fluid restrictions.

4. use a condom catheter instead of an invasive one.

Correct Answer: 1

RATIONALES: As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or
more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of
the risk of urinary tract infection (UTI) and the loss of bladder tone. Fluid restrictions aren't indicated in this case;
the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of a
client with urine retention.

When obtaining the health history from a client with retinal detachment, the nurse expects the client to report:

1. light flashes and floaters in front of the eye.

2. a recent driving accident while changing lanes.

3. headaches, nausea, and redness of the eyes.

4. frequent episodes of double vision.

Correct Answer: 1 Your Answer: 1

RATIONALES: The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of
retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which
may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma.
Double vision is common in clients with cataracts.

A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty
with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional
incontinence. This client is in what stage of Alzheimer's disease?

1. I
 2. II

3. III

4. IV

Correct Answer: 2 Your Answer: 2

RATIONALES: Stage II is exhibited by the above listed symptoms as well as communication difficulties, motor
disturbances, forgetfulness, and psychosis. This stage lasts 2 to 10 years. Stage I, which lasts 1 to 3 years, is
characterized by memory loss, poor judgment and problem-solving, difficulty adapting to new environments and
challenges, and agitation or apathy. Stage III is characterized by loss of all mental abilities and the ability to care
for self. There is no stage IV.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The
physician suspects myasthenia gravis. Which drug will be used to test for this disease?

1. Ambenonium (Mytelase)

2. Pyridostigmine (Mestinon)

3. Edrophonium (Tensilon)

4. Carbachol (Carboptic)

Correct Answer: 3

RATIONALES: Because of its short duration of action, edrophonium is the drug of choice for diagnosing
myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used
as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's
also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic
procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis
of Guillain-Barr syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve
dysfunction. On admission, which assessment is most important for this client?

1. Lung auscultation and measurement of vital capacity and tidal volume

2. Evaluation for signs and symptoms of increased intracranial pressure (ICP)

3. Evaluation of pain and discomfort

 4. Evaluation of nutritional status and metabolic state

Correct Answer: 1 Your Answer: 1

RATIONALES: In Guillain-Barr syndrome, polyneuritis commonly causes weakness and paralysis, which may
ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity,
tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure the most
serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP.
Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status, these
assessments aren't priorities.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

1. provide instructions on eye patching.

2. assess the client's visual acuity.

3. demonstrate eyedrop instillation.

4. teach about intraocular lens cleaning.

Correct Answer: 3

RATIONALES: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After
demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this
measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity
assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is
the most appropriate?

1. Encourage the client to close his eyes.

2. Notify the physician.

3. Turn out the lights in the room.

4. Instill artificial tears.

Correct Answer: 2

RATIONALES: The nurse should notify the physician, who will likely order an eye patch. Patching one eye at a
time relieves diplopia. Having the client close his eyes and making the room dark aren't the most appropriate
options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat
diplopia.

During the course of a busy shift, a nurse fails to document that a client's ventricular drain had an output of 150 ml.
Assuming that the drain was no longer draining cerebrospinal fluid, the physician removes the drain. When the
nurse arrives for work the next morning, she learns that the client became agitated during the night and his blood
pressure became elevated. What action should the nurse take?

1. Notify the physician of the documentation omission.

2. Immediately report her error to the nursing supervisor and complete an incident report.

3. No action is necessary because the change in condition wasn't related to a documentation omission.

4. Notify the on-call physician of the error and prepare the client for surgery.

Correct Answer: 1

RATIONALES: The client's health was compromised by the nurse's failure to document. Therefore, she should
notify the client's physician, not the on-call physician, so that he can revise the client's treatment plan accordingly.
After notifying the physician, the nurse should notify her nursing supervisor and complete an incident report
according to facility policy. By failing to report the incident, the nurse could further jeopardize the client's health.

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department
with multiple injuries. During the neurologic examination, the client responds to painful stimuli
with decerebrate posturing. This finding indicates damage to which part of the brain?

1. Diencephalon

2. Medulla

3. Midbrain

4. Cortex

Correct Answer: 3 Your Answer: 3

RATIONALES: Decerebrate posturing, characterized by abnormal extension in response to painful stimuli,
indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate
posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

The nurse is teaching a client with a T4 spinal cord injury and paralysis of the lower extremities how to transfer
from the bed to a wheelchair. The nurse should instruct the client to move:

1. his upper and lower body into the wheelchair simultaneously.

2. his upper body to the wheelchair first.

3. his feet to the wheelchair pedals and then his hands to the wheelchair arms.

4. his feet to the floor and then his buttocks to the wheelchair seat.

Correct Answer: 2

RATIONALES: When transferring from a bed to a wheelchair, a client with paralysis of the lower extremities
should move the strong part of his body to the chair first. Therefore, the client should move his upper body to the
chair and then move his legs from the bed to the chair. The other techniques aren't safe for the client.

When teaching a client about levodopa and carbidopa (Sinemet) therapy for Parkinson's disease, the
nurse should include which instruction?

1. "Report any eye spasms."

2. "Take this medication at bedtime."

3. "Stop taking this drug when your symptoms disappear."

4. "Be aware that your urine may appear darker than usual."

Correct Answer: 4 Your Answer: 4

RATIONALES: Levodopa and carbidopa, used to replace insufficient dopamine in clients with Parkinson's
disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision
is an expected adverse effect. The client should take levodopa and carbidopa shortly before meals, not at
bedtime, and must continue to take it for life.
A client with an inflammatory ophthalmic disorder has been receiving a -inch ribbon of corticosteroid ointment in
the lower conjunctival sac four times per day as directed. The client reports a headache and blurred vision. The
nurse suspects that these symptoms represent:

1. common adverse effects of corticosteroid therapy.

2. expected drug effects that should diminish over time.

3. incorrect ointment application.

4. increased intraocular pressure.

Correct Answer: 4

RATIONALES: Headache and blurred vision are symptoms of increased intraocular pressure such as that caused
by glaucoma. Ophthalmic corticosteroids may trigger an episode of acute glaucoma in susceptible clients.
Although the effects of some drugs may diminish with continued use, this doesn't happen with ophthalmic
corticosteroids. Incorrect ointment application doesn't cause headache or blurred vision.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a
stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the
nurse should provide which client instruction?

1. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours."

2. "Try to ambulate independently after about 24 hours."

3. "Shampoo your hair every day for 10 days to help prevent ear infection."

4. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud
sounds for 30 days."

Correct Answer: 4

RATIONALES: For 30 days after a stapedectomy, the client should avoid air travel, sudden movements that may
cause trauma, and exposure to loud sounds and pressure changes (such as those encountered at high altitudes).
Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted
but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should
be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and
swimming to keep the dressing and the ear dry.