021290neurologic Exam (Flash Card)

SECTIONONE
Neurological Disorders 3
Head Injury
1. The client has sustained a traumatic brain
injury (TBI) secondary to a motor vehicle
accident. Which signs/symptoms would the
emergency department (ED) nurse expect the
client to exhibit?
1. Blurred vision, nausea, and right-sided
hemiparesis.
2. Increased urinary output, negative
Babinski, and ptosis.
3. Autonomic dysreflexia, positive
Brudzinski, and hyperpyrexia.
4. Negative dextrostik, nuchal rigidity,
and nystagmus.
2. The intensive care nurse is caring for a client
diagnosed with a closed head injury. Which data
would warrant immediate intervention?
1. The client refuses to cough and deepbreathe.
2. The clients Glasgow Coma Scale goes
from 13 to 7.
3. The client complains of a frontal
headache.
4. The clients Mini-Mental Status Exam
(MMSE) is 30.
3. The rehabilitation nurse is caring for the
client with a closed head injury. Which cognitive
goal would be most appropriate for this client?
1. The client will be able to feed
himself/herself independently.
2. The client will attend therapy sessions
3 hours a day.
3. The client will interact appropriately
with staff members.
4. The client will be able to stay on task
for 15 minutes.
ANSWERS
Correct answer 1: Signs/symptoms of TBI
include neurological deficits, among them
blurred vision, nausea, and right-sided
hemiparesis. A positive Babinski sign would also
occur with head trauma. Autonomic dysreflexia
would be found in a client with a spinal cord
injury; a positive dextrostik for glucose would be
found in someone with a cerebrospinal fluid
leak; and a positive Brudzinski and nuchal
rigidity are signs of meningitis. Content

Medical; Category of
Health AlterationNeurological; Integrated
Process Assessment; Client Needs
Physiological Integrity, Physiological Adaptation;
Cognitive LevelAnalysis.
Correct answer 2: A 15 on the Glasgow
Coma Scale indicates the client is neurologically
intact; a decrease to 7 indicates an increase in
the intracranial pressure, which warrants
immediate intervention. A 30 on the MMSE
indicates the client is cognitively intact.
ContentMedical; Category of Health Alteration
Neurological; Integrated ProcessAssessment;
Client NeedsSafe Effective Care Environment,
Management of Care; Cognitive Level
Synthesis.
4
Correct answer 4: Cognitive is mental
functioning; therefore, the ability to stay on task
would be the clients most appropriate cognitive
goal. Content
Medical; Category of Health Alteration
Neurological; Integrated ProcessPlanning;
Client NeedsPhysiological Integrity,
Physiological Adaptation; Cognitive Level
Synthesis.
SECTIONONE
4. The intensive care nurse is caring for a client

diagnosed with a TBI who is exhibiting
decorticate posturing. Three hours later the
client has flaccid posturing. Which action should
the nurse implement first?
1. Notify the clients health-care provider
(HCP) immediately.
2. Prepare to administer mannitol
(Osmitrol), an osmotic diuretic.
3. Complete a thorough neurological
assessment on the client.
4. Reassess the client in 1 hour,
including calculating the Glasgow Coma Scale.
5. The emergency department nurse is entering
the room of a client who was at a baseball
game and was hit in the head with a bat. Which
intervention should the nurse implement first?
1. Assess the clients orientation to date,

time, and place.
2. Ask the client to squeeze the nurses
fingers.
3. Determine the clients reaction to the
door opening.
4. Request the client to move his lower
legs.
6. The nurse is preparing the client diagnosed
with a head injury for a magnetic resonance
imaging (MRI). Which interventions should the
nurse implement? Select all that apply.
1. Ask the client if he/she is
claustrophobic.
2. Have the client sign a procedural
6
Correct answer 1, 4, 5: The client is
enclosed in an MRI tube for an extended period
so the client cannot be claustrophobic or want
to stop the procedure. An MRI cannot be
completed on a client with a metal prosthesis
unless it is made with titanium because the MRI
may dislodge the prosthesis. The hospital
admission permit covers the MRI, and because
no contrast dye is now used in most MRIs, an
allergy to shellfish is not pertinent. Content
Neurological; Integrated Process
Implementation; Client NeedsPhysiological
Integrity,
Reduction of Risk Potential; Cognitive Level
Application.
permit.
3. Determine if the client is allergic to
shellfish.
4. Check if the client has any prosthetic
devices.
5. Ask the client to empty his/her
bladder.
ANSWERS
Correct answer 1: Flaccid posturing is
the worst-case scenario for a client with a TBI;
therefore, the nurse should notify the HCP.
Completing a neurological assessment,
administering an osmotic diuretic, and
reassessing the client are all plausible
interventions, but they are not the first to be
implemented. Content
Management of Care; Cognitive LevelAnalysis.
Correct answer 3: The nurse should first
determine how alert the client is by noticing the
reaction when the door opens. The best reaction
is spontaneous opening of the eyes without
verbal or noxious stimuli. The other three
options are appropriate but should not be the
nurses first intervention when entering the
clients room. ContentMedical; Category of
Process Implementation; Client Needs
Cognitive LevelApplication.
SECTIONONE
7. The client with increased intracranial

pressure is receiving mannitol (Osmitrol), an
osmotic diuretic. Which intervention should the
nurse implement?
1. Monitor the clients complete blood
cell (CBC) count.
2. Do not administer the drug if the
clients apical pulse is less than 60.
3. Ensure that the clients cardiac status
is monitored by telemetry.
4. Use a filter needle when administering
the medication.
8. The male client is being discharged from the
ED after sustaining a minor head injury. Which
statement indicates the wife understands the
discharge teaching?
1. My husband will be hard to wake up
for a couple of days.
2. He doesnt need any pain medication
because
I have some at home.
3. I should not give my husband
anything to eat or drink for 12 hours.
4. I will bring my husband back to the
emergency room if he starts vomiting.
9. The nurse is discussing the TBI Act at a

support group meeting. Which statement best
explains the act?
1. It is a federal act that provides public
policy regarding community living for clients
with a TBI.
2. It ensures that all public buildings
must have access for physically challenged
clients.
3. This act ensures that all clients with a
TBI have access to rehabilitation services.
4. It is a national policy that establishes
guidelines for neurological rehabilitation
centers.
10. The nurse is caring for a female client who
sustained a closed head injury 8 days ago due
to a motor vehicle accident. Which
signs/symptoms would alert the nurse to a
complication of the head injury?
1. The client reports having trouble
sleeping due to having nightmares about the
wreck.
2. The client tells the nurse she has a
stuffy nose and green nasal drainage.
3. The client complains of extreme thirst
and has an increased urine output.

Neurological; Integrated ProcessEvaluation;
Client NeedsHealth Promotion and
Maintenance; Cognitive Level: Evaluation.
8
Correct answer 1: The TBI Act is part of
the Childrens Act of 2000 and is the only
federal legislation designed for clients with a
TBI. The Act provides for a balanced public
policy for prevention, education, research, and
community living for clients with a TBI and their
families. ContentMedical;
Category of Health AlterationNeurological;
Integrated ProcessPlanning; Client Needs
Cognitive LevelKnowledge.
Correct answer 3: For 710 days post
head injury, the client is at risk for developing
diabetes insipidus, which is a lack of the
antidiuretic hormone, resulting in increased
urine output and increased thirst.
Analysis.
4. The client informs the nurse that she

has started her menstrual period.
ANSWERS
Correct answer 4: The nurse must use a
filter needle when administering mannitol
because crystals may form in the solution and
syringe and be inadvertently injected into the
client. The CBC and apical pulse are not
affected by the medication. Mannitol is
administered cautiously in clients with heart
failure, but telemetry is not required routinely.
Content
Implementation; Client Needs Physiological
Integrity, Pharmacological and Parenteral
Therapies; Cognitive LevelApplication.
Correct answer 4: Vomiting indicates an
increase in intracranial pressure, which is a
complication of a head injury. The client should
arouse easily, may eat and drink (not alcohol),
and should not take any type of pain medication
that would mask mental status.
SECTIONONE
Spinal Cord Injury

Which clinical manifestation would the
nurse assess in the client with a T-12 spinal cord
injury (SCI) who is experiencing spinal shock?
l 1. Flaccid paralysis below the waist. l 2. Lower
extremity muscle spasticity.
l 3. Complaints of a pounding headache. l 4.
Hypertension and bradycardia.
The nurse is caring for a client who has a
C-6 vertebral
fracture and is using Crutchfield tongs with 2pound weights. Which data would the nurse
expect the client to exhibit?
1. The client is on controlled mechanical
ventilation at 12 respirations a minute.
2. The client has no movement of the
lower extremities.
3. The client has 2 deep tendon reflexes
in the lower extremities.
4. The client has loss of sensation below
the C-6 vertebral fracture.

Analysis.
Correct answer 3: The spinal cord has
not been injured; therefore, normal body
movement, responses, and reflexes should be
intact. The Crutchfield tongs ensure that the
cervical spine remains in alignment. Content
10
13. The rehabilitation nurse caring for the

young client with a T-12 SCI is developing the
nursing care plan. Which priority intervention
should the nurse implement?
1. Monitor the clients indwelling urinary
catheter.
2. Insert a rectal stimulant at the same
time every morning.
3. Encourage active lower extremity
range of motion (ROM) exercises.
4. Refer the client to a vocational
training assistance program.
14. The nurse is caring for a client with a C-6
SCI in the neurological intensive care unit.
Which nursing intervention should be
implemented?
1. Monitor the clients heparin drip.
2. Assess the neurological status every
shift.
Correct answer 2: The clients bowel and

bladder functions must be addressed; therefore,
administering a daily rectal stimulant will
ensure a daily bowel movement. Indwelling
urinary catheters are discouraged due to the
increased risk of infection associated with their
use. ContentMedical; Category of Health
AlterationNeurological; Integrated Process
Integrity, Basic Care and Comfort; Cognitive
LevelApplication.
Correct answer 3: Current treatment
options that have proven efficacy in treating SCI
is to decrease inflammation and edema by
lowering the body temperature with ice saline
solutions. Intravenous corticosteroid therapy is
a standard of care but not intrathecal, into the
spinal cord. ContentMedical;
Integrated ProcessImplementation; Client
NeedsPhysiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive Level
Application
3. Maintain the clients ice saline

infusion.
4. Administer corticosteroids
intrathecally.
ANSWERS
Correct answer 1: Spinal shock is
associated with an SCI. It is a sudden
depression of reflex activity, a loss of sensation,
and flaccid paralysis below the level of the
injury. T-12 is just above the waist. Content
Client Needs Physiological Integrity,
SECTIONONE
15. The male client with a C-6 SCI tells the

home health nurse he has had a severe
pounding headache for the last 2 hours. Which
intervention should the clinic nurse implement?
1. Determine when and how much the
client last urinated.
2. Ask the client if he has taken any
medication for the headache.
3. Inquire when the client had his last
bowel movement.
4. Check the clients respiratory rate

reading immediately.
16. The client with a T-1 SCI complains of
lightheadedness and dizziness when the head
of the bed is elevated. The clients B/P is 84/40.
Which action should the nurse implement first?
1. Increase the clients intravenous (IV)
rate by50 mL/hr.
2. Administer dopamine, a vasopressor,
via an IV pump.
3. Notify the HCP immediately.
4. Lower the clients head of bed
immediately.
17. The nurse caring for a client with a C-6 SCI
determines the client has no plantar reflexes.
Which area on the stick figure should the nurse
document this finding?
A N S W E R S 12
15. Correct answer 1: The cause of the
pounding
17. Correct answer: Content
Medical; Category of Health
headache is most likely autonomic dysreflexia,
a
AlterationNeurological; Integrated
ProcessAssessment;
result of exaggerated autonomic responses to
stimuli.
Client NeedsSafe Effective Care,
Management of Care;
An elevated blood pressure would confirm this.
The most common cause of autonomic
dysreflexia
is a full bladder. All the other options could be
implemented, but confirming the autonomic
dysreflexia is priority. ContentMedical;

Category
of Health AlterationNeurological; Integrated
16. Correct answer 4: The blood pressure tends

to be
very unstable and low for clients with an SCI of

T-6
or above, and slight elevations of the head of

the bed
can cause profound drops in the clients vital
signs.

Implementation;

Application.
Copyright 2010 F.A. Davis Company

SECTIONONE
18. The nurse on the rehabilitation unit is caring

for the following clients with SCIs. Which client
should the nurse assess first after receiving the
change-of-shift report?
1. The client with a C-6 SCI who has a
warm, reddened edematous gastrocnemius
muscle.
2. The client with an L-4 SCI who is
concerned about being able to live
independently.
complaining of a headache and nausea.
ProcessImplementation; Client NeedsSafe

Effective
Care Environment, Management of Care;
Cognitive
LevelAnalysis.
4. The client with a T-4 SCI who is unable

to move the lower extremities.
19. The nurse is caring for clients on a
rehabilitation unit. Which nursing task would be
most appropriate for the nurse to delegate to
the unlicensed assistive personnel (UAP)?
1. Ask the UAP to hold the urinal while

the client performs the Cred maneuver.
2. Discuss the proper method of
administering tube feedings to the family
member.
3. Assist with bowel training by inserting
a suppository into the clients rectum.
Correct answer 3: The social worker is

responsible for assisting the client with financial
concerns. The ASIA assists clients to live with
their SCI, and the rehabilitation commission can
assist with employment.
Implementation; Client NeedsPsychosocial
Integrity; Cognitive LevelApplication.
4. Observe the client demonstrating selfcatheterization technique.

20. The 25-year-old client with an SCI is sharing
with the nurse that he is worried about how his
family will be able to survive financially until he
can go back to work. Which intervention should
the nurse implement?
1. Refer the client to the American Spinal
Injury Association.
2. Refer the client to the state
rehabilitation commission.
3. Refer the client to the social worker
about applying for disability.
4. Refer the client to an occupational
therapist for life skills training.
ANSWERS
Correct answer 1: The gastrocnemius
muscle is the calf muscle, and warmth, redness,
and swelling in the muscles indicate the client
has a deep vein thrombosis (DVT), which
requires immediate intervention. A client with
an L-2 SCI (option 3) would not experience
autonomic dysreflexia. A client with a T-4 SCI
(option 4) would not be expected to be able to
move the lower extremities. Content
Correct answer 1: The UAP can hold a
urinal for the client. The UAP cannot assess,
teach, evaluate, administer medications, or care
for an unstable client.
Neurological: Integrated ProcessPlanning;
Client NeedsEffective Care Management,
Synthesis.
14

SECTIONONE
Seizures
The nurse walks into the room and notes
the male client is lying supine, and the entire
body is rigid with his arms and legs contracting
and relaxing. The client is not aware of what is
going on and is making guttural sounds. Which
action should the nurse implement first?
l 1. Loosen constrictive clothing. l 2. Place
padding on the side rails. l 3. Assess the clients
vital signs. l 4. Turn the client on his side.
The client newly diagnosed with epilepsy
who works in
an office asks the nurse, What can I do to
prevent having seizures? Which statement is
the nurses best response?
1. I recommend getting about 4 hours
of sleep a night.
2. Ask your supervisor to have someone
else make copies.
3. Request your employer to provide a
work area with dim lighting.
4. You should get your serum blood
level checked every month.
23. The nurse observes a client having a tonicclonic seizure. Which information should the
nurse document in the clients chart? Select all
that apply.
1. Determine if the client is incontinent
of urine or stool.
2. Document the client had privacy

during the seizure.
3. Note the time and where the
movement or stiffness began.
4. Note the circumstances before the
clients seizure activity began.
5. Note the results of a complete
neurological assessment.
ANSWERS
Correct answer 4: Placing the client on
his side helps keep the airway patent; therefore,
it is the first intervention. All the other
interventions may be done, but airway is
priority. ContentMedical;
NeedsSafe Effective Care Environment,
Correct answer 2: Flashing lights, such
as occur with a copying machine, can evoke a
seizure and should be avoided; other causes of
seizures include stress, fatigue, and alcohol
intake. Serum blood levels will not help prevent
seizures, but they do indicate the serum drug
level. ContentMedical; Category of
Process Planning; Client NeedsPhysiological
Integrity, Reduction of Risk Potential; Cognitive
LevelSynthesis.
16
Correct answer 1, 3, 4: The nurse should
assess the client before, during, and after
seizure activity. Providing privacy is expected
and would not be documented in the chart. The
client in the postictal state needs rest;
therefore, a complete neurological
SECTIONONE
24. The UAP is holding the arms of a client who

is having a tonic-clonic seizure. Which action
should the nurse implement?
1. Help the UAP restrain the clients
upper extremities.
2. Instruct the UAP to release the clients
arms immediately.
3. Take no action because the assistant
is handling the situation.
4. Notify the charge nurse of the
situation immediately.
25. The client diagnosed with a seizure disorder
is prescribed phenytoin (Dilantin), an
anticonvulsant. Which statement indicates the
client needs more teaching concerning this
medication?
1. I will brush my teeth after every
meal.
2. I will get my Dilantin level checked
regularly.
3. My urine will turn orange while on
Dilantin.
4. This medication will help prevent my
seizures.
The client is admitted to the intensive
care unit (ICU) experiencing status epilepiticus.
Which intervention should the nurse anticipate
implementing first?
l 1. Assess the clients neurological status
frequently. l 2. Monitor the clients heart rhythm
via telemetry. l 3. Administer diazepam
(Valium), a benzodiazepine. l 4. Prepare to
administer anticonvulsant medication.
assessment would not be appropriate. Content

Medical;
The client is admitted to the ED after

experiencing a

Application.
partial seizure. Which question would be most

appropriate for the nurse to ask the client?
1. Do you know if you lost
consciousness during the seizure?
2. Are you feeling sleepy or very tired at
this time?
3. When did you last take your seizure

medication?
4. Were you feeling jittery or irritable

prior to the seizure?
SECTIONONE
ANSWERS
28. Which statement by the female client

indicates that the client understands factors
that may precipitate seizure activity?
Correct answer 2: The client should be

protected from injury but be allowed to move
freely. Restraining the clients extremities could
result in orthopedic injury to the client. Content
Process Implementation; Client NeedsSafe
Effective Care Environment, Management of
Care; Cognitive LevelApplication.
Correct answer 3: Dilantin does not turn
the urine orange; therefore this statement
indicates the client needs more teaching.
ContentMedical; Category of
Health AlterationDrug Administration;
Integrated ProcessEvaluation; Client Needs
Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive LevelSynthesis.
18
Correct answer 3: The client is in
distress; therefore, assessment is not priority.
The nurse should first administer Valium to halt
the seizure immediately to ensure adequate
oxygen supply to the brain. Anticonvulsant
medications are administered later to maintain
a seizure-free state. ContentMedical;
Integrated ProcessPlanning; Client NeedsSafe
Effective Care, Management of Care; Cognitive
LevelAnalysis.
Correct answer 3: The nurse must
determine if the client has been compliant with
medication; therefore, this question is
appropriate. The client does not
1. I should not take birth control pills to

prevent pregnancy.
2. I need to limit my intake of dairy
products.
3. I should not participate in any
contact sports.
4. My menstrual cycle may affect my
seizure disorder.
29. The clinic nurse is checking diagnostic test
results. Which diagnostic test result would
warrant notifying the client immediately?
1. The female client who is taking an
anticonvulsant who has a low bone density
scan.
2. The client who is diagnosed with
epilepsy who has a phenytoin (Dilantin) level of
28 mcg/dL.
3. The client with a seizure disorder who
has a carbamazepine (Tegretol) of 10 mcg/mL.
4. The client who has partial seizures
who has a serum sodium level of 143 mEq/L.
30. The mother of a child who had a febrile
seizure tells the pediatric clinic nurse, I am so
upset because now my child has epilepsy.
Which statement is the clinic nurses best
response?
1. Your child had a seizure due to a high
fever, not due to epilepsy.
lose consciousness in a partial seizure and does

not experience a postictal state. Hypoglycemia
(feeling jittery or irritable) causes tonic-clonic
seizures, not partial seizures. ContentMedical;
Category of Health
2. You are upset about your child having

epilepsy. Lets talk.

Assessment; Client NeedsPhysiological
Integrity, Physiological Adaptation; Cognitive
LevelAnalysis.
4. I would recommend you attend the

local epilepsy support group.
3. The Epilepsy Foundation of America

provides good information.
ANSWERS
Correct answer 4: Because of the
fluctuations in hormones that alter the
excitability of neurons in the cerebral cortex, an
increase in seizure frequency may occur during

menses. ContentMedical; Category of Health
Evaluation; Client NeedsPhysiological Integrity,
Evaluation.
Correct answer 2: The therapeutic
Dilantin level is 1020 mcg/dL; a level of 28
mcg/dL requires notifying the client. Content
ProcessAssessment; Client NeedsPhysiological
LevelSynthesis.
4. Notify the speech pathologist for an

emergency consult.
32. The nurse is assessing the client
experiencing a left-sided cerebrovascular
accident (CVA). Which clinical manifestations
would the nurse expect the client to exhibit?
1. Hemiparesis of the left arm and
apraxia.
2. Paralysis of the right side of the body
and aphasia.
3. Inability to recognize and use familiar
objects.
4. Impulsive behavior and hostility
toward family.
20
Correct answer 1: A high fever in a child
can cause a seizure, but it does not indicate the
child has a seizure disorder. The nurse should
provide information if at all possible instead of a
therapeutic response that encourages the client
to ventilate feelings. ContentMedical; Category
of Health
Evaluation; Client NeedsHealth Promotion and
Maintenance; Cognitive LevelSynthesis.
33. The HCP has discussed a carotid

endarterectomy with the client who has
experienced two transient ischemic attacks
(TIAs). The client tells the nurse, I really dont
understand why I need this procedure, and I
dont want to have it. Which scientific rationale
would support the nurses response?
1. This surgery is indicated for clients
with symptoms of a TIA due to carotid artery
stenosis.
2. This surgical procedure will ensure the
client does not have a cerebrovascular accident.

SECTIONONE
Cerebrovascular Accident
(Stroke, Brain Attack)
31. The 88-year-old client is admitted to the ED
with numbness and weakness of the left arm
and slurred speech. The computed tomography
(CT) scan was negative for bleeding. Which
nursing intervention is priority?
1. Prepare to administer tissue
plasminogen activator (TPA).
2. Discuss the precipitating factors that
caused the symptoms.
3. Determine the exact time the
symptoms occurred.
3. This surgery will remove all

atherosclerotic plaque from the carotid arteries.
4. This surgical procedure will increase
the elasticity of the carotid arterial wall.
ANSWERS
Correct answer 3: The nurse must first
determine when the symptoms started before
administering TPA, a standard of care. TPA must
be initiated within 3 hours of the start of
symptoms because, after that time,
revascularization of necrotic tissue, which
occurs with the administration of TPA, increases
the risk for cerebral edema and hemorrhage.
Client NeedsReduction of Risk Potential;
Correct answer 2: A left-sided CVA

results in right-sided paralysis, right visual field
deficit, aphasia (inability to speak), and altered
intellectual ability. All other options are results
of right-sided CVA.
Analysis.
4. Instruct the client to hold fingers in a

fist.
The nurse is planning care for the client
experiencing dysphagia secondary to a CVA.
Which intervention should be included in the
plan of care?
l 1. Evaluate the client during mealtime.
l 2. Position the client in a semi-Fowler position.
l 3. Administer oxygen during meals.
22
l 4. Refer the client to a physical therapist.
Correct answer 1: This is the rationale

the nurse would utilize to encourage the client
to have this surgical procedure. An
endartectomy does not ensure the client will not
have a CVA nor does it ensure that all
atherosclerotic plaque will be removed or that
the carotid artery wall will become more elastic.
The nurse and a UAP are caring for a

client with

Client NeedsPhysiological Adaptation,
Synthesis.

SECTIONONE
34. Which client would the nurse identify as

being least at risk for experiencing a CVA?
1. A 55-year-old African-American male
who is obese.
2. A 73-year-old Japanese female who
has essential hypertension.
3. A 67-year-old Caucasian male whose
cholesterol level is below 200 mg/dL.
4. A 39-year-old female who is taking
oral contraceptives.
35. The client diagnosed with a right-sided CVA
is admitted to the rehabilitation unit. Which
intervention should be included in the nursing
care plan?
1. Turn and reposition the client every
shift.
2. Place a small pillow under the clients
left shoulder.
3. Have the client perform quadriceps
exercises three times a day.
right-sided paralysis. Which action by the UAP

requires the nurse to intervene?
1. The UAP places the gait belt under the
clients axilla prior to ambulating.
2. The UAP places the client on the
abdomen with the clients head to the side.
3. The UAP uses a lift sheet when moving
the client up in the bed.
4. The UAP praises the client for
attempting to perform activities of daily life
(ADLs) independently.
ANSWERS
Correct answer 3: Caucasians have a
lower risk of CVA than African Americans,
Hispanics, and Native Pacific Islanders. A high
cholesterol level, being African American,
hypertension, and oral contraceptive use are
risk factors for developing a CVA. Content
Medical;
Integrated ProcessDiagnosis; Client Needs
Health Promotion and Maintenance; Cognitive
LevelAnalysis.
Correct answer 2: Placing a small pillow
under the left shoulder will prevent the shoulder
from adducting toward the chest and
developing a contracture. The client should be
repositioned at least every 2 hours; quadricep
exercises should be done for 10 minutes at least
five times a day; and the fingers are positioned
so that they are barely flexed. ContentMedical;
Integrated Process Planning; Client Needs
Physiological Integrity, Basic Care and Comfort;
Cognitive LevelSynthesis.
24
Correct answer 1: Dysphagia (swallowing
difficulty) puts the client at risk for aspiration,
pneumonia, dehydration, and malnutrition;
therefore, the nurse should evaluate the client
during mealtime. The client should be in a high
Fowler position or, preferably, in a chair.
Client Needs Physiological Integrity,
Synthesis.
Correct answer 1: The gait belt should be
around the waist because this is the clients
center of gravity. All other options are
appropriate interventions for the UAP and would
not require intervention.
Implementation; Client NeedsSafe Effective
Care Environment, Immobility; Cognitive Level
Synthesis.
40. The nurse has received the morning shift

report. Which client should the nurse assess
first?
1. The client who is complaining of a
headache at a 3 on a scale of 110.
2. The client who has an apical pulse of
56 and a blood pressure of 210/116.
3. The client who is reporting not having
a bowel movement in 3 days.
4. The client who is angry because the
call light was not answered for 1 hour.
Brain Tumors
41. The client is being admitted with rule-out
(R/O) brain tumor. Which signs/symptoms
support the diagnosis of a brain tumor?
1. Widening pulse pressure,
hypertension, and bradycardia.
2. Headache, vomiting, and diplopia.
3. Hypotension, tachycardia, and
tachypnea.

SECTIONONE
38. The client diagnosed with chronic atrial

fibrillation has experienced a transient TIA.
Which discharge instruction should the nurse
implement?
1. Keep nitroglycerin tablets in a darkcolored bottle.
2. Check the radial pulse prior to all
medications.
3. Obtain International Normalized Ratio
(INR) routinely.
4. Take over-the-counter vitamin K
tablets daily.
39. The client diagnosed with a CVA has
hemiparesis. Which problem would be priority
for the client?
1. Impaired skin integrity.
2. Fluid volume overload.
4. Abrupt loss of motor function,

diarrhea, and changes in taste.
ANSWERS
Correct answer 3: An oral anticoagulant,
warfarin (Coumadin), will be prescribed to help
prevent the formation of thrombi in the atrium
secondary to atrial fibrillation. The thrombi can
become embolic, which may cause a TIA. The
INR is the laboratory value used to determine
therapeutic oral anticoagulant levels. Content
Client NeedsHealth Promotion and
Maintenance; Cognitive LevelSynthesis
Correct answer 4: Hemiparesis is a
weakness on one side of the body that may lead
to falls; this makes high risk for injury the
priority problem for this client. ContentMedical;
Category of Health Alteration
Neurological; Integrated ProcessDiagnosis;
Client Needs Physiological Integrity, Reduction
of Risk Potential; Cognitive LevelAnalysis.
3. High risk for aspiration.

4. High risk for injury.
26
Correct answer 2: This blood pressure is

extremely high, and the pulse rate is decreased;
therefore, this client should be assessed first. A
3 headache, no bowel movement, and an upset
client would not be priority over a client who
may be having a CVA.
Correct answer 2: The classic triad of
symptoms of a brain tumor includes a headache
that is dull and unrelenting and worse in the
morning, vomiting unrelated to food intake, and
edema of the optic nerve (papilledema) causing
diplopia. Option 1 is the Cushing triad, which
indicates increased intracranial pressure that
would not be seen initially on diagnosis; option
3 is signs/symptoms of hypovolemic shock.
Analysis.
The client diagnosed with lung cancer

has developed metastasis to the brain. Which
problem would be priority for this client?
l 1. Anticipatory grieving. l 2. Impaired gas
exchange.
l 3. Altered nutritional status. l 4. Alteration in
comfort.
The client diagnosed with a brain tumor
was
admitted to the ICU with decorticate posturing.
Which indicates that the clients condition is
improving?
1. The client has purposeful movement
with painful stimuli.
2. The client assumes adduction of the
upper extremities.
3. The client assumes the decerebrate
posture upon painful stimuli.
4. The client has become flaccid and
does not respond to stimuli.
ANSWERS
SECTIONONE
The client is diagnosed with a frontal

lobe brain tumor. Which sign/symptom would
the nurse expect the client to exhibit?
l 1. Ataxia.
l 2. Decreased visual acuity. l 3. Scanning
speech.
l 4. Personality changes.
The male client diagnosed with a brain
tumor is
having a closed magnetic resonance imaging
(MRI) scan in 1 hour. The client tells the
radiology nurse, I dont like small enclosed
spaces. Which action should the nurse
implement?
1. Allow the client to express his
feelings.
2. Discuss the procedure with the client.
3. Obtain an order for an anti-anxiety
medication.
day.
4. Reschedule the procedure for another
Correct answer 4: Personality changes

occur in a client with a frontal lobe tumor.
Ataxia or gait problems indicate a temporal lobe
tumor. Decreased visual acuity is a symptom
indicating papilledema, a general symptom of
the majority of all brain tumors, not specifically
a frontal lobe tumor. Scanning speech is
symptomatic of multiple sclerosis. Content
Neurologic; Integrated ProcessAssessment;
Analysis.
Correct answer 3: The client is
claustrophobic and will need medications to
help decrease the anxiety associated with small
enclosed spaces. Ventilating feelings and
discussing the procedure will not help
claustrophobia. Reschedule for an open MRI, not
another closed MRI. ContentMedical; Category
of
Process Planning; Client NeedsPhysiological
LevelSynthesis.
28
Correct answer 1: Anticipatory grieving is
priority because brain metastasis is a terminal
diagnosis, indicating death within 6 months or
less. With the development of brain metastasis,
the nurse must address death and dying issues,
which is why this is priority over all the other
client problems. Content
Neurological; Integrated ProcessDiagnosis;
Correct answer 1: Purposeful movement
following painful stimuli would indicate an
improvement in the clients condition.
Adducting the upper extremities while internally
rotating the lower extremities is decorticate
positioning; this would indicate the clients
condition had not changed. Decerebrate
posturing and flaccid movement indicate a
worsening of the condition. ContentMedical;
Category of Health
Evaluation.
SECTIONONE
The intensive care nurse is caring for a

client following an infratentorial craniotomy.
Which interventions should the nurse
implement? Select all that apply.
l 1. Keep the head of the bed elevated at 30
degrees. l 2. Keep a humidifier in the clients
room.
l 3. Do not put anything in the clients mouth. l
4. Provide the client with a clear liquid diet.
l 5. Assess the clients respiratory status every
hour.
The client is diagnosed with a pituitary
tumor and is
scheduled for a transsphenoidal
hypophysectomy. Which postoperative
instruction is important to discuss with the
client?
1. Demonstrate to a family member how
to change a turban dressing.
2. Explain to the client how to monitor

urine output at home.
3. Tell the client not to blow his nose for
2 weeks after surgery.
4. Tell the client he will have to lie flat for
24 hours following the surgery.
48. The client has undergone a craniotomy for a
brain tumor. Which data indicate a complication
of this surgery?
1. The client complains of a headache at
a 34 on a 110 scale.
2. The client has a urinary output of 250
mL over the last 24 hours.
3. The client has a serum sodium level of
137 mEq/L.
4. The client experiences dizziness when
trying to get up too quickly.
ANSWERS
Correct answer 2, 4, 5: Humidified air
would be provided; the clients diet is started
slowly; and the respiratory status is assessed
because the centers that control respiration and
vomiting are in the area of the brain affected by
the surgery. The head of the bed would be flat,
and caution with oral care is appropriate for a
client with a transsphenoidal hypophysectomy,
not with an infratentorial craniotomy. Content
Surgical; Category of Health
LevelAnalysis.
Correct answer 3: Blowing the nose
creates increased intracranial pressure and
could result in a leak of cerebral spinal fluid. A
transsphenoidal hypophysectomy is done by an
incision above the gum line, and there is no
turban dressing. The head of the bed is
elevated to 30 degrees to allow for gravity to
assist in draining the cerebrospinal fluid.
ContentSurgical; Category of Health Alteration
Client
30
NeedsPhysiological Integrity, Physiological
Adaptation;
Correct answer 2: The decreased urinary
output may indicate syndrome of inappropriate
antidiuretic hormone (SIADH), which is a
complication of a craniotomy. A headache after
this surgery would be an expected occurrence.
The sodium level is normal (135145 mEq/L).
Dizziness upon arising quickly would not be a
complication of this surgery. Content
Surgical; Category of Health Alteration
Client NeedsPhysiological Adaptation,
Analysis.
SECTIONONE
The nurse is assessing the client

diagnosed with bacterial meningitis. In addition
to nuchal rigidity, which clinical manifestations
would the nurse assess?
l 1. Positive Cushing sign and ascending
paralysis. l 2. Negative Kernig sign and facial
tingling.
l 3. Positive Brudzinski sign and photophobia.
l 4. Negative Trousseau sign and descending
paralysis.
The nurse is admitting a client diagnosed
with
meningococcal meningitis and notes lesions
over the face and extremities. Which priority
intervention should the nurse implement?
1. Initiate the intravenous antibiotics
stat.
2. Obtain a skin biopsy for culture and
sensitivity.
3. Perform a complete neurological
assessment.
The client diagnosed with a brain tumor

is prescribed intravenous dexamethasone
(Decadron), a steroid. Which intervention should
the nurse implement when administering this
medication?
l 1. Administer medication with normal saline
only. l 2. Check the clients white blood cell
(WBC) count. l 3. Determine if the client has oral
candidiasis.
l 4. Monitor the clients glucose level.
The male client is scheduled for gamma
knife
stereotactic surgery for a brain tumor. Which
preoperative instruction should the nurse
discuss with the client?
1. Instruct the client to avoid bright
lights and wear sunscreen.
2. Tell the client he must sleep with the
head of the bed elevated.
3. Explain there are no activity
limitations after this procedure.
4. Encourage the client to take off at
least 2 weeks from work.
4. Close all the curtains in the room and

turn off lights.
ANSWERS
Correct answer 4: Decadron, a
glucocorticosteroid, will increase insulin
resistance, which increases glucose levels;
therefore, glucose levels should be monitored.
Decadron is compatible with dextrose, so
normal saline does not need to be used, and the
WBC count and oral candidiasis would not be
interventions pertinent to administering this
medication. ContentMedical; Category of
Health
AlterationDrug Administration; Integrated
Physiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive Level
Application.
Correct answer 3: This is a day-surgery
procedure, and the client is usually discharged
home 34 hours after the surgery and can
resume normal activities.
Surgical; Integrated ProcessPlanning; Client
Needs Safe Effective Care Environment,
Synthesis.
Meningitis
32
Correct answer 3: A positive Brudzinski

sign (raise the clients head, and the knees will
come up) and photophobia due to meningeal
irritation are key signs of meningitis. A positive
Kernig sign (client is unable to extend leg when
lying flat) would also be expected. Content
Diagnosis; Client NeedsPhysiological Integrity,
Analysis.
Correct answer 1: Purpuric lesions over
the face and extremities are the signs of a
fulminating infection in clients with
meningococcal meningitis. The infection can
lead to death within a few hours. The nurse
should start the antibiotics immediately.
Content
55. The nurse is preparing for a lumbar

puncture for the client diagnosed with R/O
meningitis. Which interventions should the
nurse implement? Select all that apply.
1. Determine if the client has any
allergies to iodine.
2. Do not let the client urinate 2 hours
before the procedure.
3. Place the client in a prone position
with the face turned to the side.
4. Instruct the client to take slow deep
breaths during the procedure.
5. Label the specimen and send to the
laboratory for cultures.
56. The client diagnosed with septic meningitis
is admitted to the medical floor at 1200. Which
HCPs order would the nurse implement first?
1. Administer intravenous antibiotic.
2. Start the clients intravenous line.
3. Provide a quiet, calm dark room.

SECTIONONE
Which type of precautions should the

nurse implement for the client diagnosed with
aseptic meningitis?
l 1. Standard precautions. l 2. Airborne
precautions. l 3. Contact precautions. l 4.
Droplet precautions.
A college student came to the university
health clinic
and was diagnosed with bacterial meningitis
and admitted to a local hospital. Which
intervention should the university health clinic
nurse implement?
1. Place the clients dormitory under
strict respiratory isolation.
2. Notify the parents of all students
about the meningitis outbreak.
3. Arrange for students to receive the
meningococcal vaccination.
4. Ensure dormitory roommates receive
chemoprophylaxis using rifampin.
4. Initiate seizure precautions.

ANSWERS
Correct answer 1: Aseptic meningitis is
caused by a noninfectious agent or a virus and
is not likely to be transmitted to other people;
therefore, standard precautions would be
expected. Septic meningitis would require
droplet precautions for 24-48 hours after
initiation of antibiotics. ContentMedical;
Application.
Correct answer 4: People in close contact
with clients diagnosed with meningococcal
meningitis, the most common type of infectious
agent in group settings, should receive
chemoprophylaxis for prevention of meningitis.
The public health nurse or college
administration would notify parents. It is too
late for the vaccine. ContentMedical; Category
of
Health AlterationInfectious Disease; Integrated
ProcessPlanning; Client NeedsSafe Effective
Care Environment, Safety and Infection Control;
34
Correct answer 1, 4, 5: The lumbar area
is cleansed with Betadine; therefore, iodine
allergies should be noted. The clients bladder
should be empty for comfort during the
procedure, and the client should be in a sidelying position with back arched for access to
intravertebral space. Taking slow deep breaths
will help calm the client, and specimens are
sent to the laboratory. ContentMedical;
Category of
Physiological Integrity, Reduction of Risk
Potential; Cognitive LevelApplication.
Correct answer 2: Intravenous antibiotics
are of paramount importance, so the nurse
must start an intravenous line first. Content
59. The nurse is developing a plan of care for a

client diagnosed with septic meningitis. Which
client goal would be most appropriate for the
client problem of altered thermoregulation?
1. The client will have no injury from
using the hypothermia blanket.
2. The client will be protected from injury
if seizure activity occurs.
3. The client will be afebrile for 48 hours
prior to discharge.
4. The client will have serum electrolytes
within normal limits.
60. The nurse is admitting a client diagnosed
with meningitis who has AIDS. Which
signs/symptoms would the nurse expect the
client to exhibit?
1. A positive Babinski sign.
2. Diplopia and blurred vision.
Health AlterationInfectious Diseases;

Care; Cognitive LevelSynthesis.
3. Auditory deficits.
4. The client may be asymptomatic.
ANSWERS

SECTIONONE
The nurse asks the UAP to help admit

the client diagnosed with bacterial meningitis.
Which nursing task is priority?
l 1. Take the clients vital signs.
l 2. Obtain the clients height and weight.
l 3. Prepare the room for respiratory isolation.
l 4. Pull the drapes and make sure the room is
dim.
Correct answer 3: Equipment needed for

the staff to enter the clients room safely is the
priority nursing task that can be delegated. All
other tasks could be safely delegated to the
UAP, but they are not priority. ContentMedical;
CategoryInfectious
Diseases; Integrated ProcessPlanning; Client
Needs Safe Effective Care Environment,
Synthesis.
The 18-year-old client is admitted to the

medical
Correct answer 4: Meningitis directly

affects the clients brain; therefore, assessing
the neurological status would have priority for
this
floor with a diagnosis of meningitis. Which

priority intervention should the nurse assess?
1. Assess the clients neurovascular
status.
client. Neurovascular assessment involves

peripheral nerves and changes such as
paralysis and skin temperature. Content
2. Assess the clients cranial nerve IX

function.
3. Assess the clients brachioradialis
AlterationInfectious Diseases; Integrated

Process Assessment; Client NeedsSafe
Care; Cognitive LevelAnalysis.
4. Assess the clients neurological status.
36
reflex.
Correct answer 3: The client with septic

meningitis has a high fever; therefore, being
afebrile for 48 hours would be an appropriate
goal. ContentMedical; Cate-gory of Health
AlterationInfectious Diseases; Integrated
ProcessPlanning; Client NeedsPhysiological
LevelSynthesis.
1. Feed the client with Parkinson disease

who has intention tremors of the hand.
Correct answer 4: The client with AIDS

may be asymptomatic or may exhibit atypical
symptoms because of blunted inflammatory
responses. Content
Infectious Diseases; Integrated Process
Assessment; Client Needs Physiological
LevelAnalysis.
4. Obtain vital signs on a client with

Parkinson disease who is hallucinating.

SECTIONONE
Parkinson Disease
Which clinical manifestations would the
nurse expect to assess in the client diagnosed
with Parkinson disease (PD)?
l 1. Nausea, vomiting, and diarrhea.
l 2. Polyuria, polydipsia, and polyphagia.
l 3. Dysphonia, dysphagia, and scanning
speech. l 4. Tremors, rigidity, and bradykinesia.
2. Change the sterile pressure ulcer

dressing for a client who is on bedrest.
3. Give the client who is having
heartburn 30 mL of the antacid Maalox.
ANSWERS
Correct answer 4: Tremors, rigidity, and
bradykinesia are the classic manifestations of
PD. They are known as the triad of PD. Content
Correct answer 4: Bite-sized foods
require less energy from the client for chewing,
and a plate warmer preserves the appeal of the
food. Nothing in the stem of the question
indicates that the client has diabetes, so the
ADA diet would not be necessary. The client
should have a high-residue (fiber) diet to
prevent constipation. A pureed diet has babyfood consistency and should not be given to a
client
who can chew. ContentMedical; Category of
Health
The nurse caring for a client diagnosed

with Parkinson

Planning; Client NeedsSafe Effective Care
Environment, Management of Care; Cognitive
LevelSynthesis.
disease writes a problem of Impaired

Nutrition. Which nursing intervention would be
included in the plan of care?
1. Give the client a pureed diet.
38
diet.
2. Request a low-residue heart-healthy
3. Provide an 1800-calorie American

Diabetic Association diet.
4. Offer bite-sized foods on a plate
warmer.
63. The nurse and the UAP are caring for clients
on a medical surgical unit. Which task would be
most appropriate to assign to the UAP?
Correct answer 1: The client with

intention tremors is stable but cannot keep the
food on the eating utensil to get it to the mouth;
this task could be safely delegated to the UAP.
UAP cannot assess, teach, evaluate, administer
medications, or care for an unstable client. The
client hallucinating is having a reaction to the
Parkinson disease medications and is unstable.
ContentMedical; Category of Health
LevelSynthesis.

SECTIONONE
64. The charge nurse is making assignments on

a medical surgical unit. Which client should be
assigned to the licensed practical nurse (LPN)?
1. The client with Parkinson disease who
became disoriented throughout the night.
2. The client with aseptic meningitis who
is complaining the light is bothersome.
3. The client newly diagnosed with
Parkinson disease who is being discharged.
4. The client diagnosed with a brain
tumor who had a seizure at the change of shift.
65. The nurse is planning the care for a client
diagnosed with Parkinson disease. Which goal
would be appropriate for the client problem of
impaired mobility?
1. The client will experience periods of
akinesia throughout the day.
2. The client will be able to turn from
side to side in bed.
3. The client will be able to ambulate in
the hall three times a day.
4. The client will be able to carry out
normal saline to infuse over 30 minutes. Which

rate should the nurse set the intravenous
pump?
Answer: ____________________
ANSWERS
Correct answer 2: Photophobia is an
expected clinical manifestation of aseptic
meningitis, so the LPN could be assigned to this
client. New-onset disorientation indicates the
client is unstable and would require the
registered nurse (RN) to assess the client. The
newly diagnosed client with PD requires
extensive teaching. Seizure activity may
indicate increasing intracranial pressure.
LevelSynthesis.
Correct answer 3: The goal of a client
with impaired mobility would be to be mobile;
walking in the hall would be an appropriate
goal. Akinesia is lack of movement, and the
client should not be allowed to stay in bed due
to immobility complications. Ability to do ADLs
would be appropriate for self-care deficit
problem. ContentMedical; Category of Health
Planning; Client NeedsPhysiological Integrity,
Basic Care and Comfort; Cognitive Level
Synthesis.
ADLs.
40
66. The client diagnosed with Parkinson disease
is being discharged. Which statement made by
the clients significant other indicates a need for
more teaching?
1. I know that my husband may have
some emotional mood swings.
2. My spouse may experience
hallucinations until the medication starts
working.
3. I will schedule appointments late in
the morning after his morning bath.
4. My spouse must take his medication
at the same time every day.
67. The client with Parkinson disease is
admitted to the medical unit diagnosed with
pneumonia. The nurse needs to administer
ceftriaxone (Rocephin) 100 mg in 100 mL of
Correct answer 2: Hallucinations are a

sign that the client is experiencing drug toxicity;
therefore, this statement indicates that the
significant other needs more teaching. The
other statements indicate the clients significant
other understands the discharge teaching.
Planning; Client NeedsPhysiological Integrity,
Synthesis.
Correct answer 200 mL/hour:
Intravenous pumps are set at an hourly rate; if
100 mL is infused in
1 hour, the nurse should double the rate so that
100 mL would infuse in 30 minutes. Content
Medical;
Category of Health AlterationDrug
Administration; Integrated Process

Cognitive LevelApplication.
ANSWERS
Correct answer 3: Memory deficits are

cognitive impairments; the client may also
develop a dementia. Emotional liability,
depression, and paranoia are psychosocial
problems, not cognitive ones. Content
SECTIONONE
68. The home health nurse is caring for a client

diagnosed with Parkinson disease. Which
comment by the clients significant other would
suggest a common cognitive problem
associated with Parkinson disease?
1. My wife is never happy about
anything I do for her.
2. All my wife does is sit on the porch
and look at her garden.
3. My wife is becoming more forgetful
about routine things.
4. My wife thinks the medication I give
her is poison.
69. The nurse is conducting a support group for
clients diagnosed with PD and their significant
others. Which information regarding
physiological needs should be included in the
discussion?
1. Remove all throw rugs and tack down
all loose carpet.

Neurological; Integrated ProcessEvaluation;
Client NeedsPsychosocial Integrity; Cognitive
LevelEvaluation.
Correct answer 1: The clients safety is
priority due to the physiological shuffling gait
that makes the client high risk for injuries due
to falls. ContentMedical;
Integrated ProcessPlanning; Client Needs
42
Correct answer 2: Dyskinesia is
abnormal involun-tary movement, including
facial grimacing, rhythmic jerking movements,
and head-bobbing. These move-ments indicate
a complication of the L-dopa.
Pharmacological and Parenteral Therapies;
2. Recommend the client completes an

advance directive.
3. Explain the reason why the client has
pill rolling tremors.
4. Give simple, short, concise directions
to their loved one.
70. The client has been diagnosed with
Parkinson disease for 12 years and has been
taking levodopa (L-dopa) for the last 8 years.
Which symptom would alert the nurse to a
possible medication complication?
1. The client is unable to initiate
voluntary movement.
2. The client has recently developed
dyskinesia.
3. The client has masklike facies and
cogwheel movements.
4. The client has excessive saliva
production.

SECTIONONE
Sensory Deficits
The client is diagnosed with acute otitis
media. Which statement would cause the nurse
to suspect the client had a ruptured tympanic
membrane?
l 1. I always have a lot of earwax buildup.
l 2. I have been running a fever with my ear
pain. l 3. I had ear pain but then it went away
on its own.
l 4. I had a sinus infection prior to getting the

ear pain.
The client is diagnosed with Mnire
disease. Which
statement by the client supports that the client
needs more teaching concerning the
management for this disease?
1. Surgery is the only cure for Mnire,
but I may be deaf.
2. I will have to use a hearing aid for
the rest of my life.
3. I must adhere to a low-sodium diet,
2000 mg/day.
4. When I get dizzy I need to lie down
on my bed.
73. The nurse is preparing to administer otic

drops into the adult clients right ear. Which
action should the nurse implement?
diet is prescribed to help control the symptoms

of Mnire disease. ContentMedical;
Category of Health AlterationNeurosensory;
Cognitive LevelEvaluation.
44
Correct answer 4: Pulling the auricle
down and back prior to instilling drops will
straighten the ear canal so that the ear drops
will enter the ear canal and drain toward the
tympanic membrane (eardrum). Nothing should
be placed in the outer ear canal.
Drug Administration; Integrated Process
1. Grasp the ear lobe and pull up and out

when putting drops in the ear.
SECTIONONE
2. Insert the eardrops without touching

the outside of the ear.
74. The client is scheduled for right

tympanoplasty. Which statement indicates the
client understands the preoperative teaching
concerning the surgery?
3. Place the applicator 14 inch into the

outer ear canal.
4. Pull the auricle down and back prior to
instilling drops.
ANSWERS
Correct answer 3: The pain associated
with otitis media is relieved after spontaneous
perforation or therapeutic incision of the
tympanic membrane.
Ear pain and fever are expected with otitis
media.
Neurosensory; Integrated ProcessAssessment;
Client NeedsPhysiological Integrity, Reduction
of Risk Potential; Cognitive LevelAnalysis.
Correct answer 2: Mnire disease does
not lead to deafness unless surgery is done,
which may result in permanent deafness in the
affected ear. Sodium regu-lates the balance of
fluid within the body; therefore, a low-sodium
1. If I have to sneeze or blow my nose, I

will do it with my mouth open.
2. If I have any dizzy spells, I will
contact my doctor immediately.
3. I will probably have permanent
hearing loss in my right ear.
4. I can shampoo my hair the day after
surgery as long as I am careful.
75. The client diagnosed with osteoarthritis has
been self-medicating with high doses of aspirin
for the pain. Which comment by the client
would warrant further evaluation by the nurse?
1. I always take my medication with
food.
ears.
2. I have noticed a buzzing sound in my
3. I soak in a hot tub bath in the

morning.
4. I will call my doctor if my gums

bleed.
The client is diagnosed with cataracts.
Which symptom would the nurse expect the
client to report? l 1. Halos around lights.
l 2. Floating spots in the eye.
l 3. Everything has a yellow haze. l 4. Painless,
blurry vision.
The 65-year-old client is diagnosed with
macular
degeneration. Which statement indicates the
client understands the discharge teaching
concerning this diagnosis?
1. I should use artificial tears three
times a day.
2. I will look at my Amsler grid at least
twice a week.
Correct answer 4: A cataract is a lens

opacity or cloudiness resulting in painless,
blurry vision. The symptom in option 1 is
characteristic of glaucoma; that in option 2 of
retinal detachment; and that in option 3 of
digoxin toxicity. ContentMedical;
Category of Health AlterationNeurosensory;
Integrated ProcessAssessment; Client Needs
Correct answer 2: Amsler grids provide
the earliest sign of worsening of the clients
macular degeneration. If the lines of the grid
become distorted or faded,
the client should call the ophthalmologist.
Content
Neurosensory; Integrated ProcessEvaluation;
Evaluation.
3. I am going to use low-watt lightbulbs

in my house.
4. I will wear dark sunglasses when I go
outside.
ANSWERS
SECTIONONE
Correct answer 1: Leaving the mouth

open when coughing or sneezing will minimize
the pressure changes in the middle ear.
Dizziness is expected after ear surgery.
Tympanoplasty is a repair of the inner ear
structure and will not cause permanent hearing
loss. Shampooing is avoided to prevent
contamination of the ear canal. Content
Surgical: Category of Health
78. The nurse is preparing to administer

eyedrops to a client. To which area should the
nurse apply pressure to prevent systemic
absorption of the medication?
1. A
2. B
3. C
AlterationNeurosensory; Integrated Process

Reduction of Risk Potential: Cognitive Level
Evaluation.
Correct answer 2: The buzzing should
alert the nurse to possible tinnitus, which is a
sign of aspirin toxicity and warrants further
evaluation by the nurse.
46
4. D
A male client is brought to the employee

health clinic reporting some type of chemical
was splashed in his eyes. Which action should
the nurse implement first?
l 1. Arrange for transportation to the

ophthalmologist. l 2. Perform a vision screening
test on the client.
l 3. Flush the eye continuously with water.
l 4. Complete an occurrence report for the
situation.
wash the hands but not wear gloves. Content

Health AlterationDrug Administration;
Health Promotion and Maintenance; Cognitive
LevelEvaluation.
The client with glaucoma is prescribed a

miotic
cholinergic medication. Which data support the
teaching for this medication has been effective?
1. The client reports taking the

medication on vacations.
SECTIONONE
2. The client reports taking a stool

softener every day.
Management Issues
3. The client places the medication in

the inner canthus.
81. The nurse is caring for clients on a medical

surgical floor. Which client should be assessed
first?
4. The client wears gloves when instilling

the medication.
1. The client diagnosed with epilepsy

who reports over the intercom having an aura.
ANSWERS

complaining of shortness of breath while
exercising.
Correct answer 4: The area marked A is

known as the inner canthus; gentle pressure to
this area will prevent systemic absorption of the
medication.
3. The client diagnosed with Parkinson

disease who is being discharged today.

Adaptation, Pharmacological and Parenteral
Therapies; Cognitive LevelSynthesis.
4. The client diagnosed with a CVA who

has resolving left hemiparesis.
Correct answer 3: The first and most

important intervention is to flush the agent out
of the eye. Then the nurse should refer the
client to an ophthalmologist, maybe check
vision, and then complete an occurrence report
because the client was not wearing goggles.
ContentMedical; Category of
82. The charge nurse in the medical/surgical

department is making rounds at 0700. Which
client should the nurse see first?
Health AlterationNeurosensory; Integrated

Process Implementation; Client NeedsSafe
Care; Cognitive LevelSynthesis.
48
Correct answer 1: The client realizes that
medication compliance is priority for glaucoma
and consequently takes the medication while on
vacation. The client should prevent
constipation, but it has nothing to do with
miotic medications. Medication should be
placed in the conjunctiva. The client needs to
1. The client diagnosed with a brain

tumor who is complaining of a headache.
2. The client diagnosed with meningitis
who is complaining of a stiff neck.
3. The client diagnosed with diabetes
who is reporting seeing spots in the eyes.
4. The client diagnosed with low back
pain who has radiating pain down the left leg.
83. The registered nurse (RN), an LPN, and a
UAP are caring for clients on a neurological unit.
Which task would be most appropriate for the
nurse to assign/delegate?
1. Instruct the LPN to complete the
clients admission assessment.
2. Request the UAP to change the central

line dressing.
3. Assign the LPN to administer routine
medications.
4. Tell the UAP to complete the Glasgow
Coma Scale.
101.6F, P 128, R 32, B/P 96/46. Which action

should the nurse implement first?
1. Notify the HCP.
2. Assess the client immediately.
3. Prepare to administer acetaminophen
(Tylenol).
ANSWERS
4. Check the chart for the culture and

sensitivity report.
Correct answer 1: The client with an aura

is getting ready to have a seizure. This client
should be seen first. ContentMedical; Category
of Health Alteration
85. The nurse is preparing to administer

dexamethasone (Decadron) intravenous push
(IVP) to a client with an acute spinal cord injury.
Which interventions should the nurse
implement? Rank in order.
1. Administer the medication over 2
minutes.
Correct answer 3: Seeing spots could

indicate a retinal detachment, and this requires
the nurse to assess this client first. If the
signs/symptoms are expected for the disease
processsuch as headache with a brain tumor,
a stiff neck with meningitis, and pain radiating
down the leg in a client with low back pain
then the nurse should not assess that client first
unless the symptom is life-threatening.
Content
50
Correct answer 3: The LPN can
administer routine medications. The RN should
not delegate/assign assessment to an LPN or a
UAP (options 1 and 4). The central line dressing
change is a sterile dressing that should not be
delegated to a UAP. Content
Medical; Category of Health AlterationDrug
Administration; Integrated ProcessPlanning;
Synthesis.

SECTIONONE
84. The nurse is caring for a client diagnosed

with septic meningitis. The UAP reports T
2. Dilute the medication with normal

saline.
3. Check the clients medication
administration record (MAR).
4. Check the clients identification band.
port.
5. Clamp the primary tubing distal to the
86. The 22-year-old client with a severe head

injury is admitted to the critical care unit. Some
of the clients friends come to the nurses
station requesting information. Which action
would be most appropriate by the nurse?
1. Tell the friends to talk to the parents.
2. Discuss the clients situation with the
friends.
3. Allow the friends to visit the client for
10 minutes.
4. Explain that no information can be
shared with the friends.
87. The male client diagnosed with a brain
tumor who is receiving hospice care is admitted
to the hospital and provides the nurse with a
copy of his living will, stating he does not want
any heroic measures. Which action should the
nurse implement first?
1. Check the chart to make sure there is
a do not resuscitate (DNR) order.
2. Inform the HCP that the client has a
living will.
3. Place a copy of the living will in the
front of the clients chart.
4. Request the hospital chaplain to come

and talk to the client.
ANSWERS
Correct answer 2: Whenever another
health-care team member reports information
to the nurse, assessment should be completed
to confirm the data. Then the nurse should
notify the HCP, administer Tylenol to decrease
the fever, and check the chart, but the nurse
must first realize this is potential septic shock,
and the client should be assessed. Content
Health AlterationInfectious Diseases;
Integrated Process Implementation; Client
Application.
Correct answer 3, 2, 4, 5, 1: First check
the MAR to ensure the right medication, the
right dose, at the right time. Diluting the
medication saves the vein and decreases the
clients pain during administration. Check for
the right client by checking the clients
identification band. Clamping the tubing will
ensure the medication goes into the vein, and 2
minutes is the recommended administration
time. Content
Medical; Category of Health AlterationDrug
Administration; Integrated Process
Implementation;

Application.
SECTIONONE
88. The charge nurse has received laboratory

data for clients. Which situation requires the
charge nurses intervention first?
1. The client with a brain tumor who has
ABGs: ph 7.36, PaO2 95, PaCO2 38, HCO3 24.
2. The postoperative craniotomy client
who has a serum sodium level of 153 mEq/L.
3. The client with septic meningitis who
has a white blood cell count of 12,000 mm.
4. The client with epilepsy who has a
serum phenytoin (Dilantin) level 15 mcg/mL.
89. The primary nurse in the neurological
critical care unit is very busy. Which nursing
task must be implemented first?
1. Assist the HCP with a sterile dressing
change for a client who has a turban dressing.
52
2. Obtain a tracheostomy tray for a

client with a
C-4 SCI who is exhibiting air hunger.
Cognitive LevelSafe Effective Care

Environment,
3. Transcribe orders for a client who was

transferred from the emergency department.

Application.
4. Administer the antibiotic therapy to

the client diagnosed with meningitis.
Correct answer 4: The nurse cannot

violate the clients confidentiality according to
the Health Information Privacy and Portability
Act (HIPPA).
ContentFundamentals; Category of Health
Alteration Neurological; Integrated Process
LevelApplication.
Correct answer 1: This action should be
implemented first to ensure the clients wishes
will be honored in case the client codes. All
other actions could be taken, but the clients
wishes are priority. ContentMedical;
90. The nurse and a UAP are caring for a client

with right-sided paralysis secondary to a CVA.
Which action by the UAP requires the nurse to
intervene?
1. The UAP encourages the client to
perform ROM exercises.
2. The UAP places the client on a side
with a pillow between the legs.
3. The UAP leaves a urinal full of urine at
the clients bedside.
4. The UAP praises the client for

attempting to get dressed alone.

ANSWERS
Correct answer 2: The client with a C-4

SCI may have ascending edema that could
cause respiratory compromise; therefore, the
nurse should have a tracheostomy tray at the
bedside. ContentMedical;
Correct answer 2: An elevated serum

sodium level (normal is 135145 mEq/L)
indicates possible diabetes insipidus, which is a
complication of brain surgery. The ABGs are
within normal limits, the WBC count would be
elevated in a client with meningitis, and the
therapeutic Dilantin level is 1020 mcg/mL.
AlterationSurgical; Integrated Process

Care; Cognitive LevelEvaluation.a

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SECTIONONE

rigidity are signs of meningitis. Content

4. The intensive care nurse is caring for a client

1. Assess the clients orientation to date,

7. The client with increased intracranial

9. The nurse is discussing the TBI Act at a

ContentMedical; Category of Health Alteration

4. The client informs the nurse that she

Spinal Cord Injury

Physiological Adaptation; Cognitive Level

13. The rehabilitation nurse caring for the

Correct answer 2: The clients bowel and

3. Maintain the clients ice saline

15. The male client with a C-6 SCI tells the

4. Check the clients respiratory rate

implemented, but confirming the autonomic

dysreflexia is priority. ContentMedical;

16. Correct answer 4: The blood pressure tends

very unstable and low for clients with an SCI of

or above, and slight elevations of the head of

Neurological; Integrated Process

Management of Care; Cognitive Level

Copyright 2010 F.A. Davis Company

18. The nurse on the rehabilitation unit is caring

ProcessImplementation; Client NeedsSafe

4. The client with a T-4 SCI who is unable

1. Ask the UAP to hold the urinal while

Correct answer 3: The social worker is

4. Observe the client demonstrating selfcatheterization technique.

Copyright 2010 F.A. Davis Company

2. Document the client had privacy

24. The UAP is holding the arms of a client who

assessment would not be appropriate. Content

The client is admitted to the ED after

Category of Health AlterationNeurological;

partial seizure. Which question would be most

Copyright 2010 F.A. Davis Company

3. When did you last take your seizure

4. Were you feeling jittery or irritable

28. Which statement by the female client

Correct answer 2: The client should be

1. I should not take birth control pills to

lose consciousness in a partial seizure and does

2. You are upset about your child having

AlterationNeurological; Integrated Process

4. I would recommend you attend the

Copyright 2010 F.A. Davis Company

3. The Epilepsy Foundation of America

increase in seizure frequency may occur during

4. Notify the speech pathologist for an

33. The HCP has discussed a carotid

Copyright 2010 F.A. Davis Company

3. This surgery will remove all

Correct answer 2: A left-sided CVA

4. Instruct the client to hold fingers in a

l 4. Refer the client to a physical therapist.

Correct answer 1: This is the rationale

The nurse and a UAP are caring for a

ContentMedical; Category of Health Alteration

Copyright 2010 F.A. Davis Company

34. Which client would the nurse identify as

right-sided paralysis. Which action by the UAP

40. The nurse has received the morning shift