AEIII Exam 1 Medsurge Questions

Question 1

1. The client is diagnosed with glaucoma. Which symptom would the nurse expect the
   client to report?
2. Halos around lights.
3. Floating spots in the vision.
4. A yellow haze around everything.
5. A curtain coming across vision.

Answer 1

1

1. In glaucoma, the client is often unaware that he or she has the disease until the client experiences blurred vision, halos
   around lights, difficulty focusing, or loss of peripheral vision. Glaucoma is often called the “silent thief.”
2. Floating spots in the vision is a symptom of retinal detachment.
3. A yellow haze around everything is a complaint
   of clients experiencing digoxin toxicity.
4. The complaint of a curtain coming across vision is a symptom of retinal detachment.

Question 2

2. The client is scheduled for right-eye cataract removal surgery in five (5) days. Which
   preoperative instruction should be discussed with the client?
3. Administer dilating drops to both eyes for 72 hours prior to surgery.
4. Prior to surgery do not lift or push any objects heavier than 15 pounds.
5. Make arrangements for being in the hospital for at least three (3) days.
6. Avoid taking any type of medication that causes bleeding, such as aspirin.

Answer 2

4

1. Dilating drops are administered every ten (10) minutes for four (4) doses one (1) hour prior to surgery, not for three (3) days prior to surgery.
2. Lifting and pushing objects should be avoided after surgery, not prior to surgery.
3. All types of cataract removal surgery are usually done in day surgery.
4. To reduce retrobulbar hemorrhage, any anticoagulation therapy is withheld, including
   aspirin, nonsteroidal anti inflammatory drugs (NSAIDs), and warfarin (Coumadin).

Question 3

4. The 65-year-old client is diagnosed with macular degeneration. Which statement by the nurse indicates the client needs more discharge teaching?
5. “I should use magnification devices as much as possible.”
6. “I will look at my Amsler grid at least twice a week.”
7. “I am going to use low-watt light bulbs in my house.”
8. “I am going to contact a low-vision center to evaluate my home.”

Answer 3

3

1. Magnifying devices used with activities such as
   threading a needle will help the client’s visual
   sight; therefore, this statement does not indicate
   the client needs more teaching.
2. An Amsler grid is a tool to assess macular degeneration that often provides the earliest sign of a worsening of the condition. If the lines of the grid become distorted or faded, the client should call the ophthalmologist.
3. Macular degeneration is the most common cause of visual loss in people older than age 60 years. Any intervention that can help increase vision should be included in the teaching such as bright lighting, not decreased
   lighting.
4. Low-vision centers will send representatives to the client’s home or work to make recommendations about improving lighting, thereby
   improving the client’s vision and safety.

Question 4

5. The nurse who is at a local park sees a young man on the ground and realizes he has
   fallen on a stick and it is lodged in his eye. Which action should the nurse implement at the scene?
6. Carefully remove the stick from the eye.
7. Stabilize the stick as best as possible.
8. Flush the eye with water if available.
9. Place the young man in a high-Fowler’s position.

Answer 4

2

1. A foreign object should never be removed at the scene of the accident because this may cause
   more damage.
2. The foreign object should be stabilized to prevent further movement that could cause
   more damage to the eye.
3. Flushing with water may cause further movement of the foreign object and should be avoided.
4. The person should be kept flat and not in a sitting position that may dislodge or cause movement of the foreign object.

Question 5

6. The employee health nurse is teaching a class on “Preventing Eye Injury.” Which information
should be discussed in the class?

1. Read instructions thoroughly before using tools and chemicals.
2. Wear some type of glasses when working around flying fragments.
3. Always wear a protective helmet with eye shield around dust particles.
4. Pay close attention to the surroundings so that eye injuries will be prevented.

Answer 5

1

1. Instructions provide precautions that should be used and steps to take if eye injuries occur secondary to the use of tools or chemicals.
2. The employee must wear safety glasses, not just any type of glasses and especially not regular prescription glasses.
3. A protective helmet is usually used to help pre-vent sports eye injuries, not work-related
   injuries.
4. Eye injuries will not be prevented by paying
   close attention to the surroundings. They are
   prevented by wearing protective glasses or eye
   shields.

Question 6

7. The 65-year-old male client who is complaining of blurred vision reports that he thinks
   his glasses need to be cleaned all the time. He denies any type of pain in his eyes. Based on these signs/symptoms, which eye disorder would the nurse suspect the client has?
8. Corneal dystrophy.
9. Conjunctivitis.
10. Diabetic retinopathy.
11. Cataracts.

Answer 6

4

1. Corneal dystrophy is an inherited eye disorder that occurs at about age 20 years and results in decreased vision and the development of blisters
   and is usually associated with primary open-angle glaucoma.
2. Conjunctivitis is an inflammation of the conjunctiva, which results in a scratching or
   burning sensation, itching, and photophobia.
3. Diabetic retinopathy results from deterioration of the small blood vessels that nourish the
   retina; it leads to blindness.
4. A cataract is a lens opacity or cloudiness, resulting in the signs/symptoms discussed
   in the stem.

Question 7

8. The nurse is administering eye drops to the client. Which guidelines should the nurse
   adhere to when instilling the drops into one eye? Select all that apply.
9. Do not touch the tip of the medication container to the eye.
10. Apply gently pressure on the outer canthus of the eye.
11. Apply sterile gloves prior to instilling eye drops.
12. Hold the lower lid down and instill drops into the conjunctiva.
13. Gently pat the skin to absorb excess eye drops that run onto the cheek.

Answer 7

1, 4

1. Touching the tip of the container to the eye could cause eye injury or an eye infection.
2. Gentle pressure should be applied on the inner canthus near the bridge of the nose for
   one (1) or two (2) minutes after instilling eye drops.
3. The nurse should wash hands prior to and after instilling medications; this is not a sterile procedure.
4. Medication should not be placed directly on the eye but in the lower part of the eye.
5. Eye drops are meant to go in the eye, not on the skin, so the nurse should use a clean tissue
   to remove excess medication.

Question 8

10. The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data support that the medication has been effective?
11. No redness or irritation of the eyes.
12. A decrease in intraocular pressure.
13. The pupil reacts briskly to light.
14. The client denies any type of floaters.

Answer 8

2

1. Steroid medication is administered to decrease inflammation.
2. Both systemic and topical medications are used to decrease the intraocular pressure in the eye, which is what causes glaucoma.
3. Glaucoma does not affect the pupillary reaction.
4. Floaters are a complaint of clients with retinal detachment.

Question 9

11. The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for
    severe myopia. Which discharge teaching should the nurse discuss prior to the client’s discharge from day surgery?
12. Wear bilateral eye patches for three (3) days.
13. Wear corrective lenses until the follow-up visit.
14. Do not read any material for at least one (1) week.
15. Teach the client how to instill corticosteroid ophthalmic drops.

Answer 9

4

1. The client does not have to wear eye patches after this surgery.
2. The purpose of this surgery is to ensure the client does not have to wear any type of corrective lens.
3. The client can read immediately after this surgery.
4. LASIK surgery is an effective, safe, predictable surgery that is performed in day surgery;
   there is minimal postoperative care, which includes instilling topical corticosteroid
   drops.

Question 10

12. The client is admitted to the emergency department after splashing chemicals into the
    eyes. Which intervention should the nurse implement first?
13. Have the client move the eyes in all directions.
14. Administer a broad-spectrum antibiotic.
15. Irrigate the eyes with normal saline solution.
16. Determine when the client had a tetanus shot.

Answer 10

3

1. Movement of the eye should be avoided until the client has received general anesthesia;
   therefore, this is not the first intervention that should be implemented.
2. Parenteral broad-spectrum antibiotics are initiated but not until the eyes are treated first.
3. Before any further evaluation or treatment, the eyes must be thoroughly flushed with sterile normal saline solution.
4. Tetanus prophylaxis is recommended for fullthickness
   ocular wounds.

Question 11

13. Which statement by the client would indicate that the client is experiencing some
    hearing loss?
14. “I clean my ears every day after I take a shower.”
15. “I keep turning up the sound on my television.”
16. “My ears hurt, especially when I yawn.”
17. “I get dizzy when I get up from the chair.”

Answer 11

2

1. Cleaning the ears daily does not indicate the client has a hearing loss.
2. The need to turn up the volume on the television is an early sign of hearing impairment.
3. Pain in the ears is not a clinical manifestation of hearing loss/impairment.
4. This statement may indicate a balance problem secondary to an ear disorder, but it does not
   indicate a hearing loss.

Question 12

14. Which factors increase the client’s risk of developing hearing loss? Select all that apply.
15. Perforation of the tympanic membrane.
16. Chronic exposure to loud noises.
17. Recurrent ear infections.
18. Use of nephrotoxic medications.
19. Multiple piercings in the auricle.

Answer 12

1, 2, 3

1. The tympanic membrane is the eardrum, and if it is punctured it may lead to hearing loss.
2. Loud persistent noise, such as that from heavy machinery, engines, and artillery, over time has been found to cause noiseinduced hearing loss.
3. Multiple ear infections scar the tympanic membrane, which can lead to hearing loss.
4. Nephrotoxic means harmful to the kidneys; ototoxic would be harmful to the ears.
5. Multiple pierced earrings do not lead to hearing loss. The auricle (skin attached to the head)
   is composed mainly of cartilage, except for the fat and subcutaneous tissue in the earlobe.

Question 13

18. The client reports to the nurse that there is a ringing in the ears. Which documentation
    would be most appropriate for the nurse to document in the client’s chart?
19. Complaints of vertigo.
20. Complaints of otorrhea.
21. Complaints of tinnitus.
22. Complaints of presbycusis.

Answer 13

3

1. Vertigo is an illusion of movement in which the client complains of dizziness.
2. Otorrhea is drainage of the ear.
3. Tinnitus is “ringing of the ears.” It is a subjective perception of sound with internal
   origins.
4. Presbycusis is progressive hearing loss associated
   with aging.

Question 14

19. Which statement best describes the scientific rationale for the nurse to hold the
    otoscope in the right hand in a pencil-hold position when examining the client’s ear?
20. It is usually the most comfortable position to hold the otoscope.
21. This allows the best visualization of the tympanic membrane.
22. This prevents inserting the otoscope too far into the external ear.
23. It ensures that the nurse will not cause pain when examining the ear.

Answer 14

3

1. This is not the rationale for holding the otoscope in this manner.
2. Holding the otoscope in this manner does not help visualize the membrane any better than
   does holding the otoscope in other ways.
3. Inserting the speculum of the otoscope into the external ear can cause ear trauma if not
   done correctly.
4. If the ear is inflamed, it may be impossible to prevent hurting the client on examination.

Question 15

20. The nurse is preparing to administer otic drops into an adult client’s right ear. Which
    action should the nurse implement?
21. Grasp the ear lobe and pull back and out when putting drops in the ear.
22. Insert the eardrops without touching the outside of the ear.
23. Instruct the client to close the mouth and blow prior to instilling drops.
24. Pull the auricle down and back prior to instilling drops.

Answer 15

4

1. This is not the correct way to administer eardrops.
2. The nurse must straighten the ear canal; therefore the outside of the ear must be moved.
3. This will increase pressure in the ear and should not be done prior to administering
   eardrops.
4. This will straighten the ear canal so that the eardrops will enter the ear canal and drain
   toward the tympanic membrane (eardrum).

Question 16

21. Which ototoxic medication should the nurse administer cautiously?
22. An oral calcium-channel blocker.
23. An intravenous aminoglycoside antibiotic.
24. An intravenous glucocorticoid.
25. An oral loop diuretic.

Answer 16

2

1. Calcium channel blockers are not going to affect the client’s hearing.
2. Aminoglycoside antibiotics are ototoxic. Overdosage of these medications can cause
   the client to go deaf, which is why peak and trough serum levels are drawn while the
   client is taking a medication of this type. These antibiotics are also very nephrotoxic.
3. Steroids cause many adverse effects, but damage to the ear is not one of them.
4. Administering an intravenous push loop diuretic too fast can cause auditory nerve damage,
   but an oral loop diuretic does not.

Question 17

22. Which teaching instruction should the nurse discuss with students who are on the high
    school swim team when discussing how to prevent external otitis?
23. Do not wear tight-fitting swim caps.
24. Avoid using silicone earplugs while swimming.
25. Use a drying agent in the ear after swimming.
26. Insert a bulb syringe into each ear to remove excess water.

Answer 17

3

1. Tight-fitting swim caps or wet suit hoods should be worn because they prevent water
   from entering the ear canal.
2. Silicone earplugs should be worn because they keep water from entering the ear canal without reducing hearing significantly.
3. A 2% acetic acid solution or 2% boric acid in ethyl alcohol is effective in drying the canal and restoring its normal acidic environment.
4. A bulb syringe with a Teflon catheter can be used to remove impacted debris from the ear,
   but it is not used to remove excess water.

Question 18

24. The client is scheduled for ear surgery. Which statement indicates the client needs
    more preoperative teaching concerning the surgery?
25. “If I have to sneeze or blow my nose, I will do it with my mouth open.”
26. “I may get dizzy after the surgery, so I must be careful when walking.”
27. “I will probably have some hearing loss after surgery, but hearing will return.”
28. “I can shampoo my hair the day after surgery as long as I am careful.”

Answer 18

4

1. Leaving the mouth open when coughing or sneezing will minimize the pressure changes in
   the middle ear.
2. Surgery on the ear may disrupt the client’s equilibrium, increasing the risk for falling.
3. Hearing loss secondary to postoperative edema is common after surgery, but the hearing will
   return after the edema subsides.
4. Shampooing, showering, and immersing the head in water are avoided to prevent contamination of the ear canal; therefore,
   this comment indicates the client does not understand the preoperative teaching.

Question 19

1. Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?
2. Suggest installing multiple smoke alarms in the home.
3. Recommend using a night light in the hallway and bathroom.
4. Discuss keeping a high-humidity atmosphere in the bedroom.
5. Encourage the client to smell food prior to eating it.

Answer 19

1

1. The decreased sense of smell resulting from atrophy of olfactory organs is a safety
   hazard and clients may not be able to smell gas leaks or fire, so the nurse should recommend
   a carbon monoxide detector and
   a smoke alarm. This safety equipment is critical for the elderly.
2. Night lights do not address the client’s sense of smell.
3. High humidity may help with breathing, but it does not help the sense of smell.
4. The client’s sense of smell is decreased; therefore, smelling food before eating is not an
   appropriate intervention.

Question 20

2. The elderly male client tells the nurse, “My wife says her cooking hasn’t changed, but it is bland and tasteless.” Which response by the nurse would be most appropriate?
3. “Would you like me to talk to your wife about her cooking?”
4. “Taste buds change with age, which may be why the food seems bland.”
5. “This happens because the medications sometimes cause a change in taste.”
6. “Why don’t you barbecue food on a grill if you don’t like your wife’s cooking?”

Answer 20

2

1. The nurse needs to discuss possible causes with the client and not talk to the wife.
2. The acuity of the taste buds decreases with age, which could cause regular foods to seem bland and tasteless.
3. Some medications may cause a metallic taste in the mouth, but medication would not cause
   foods to taste bland.
4. Telling the client to cook if he doesn’t like his wife’s food is an argumentative and judgmental
   response.

Question 21

3. The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?
4. Ensure the client’s room temperature is cool.
5. Talk louder to make sure the client hears clearly.
6. Complete the admission as fast as possible.
7. Provide extra orientation to the surroundings.

Answer 21

4

1. Because of altered temperature regulation, the client usually needs a warmer room temperature, not a cooler room temperature.
2. The nurse should use a low-pitched, normal level, clear voice. Talking louder or shouting
   only makes it harder for the client to understand the nurse.
3. The elderly client requires adequate time to receive and respond to stimuli, to learn, and to react; therefore the nurse should take time and
   not rush the admission.
4. Sensory isolation resulting from visual and hearing loss can cause confusion, anxiety, disorientation, and misinterpretation of the
   new environment; therefore, the nurse should provide extra orientation.

Question 22

4. Which assessment technique would be indicated when assessing the client’s cranial
   nerves for vibration?
5. Move the big toe up and down and ask in which direction the vibration is felt.
6. Place a tuning fork on the big toe and ask if the vibrations are felt.
7. Tap the client’s cheek with the finger and determine if vibrations are felt.
8. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.

Answer 22

2

1. This assesses proprioception, or position sense; direction of the toe must be evaluated.
2. Vibration is assessed by using a lowfrequency tuning fork on a bony prominence
   and asking the client whether he or she feels the sensation and, if so, when the sensation ceases.
3. Tapping the cheek assesses for tetany, not cranial nerve involvement.
4. A two-point discrimination test evaluates integration of sensation, but it does not assess for vibration.

Question 23

5. Which intervention should the nurse include when conducting an in-service on caring for elderly clients that addresses normal developmental sensory changes?
6. Ensure curtains are open when having the client read written material.
7. Provide a variety of written material when discussing a procedure.
8. Assist the client when getting out of the bed and sitting in the chair.
9. Request a telephone for the hearing impaired for all elderly clients.

Answer 23

3

1. Adequate lighting without a glare should be provided when having the client read written
   material; therefore, the curtains should be closed, not open.
2. The nurse should provide material that is short, concise, and concrete, not a variety.
3. Because fewer tactile cues are received from the bottom of the feet, the client may get confused as to body position and location.
   Safety is priority and assisting the client getting out of bed and sitting in a chair is appropriate.
4. This is making a judgment. Not all elderly clients are hard of hearing, and telephones for
   the hearing impaired require special training for the user.

Question 24

6. Which situation would make the nurse think the client has glaucoma?
7. An automobile accident because the client not seeing the car in the next lane.
8. The cake tasted funny because the client could not read the recipe.
9. The client has been wearing mismatched clothes and socks.
10. The client ran a stoplight and hit a pedestrian walking in the crosswalk.

Answer 24

1

1. Loss of peripheral vision as a result of glaucoma causes the client problems with seeing things on each side, resulting in a
   “blind spot.” This problem can lead to the client having car accidents when switching
   lanes.
2. This would be indicative of cataracts because clients with cataracts have blurred vision and
   cannot read clearly.
3. This would be indicative of cataracts because there is a color shift to yellow–brown and there
   is reduced light transmission.
4. This would be indicative of macular degeneration, in which the central vision is affected.

Question 25

8. The nurse is conducting a Weber test on the client who is suspected of having conductive
   hearing loss in the left ear. Where should the nurse place the tuning fork when conducting this test?
9. A
10. B
11. C
12. D

Answer 25

1

1. The tuning fork should be struck to produce vibrations and then placed midline between the ears on top of the head.
2. The right temple area is not an appropriate place to assess for conductive hearing
   loss.
3. The right occipital area is not the appropriate place to place the tuning fork; this is the area
   behind the ear where the Rinne test is performed.
4. The chin area is not the appropriate area to put
   the tuning fork.

Question 26

9. The student nurse asks the nurse, “Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?” Which statement is the best response of the nurse?
10. “It is called conductive hearing loss.”
11. “It is called a functional hearing loss.”
12. “It is called a mixed hearing loss.”
13. “It is called sensorineural hearing loss.”

Answer 26

4

1. Conductive hearing loss results from an external ear disorder, such as impacted cerumen, or
   a middle ear disorder, such as otitis media or otosclerosis.
2. Functional (psychogenic) hearing loss is nonorganic and unrelated to detectable structural
   changes in the hearing mechanisms. It is usually a manifestation of an emotional disturbance.
3. Mixed hearing loss involves both conductive loss and sensorineural loss. It results from dysfunction of air and bone conduction.
4. Sensorineural hearing loss is described in the stem of the question. It involves damage
   to the cochlea or vestibulocochlear nerve.

Question 27

11. The female client tells the clinic nurse that she is going on a seven (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss
    with the client?
12. Make an appointment for the client to see the health-care provider.
13. Recommend getting an over-the-counter scopolamine patch.
14. Discourage the client from taking the trip because she is worried.
15. Instruct the client to lie down and the motion sickness will go away.

Answer 27

2

1. This is not a condition that requires an appointment
   with the health-care provider.
2. Anticholinergic medications, such as scopolamine
   patches, can be recommended by the nurse; this is not prescribing. Motion
   sickness is a disturbance of equilibrium caused by constant motion.
3. Motion sickness can be controlled with medication
   and it may not even occur. Therefore, canceling the trip is not providing the client
   with appropriate information.
4. This is providing the client with false information. Lying down may or may not help motion
   sickness. To be able to enjoy the cruise, the client needs medication.

Question 28

12. The nurse writes the diagnosis “risk for trauma related to impaired balance” for the
    client diagnosed with vertigo. Which nursing intervention should be included in the
    plan of care?
13. Provide information about vertigo and its treatment.
14. Assess for level and type of diversional activity.
15. Assess for visual acuity and proprioceptive deficits.
16. Refer the client to a support group and counseling.

Answer 28

3

1. This would be appropriate for a diagnosis of “knowledge deficit.”
2. This would be appropriate for a diagnosis of “deficient diversional activity” related to environmental
   lack of activity.
3. Balance depends on visual, vestibular, and proprioceptive systems; therefore the nurse
   should assess these systems for signs/symptoms.
4. This would be appropriate for a diagnosis “ineffective coping.”

Question 29

13. The nurse is assessing the client’s cranial nerves. Which assessment data indicate that
    cranial nerve I is intact?
14. The client can identify cold and hot on the face.
15. The client does not have any tongue tremor.
16. The client has no ptosis of the eyelids.
17. The client is able to identify a peppermint smell.

Answer 29

4

1. Being able to identify cold and hot on the face indicates an intact trigeminal nerve, cranial
   nerve V.
2. Not having any tongue tremor indicates an intact hypoglossal nerve, cranial nerve XI.
3. No ptosis of the eyelids indicates an intact oculomotor nerve (cranial nerve III), trochlear
   nerve (IV), and abducens nerve (VI). Tests also assess for ocular motion, conjugate movements,
   nystagmus, and papillary reflexes.
4. Cranial nerve I is the olfactory nerve, which involves the sense of smell. With the eyes closed the client must identify familiar
   smells to indicate an intact cranial nerve I.

Question 30

14. The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client’s perception of pain?
15. Elderly clients react to pain the same way any other age group does.
16. The elderly client usually requires more pain medication.
17. Reaction to painful stimuli may be decreased with age.
18. The elderly client should use the Wong scale to assess pain.

Answer 30

3

1. This is an inaccurate statement.
2. The elderly client usually requires less pain medication because of the effects of the normal aging process of the liver (metabolism) and renal (excretion) system.
3. Decreased reaction to painful stimuli is a normal developmental change; therefore, complaints of pain may be more serious
   than the client’s perception might indicate and thus such complaints require careful evaluation.
4. The Wong scale is used to assess pain for the pediatric client, not the adult client.

Question 31

15. During a sensory assessment, which instruction should the nurse discuss with the
    client?
16. Instruct the client to lie flat without a pillow during the assessment.
17. Instruct the client to keep both eyes shut during the assessment.
18. During the assessment the client must be in a treatment room.
19. Keep the lights off during the client’s sensory assessment.

Answer 31

2

1. The client should be in the sitting position during a sensory assessment.
2. The eyes are closed so that tactile, superficial pain, vibration, and position sense
   (proprioception) can be assessed without the client seeing what the nurse is doing.
3. The sensory assessment can be conducted at the bedside; there is no reason to take the
   client to the treatment room.
4. There is no reason the lights should be off during the sensory assessment; the client should
   close his or her eyes.

Question 32

17. Which assessment technique should the nurse use to assess the client’s optic nerve?
18. Have the client identify different smells.
19. Have the client discriminate between sugar and salt.
20. Have the client read the Snellen chart.
21. Have the client say “ah” to assess the rise of the uvula.

Answer 32

3

1. This assesses cranial nerve I, the olfactory nerve.
2. This assesses cranial nerve IX, the glossopharyngeal nerve.
3. This assesses cranial nerve II, the optic nerve, along with visual field testing and ophthalmoscopic examination.
4. This assesses cranial nerve X, the vagus nerve.

Question 33

18. Which referral would be most important for the client with permanent hearing loss?
19. Aural rehabilitation.
20. Speech therapist.
21. Social worker.
22. Vocational rehabilitation.

Answer 33

1

1. The purpose of aural rehabilitation is to maximize the communication skills of the
   client who is hearing impaired. It includes auditory training, speech reading, speech training, and the use of hearing aids and hearing guide dogs.
2. A speech therapist may be part of the aural rehabilitation team, but the most important referral is aural rehabilitation.
3. The client may or may not need financial assistance,
   but the most important referral is aural rehabilitation.
4. The client may or may not need assistance with employment because of hearing loss, but the most important referral is the aural rehabilitation.

Question 34

19. Which instruction should the nurse discuss with the female client with viral conjunctivitis?
20. Contact the HCP if pain occurs.
21. Do not share towels or linens.
22. Apply warm compresses to the eyes.
23. Apply makeup very lightly.

Answer 34

2

1. The client should be aware that eye pain (a sandy sensation and sensitivity to light) will
   occur with conjunctivitis.
2. Viral conjunctivitis is a highly contagious eye infection. It is easily spread from one
   person to another; therefore the client should not share personal items.
3. Cold compresses should be placed over the eyes for about ten (10) minutes four (4) to five
   (5) times a day to soothe the pain.
4. The client must not apply any makeup until the disease is over and should discard all old
   makeup to help prevent reinfection.

Question 35

20. The client is two (2) hours postoperative right-ear mastoidectomy. Which assessment data should be reported to the health-care provider?
21. Complaints of aural fullness.
22. Hearing loss in the affected ear.
23. No vertigo.
24. Facial drooping.

Answer 35

4

1. Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle
   ear. This is an expected occurrence after surgery, and the nurse should administer the
   prescribed analgesic.
2. Hearing in the operated ear may be reduced for several weeks because of edema, accumulation of blood and tissue fluid in the middle ear, and dressings or packing, so this would not be reported to the health-care provider.
3. Vertigo (dizziness) is uncommon after this surgery, but if it occurs the nurse should
   administer an antiemetic or antivertigo medication
   and does not need to report it to the health-care provider.
4. The facial nerve, which runs through the middle ear and mastoid, is at risk for injury
   during mastoid surgery; therefore, a facial paresis should be reported to the healthcare
   provider.

Question 36

21. Which behavior by the male client would make the nurse suspect the client has a hearing
    loss? Select all that apply.
22. The client reports hearing voices in his head.
23. The client becomes irritable very easily.
24. The client has difficulty making decisions.
25. The client’s wife reports that he ignores her.
26. The client does not dominate a conversation.

Answer 36

2, 3, 4

1. Voices in the head may indicate schizophrenia, but it is not a symptom of hearing loss.
2. Fatigue may be the result of straining to hear and a client may tire easily when listening to a conversation. Under these
   circumstances, the client may become irritable very easily.
3. Loss of self-confidence makes it increasingly difficult for a person who is hearing
   impaired to make a decision.
4. Often it is not the person with the hearing loss, but a significant other, that notices hearing loss; hearing loss is usually gradual.
5. Many clients who are hearing impaired tend to dominate the conversation because, as long as
   it is centered on the client, they can control it and are not as likely to be embarrassed by some
   mistake.

Question 37

22. The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
23. Do not push or pull objects heavier than 50 pounds.
24. Lie on the affected eye with two pillows at night.
25. Wear glasses or metal eye shields at all times.
26. Bend and stoop carefully for the rest of your life.

Answer 37

3

1. The client should not lift, push, or pull objects heavier than 15 pounds; 50 pounds is excessive.
2. The client should avoid lying on the side of the affected eye at night.
3. The eyes must be protected by wearing glasses or metal eye shields at all times following
   surgery. Very few answer options
   with “all” will be correct, but if the option involves ensuring safety, it may be the correct option.
4. The client should avoid bending or stooping for an extended period—but not forever.

Question 38

24. Which statement by the daughter of an 80-year-old female client who lives alone
    would warrant immediate intervention by the nurse?
25. “I put a night light in my mother’s bedroom.”
26. “There are smoke alarms in every room.”
27. “I changed my mother’s furniture around.”
28. “I got my mother large-print books.”

Answer 38

1. With normal aging comes decreased peripheral
   vision, constricted visual field, and tactile alterations. A night light addresses safety issues and would warrant praise, not intervention.
2. As a result of normal aging of the olfactory sense, the client may not smell fire, so smoke
   alarms address safety for the client and would warrant praise.
3. Decreased peripheral vision, constricted visual fields, and tactile alterations are associated
   with normal aging. The client needs a familiar arrangement of furniture for safety. Moving the furniture may cause the client to trip or fall. The nurse should intervene in this situation.
4. As a result of normal aging, vision may become impaired, and the provision of large print
   books warrants praise.

Question 39

25. The 72-year-old client tells the nurse that food does not taste good anymore and that
    he has lost a little weight. Which information should the nurse discuss with the client?
26. Suggest using extra seasoning when cooking.
27. Instruct the client to keep a seven (7)-day food diary.
28. Refer the client to a dietitian immediately.
29. Recommend eating three meals a day.

Answer 39

1

1. The acuity of taste buds decreases with age, which may cause a decreased appetite and
   subsequent weight loss. Extra seasoning may help the food taste better to the client.
2. This may be an appropriate intervention if excessive weight is lost or if seasoning the food
   does not increase appetite, but it is not necessary at this time.
3. The client does not need a dietary consult for food not tasting good. The nurse can address the client’s concern.
4. This recommendation does not address the client’s comment about food not tasting good.

Question 40

26. The male client diagnosed with Type 2 diabetes mellitus tells the nurse that he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.
27. Notify the health-care provider.
28. Check the client’s hemoglobin A1c.
29. Assess the client’s vision using the Amsler grid.
30. Teach the client about controlling blood glucose levels.
31. Determine where the spots appear to be in the client’s field of vision.

Answer 40

In order of priority: 5, 3, 2, 1, 4

5. The nurse should question the client further to obtain information such as which
   eye is affected, how long the client been seeing the spots, and whether this ever occurred before.
6. The Amsler grid is helpful in determining losses occurring in the visual fields.
7. The hemoglobin A13 laboratory tests results indicate glucose control over the
   past two (2) to three (3) months. Diabetic retinopathy is directly related to poor blood glucose control.
8. The health-care provider should be notified to plan for laser surgery on the eye.
9. The client should be instructed about controlling blood glucose levels, but this can wait until the immediate situation is resolved or at least until measures to
   address the potential loss of eyesight have been taken.

Question 41

Cerebrovascular Accident (Stroke)

Answer 41

*

Question 42

1. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
2. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
3. Discuss the precipitating factors that caused the symptoms.
4. Schedule for a STAT computed tomography (CT) scan of head.
5. Notify the speech pathologist for an emergency consult.

Answer 42

3

A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it
is a hemorrhagic or ischemic accident and guide treatment.

Question 43

2. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?
3. Hemiparesis of the client’s left arm and apraxia.
4. Paralysis of the right side of the body and ataxia.
5. Homonymous hemianopsia and diplopia.
6. Impulsive behavior and hostility toward family.

Answer 43

2

The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate
movement.

Question 44

3. Which client would the nurse identify as being most at risk for experiencing a CVA?
4. A 55-year-old African American male.
5. An 84-year-old Japanese female.
6. A 67-year-old Caucasian male.
7. A 39-year-old pregnant female.

Answer 44

1

African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.

Question 45

4. The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
5. Position the client to prevent shoulder adduction.
6. Turn and reposition the client every shift.
7. Encourage the client to move the affected side.
8. Perform quadriceps exercises three (3) times a day.
9. Instruct the client to hold the fingers in a fist.

Answer 45

1, 3

1. Placing a small pillow under the shoulderwill prevent the shoulder from adducting toward the chest and developing a contracture.
2. The client should be repositioned at least every two (2) hours to prevent contractures, pneumonia, skin breakdown, and other complications
   of immobility.
3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.
4. These exercises are recommended, but they must be done at least five (5) times a day for ten (10) minutes to help strengthen the muscles for walking.
5. The fingers are positioned so that they are barely flexed to help prevent contracture of the hand.

Question 46

5. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
6. Observing the client swallowing for possible aspiration.
7. Positioning the client in a semi-Fowler’s position when sleeping.
8. Placing a suction set-up at the client’s bedside during meals.
9. Referring the client to an occupational therapist for evaluation.

Answer 46

4

A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy— is used in the care of the client.

Question 47

6. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with rightsided paralysis. Which action by the UAP requires the nurse to intervene?
7. The assistant places a gait belt around the client’s waist prior to ambulating.
8. The assistant places the client on the back with the client’s head to the side.
9. The assistant places her hand under the client’s right axilla to help him/her move up
   in bed.
10. The assistant praises the client for attempting to perform ADLs independently.

Answer 47

3

This action is inappropriate and would
require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

Question 48

7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on
   discharge?
8. An oral anticoagulant medication.
9. A beta-blocker medication.
10. An anti-hyperuricemic medication.
11. A thrombolytic medication.

Answer 48

1

The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation.
The thrombi can become embolic and may cause a TIA or CVA (stroke).

Question 49

8. The client has been diagnosed with a cerebrovascular accident (stroke). The client’s wife
   is concerned about her husband’s generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
9. Obtain a rubber mat to place under the dinner plate.
10. Purchase a long-handled bath sponge for showering.
11. Purchase clothes with Velcro closure devices.
12. Obtain a raised toilet seat for the client’s bathroom.

Answer 49

4

Raising the toilet seat is modifying the home and addresses the client’s weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

Question 50

9. The client is diagnosed with expressive aphasia. Which psychosocial client problem
   would the nurse include in the plan of care?
10. Potential for injury.
11. Powerlessness.
12. Disturbed thought processes.
13. Sexual dysfunction.

Answer 50

2

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

Question 51

10. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
11. A blood glucose level of 480 mg/dL.
12. A right-sided carotid bruit.
13. A blood pressure of 220/120 mm Hg.
14. The presence of bronchogenic carcinoma.

Answer 51

3

Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

Question 52

11. The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
12. Administer a nonnarcotic analgesic.
13. Prepare for STAT magnetic resonance imaging (MRI).
14. Start an intravenous line with D5W at 100 mL/hr.
15. Complete a neurological assessment.

Answer 52

4

The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further
action.

Question 53

12. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
13. Administer a stool softener BID.
14. Encourage the client to cough hourly.
15. Monitor neurological status every shift.
16. Maintain the dopamine drip to keep BP at 160/90.

Answer 53

1

The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when
straining during defecation. Therefore stool softeners would be appropriate.

Question 54

13. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client’s significant
    other?
14. Awaken the client every two (2) hours.
15. Monitor for increased intracranial pressure.
16. Observe frequently for hypervigilance.
17. Offer the client food every three (3) to four (4) hours.

Answer 54

1

Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety—all
signs of post-concussion syndrome—that would warrant the significant other’s taking the client back to the emergency department.

Question 55

14. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips™. Which signs/symptoms would warrant transferring the resident to the emergency department?
15. A 4-cm area of bright red drainage on the dressing.
16. A weak pulse, shallow respirations, and cool pale skin.
17. Pupils that are equal, react to light, and accommodate.
18. Complaints of a headache that resolves with medication.

Answer 55

2

These signs/symptoms—weak pulse, shallow respirations, cool pale skin—indicate increased intracranial pressure from cerebral edema secondary to the fall, and they
require immediate attention.

Question 56

15. The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report?
16. The 22-year-old male client diagnosed with a concussion who is complaining someone
    is waking him up every two (2) hours.
17. The 36-year-old female client admitted with complaints of left-sided weakness who
    is scheduled for a magnetic resonance imaging (MRI) scan.
18. The 45-year-old client admitted with blunt trauma to the head after a motorcycle
    accident who has a Glasgow Coma Scale score of 6.
19. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has
    expressive aphasia.

Answer 56

3

The Glasgow Coma Scale is used to determine a client’s response to stimuli (eyeopening response, best verbal response, and best motor response) secondary to a
neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse.

Question 57

16. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is “brain dead.” Which data support that the client is brain dead?
17. When the client’s head is turned to the right, the eyes turn to the right.
18. The electroencephalogram (EEG) has identifiable waveforms.
19. There is no eye activity when the cold caloric test is performed.
20. The client assumes decorticate posturing when painful stimuli are applied.

Answer 57

3

The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client’s eyes moved, that would indicate that the brain
stem is intact.

Question 58

17. The client is admitted to the medical floor with a diagnosis of closed head injury.
    Which nursing intervention has priority?
18. Assess neurological status.
19. Monitor pulse, respiration, and blood pressure.
20. Initiate an intravenous access.
21. Maintain an adequate airway.

Answer 58

4

The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.

Question 59

18. The client diagnosed with a closed head injury is admitted to the rehabilitation department.
    Which medication order would the nurse question?
19. A subcutaneous anticoagulant.
20. An intravenous osmotic diuretic.
21. An oral anticonvulsant.
22. An oral proton pump inhibitor.

Answer 59

2

An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation
unit.

Question 60

19. The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?
20. Purposeless movement in response to painful stimuli.
21. Flaccid paralysis in all four extremities.
22. Decerebrate posturing when painful stimuli are applied.
23. Pupils that are 6 mm in size and nonreactive on painful stimuli.

Answer 60

1

Purposeless movement indicates that the client’s cerebral edema is decreasing. The best motor response is purposeful movement,
but purposeless movement indicates
an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

Question 61

20. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
21. Maintain the head of the bed at 60 degrees of elevation.
22. Administer stool softeners daily.
23. Ensure that pulse oximeter reading is higher than 93%.
24. Perform deep nasal suction every two (2) hours.
25. Administer mild sedatives.

Answer 61

2, 3, 5

2) Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial
pressure

3) Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema.
5) Mild sedatives will reduce the client’s agitation; strong narcotics would not be administered because they decrease the client’s level of consciousness.

Question 62

21. The client with a closed head injury has clear fluid draining from the nose. Whichaction should the nurse implement first?
22. Notify the health-care provider immediately.
23. Prepare to administer an antihistamine.
24. Test the drainage for presence of glucose.
25. Place 2 ! 2 gauze under the nose to collect drainage.

Answer 62

3

The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid and the HCP should be notified immediately once this is determined.

Question 63

22. The nurse is enjoying a day out at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
23. Assess the client’s level of consciousness.
24. Organize onlookers to remove the client from the lake.
25. Perform a head-to-toe assessment to determine injuries.
26. Stabilize the client’s cervical spine.

Answer 63

4

The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord
and cause paralysis; therefore, the nurse should stabilize the cervical spinal cord as best as possible prior to removing the client from the water.

Question 64

23. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care?
24. Position the client with the head of the bed elevated at intervals.
25. Perform active range of motion exercises every four (4) hours.
26. Turn the client every shift and massage bony prominences.
27. Explain all procedures to the client before performing them.

Answer 64

1

The head of the client’s bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.

Question 65

24. The 29-year-old client that was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
25. The client will return to work within six (6) months.
26. The client is able to focus and stay on task for ten (10) minutes.
27. The client will be able to dress self without assistance.
28. The client will regain bowel and bladder control.

Answer 65

2

Cognitive pertains to mental processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal
would be for the client to stay on task for 10 minutes.

Question 66

37. The male client is sitting in the chair and his 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?
38. Push aside any furniture.
39. Place the client on his side
40. Assess the client’s vital signs.
41. Ease the client to the floor.

Answer 66

4

The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.

Question 67

38. The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement?
39. Ensure that helmets are worn in appropriate areas.
40. Implement daily exercise programs for the staff.
41. Provide healthy foods in the cafeteria.
42. Encourage employees to wear safety glasses.

Answer 67

1

Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway
safety programs.

Question 68

39. The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?
40. Tell the client to take any routine anti-seizure medication prior to the EEG.
41. Tell the client not to eat anything for eight (8) hours prior to the procedure.
42. Instruct the client to stay awake 24 hours prior to the EEG.
43. Explain to the client that there will be some discomfort during the procedure.

Answer 68

3

The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating,
or flashing lights may induce a
seizure.

Question 69

40. The nurse enters the room as the client is beginning to have a tonic-clonic seizure.What action should the nurse implement first?
41. Note the first thing the client does in the seizure.
42. Assess the size of the client’s pupils.
43. Determine if the client is incontinent of urine or stool.
44. Provide the client with privacy during the seizure.

Answer 69

1

Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the
brain. It is important to document whether the beginning of the seizure was observed.

Question 70

41. The client that just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
42. Perform a complete neurological assessment.
43. Awaken the client every 30 minutes.
44. Turn the client to the side and allow him to sleep.
45. Interview the client to find out what caused the seizure.

Answer 70

3

During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.

Question 71

42. The unlicensed nursing assistant is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?
43. Help the assistant to insert the oral airway in the mouth.
44. Tell the assistant to stop trying to insert anything in the mouth.
45. Take no action because the assistant is handling the situation.
46. Notify the charge nurse of the situation immediately.

Answer 71

2

The nurse should tell the assistant to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may
result from trying to put anything in the clenched jaws of a client having a grand mal seizure.

Question 72

43. The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder.Which statement indicates the client understands the discharge teaching concerning this medication?
44. “I will brush my teeth after every meal.”
45. “I will check my Dilantin level daily.”
46. “My urine will turn orange while on Dilantin.”
47. “I won’t have any seizures while on this medication.”

Answer 72

1

Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common
occurrence in clients taking Dilantin.

Question 73

44. The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
45. Assess the client’s neurological status every hour.
46. Monitor the client’s heart rhythm via telemetry.
47. Administer an anticonvulsant medication intravenous push.
48. Prepare to administer a glucocorticosteroid orally.

Answer 73

3

Administering an anticonvulsant medication intravenous push requires the nurse to have an order or confer with another member
of the health-care team.

Question 74

45. The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.
46. Keep a record of seizure activity.
47. Take tub baths only; do not take showers.
48. Avoid over-the-counter medications.
49. Have anticonvulsant medication serum levels checked regularly.
50. Do not drive alone; have someone in the car.

Answer 74

1, 3, 4

1. Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with the health-care provider and in identifying activities that may
   trigger a seizure.
2. Over-the-counter medications may contain ingredients that will interact with antiseizure medications or, in some cases, as with use of stimulants, possibly cause a
   seizure.
3. Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct
   level.

Question 75

46. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?
47. “It is all right for me to drink coffee for breakfast.”
48. “My menstrual cycle will not affect my seizure disorder.”
49. “I am going to take a class in stress management.”
50. “I should wear dark glasses when I am out in the sun.”

Answer 75

3

Tension states, such as anxiety and frustration, induce seizures in some clients so stress management may be helpful in preventing seizures.

Question 76

47. The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, “I don’t know what you mean. What are auras?” Which statement by the nurse would be the best response?
48. “Some people have a warning that the seizure is about to start.”
49. “Auras occur when you are physically and psychologically exhausted.”
50. “You’re concerned that you do not have auras before your seizures?”
51. “Auras usually cause you to be sleepy after you have a seizure.”

Answer 76

1

An aura is a visual, auditory, or olfactory
occurrence that takes place prior to a
seizure and warns the client a seizure is
about to occur. The aura often allows time
for the client to lie down on the floor or
find a safe place to have the seizure.

Question 77

48. The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly?
49. Alzheimer’s disease.
50. Parkinson’s disease.
51. Cerebral vascular accident (stroke).
52. Brain atrophy due to aging.

Answer 77

3

A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures.

Question 78

73. The client diagnosed with Parkinson’s disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain this assessment data?
74. Masklike facies and shuffling gait.
75. Difficulty swallowing and immobility.
76. Pill rolling of fingers and flat affect.
77. Lack of arm swing and bradykinesia.

Answer 78

2

Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications.

Question 79

74. The client diagnosed with PD is being discharged on Sinemet, carbidopa/levodopa, an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?
75. There will be fewer side effects with this combination than with carbidopa alone.
76. Dopamine D requires the presence of both of these medications to work.
77. Carbidopa makes more levodopa available to the brain.
78. Carbidopa crosses the blood–brain barrier to treat Parkinson’s disease.

Answer 79

3

Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Sinemet
is the most effective treatment for PD.

Question 80

75. The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of “impaired nutrition.” Which nursing intervention would be included in the plan of care?
76. Consult the occupational therapist for adaptive appliances for eating.
77. Request a low-fat, low-sodium diet from the dietary department.
78. Provide three meals per day that include nuts and whole-grain breads.
79. Offer six meals per day with a soft consistency.

Answer 80

4

The client’s energy levels will not sustain eating for long periods. Offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan.

Question 81

76. The nurse and the unlicensed nursing assistant are caring for clients on a medicalsurgical unit. Which task should not be assigned to the assistant?
77. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty
    swallowing.
78. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary
    to Parkinson’s disease.
79. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training
    activities.
80. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to
    Parkinson’s disease.

Answer 81

1

The nurse should not delegate feeding a client that is at risk for complications during feeding. This requires judgment that the assistant is not expected to possess.

Question 82

77. The charge nurse is making assignments. Which client should be assigned to the new graduate nurse?
78. The client diagnosed with aseptic meningitis who is complaining of a headache and
    the light bothering his eyes.
79. The client diagnosed with Parkinson’s disease who fell during the night and is
    complaining of difficulty walking.
80. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R
    14, and BP 198/68.
81. The client diagnosed with a brain tumor who has a new complaint of seeing spots
    before the eyes.

Answer 82

1

Headache and photophobia are expected clinical manifestations of meningitis. The new graduate could care for this client.

Question 83

78. The nurse is planning the care for a client diagnosed with Parkinson’s disease. Which would be a therapeutic goal of treatment for the disease process?
79. The client will experience periods of akinesia throughout the day.
80. The client will take the prescribed medications correctly.
81. The client will be able to enjoy a family outing with the spouse.
82. The client will be able to carry out activities of daily living.

Answer 83

4

The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing
routine daily tasks.

Question 84

79. The nurse researcher is working with clients diagnosed with Parkinson’s disease. Which is an example of an experimental therapy?
80. Sterotactic pallidotomy/thalamotomy.
81. Dopamine receptor agonist medication.
82. Physical therapy for muscle strengthening.
83. Fetal tissue transplantation.

Answer 84

4

Fetal tissue transplantation has shown some success in PD, but it is an experimental and highly controversial procedure.

Question 85

80. The client diagnosed with Parkinson’s disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions?
81. “All of my spouse’s emotions will slow down now just like his body movements.”
82. “My spouse may experience hallucinations until the medication starts working.”
83. “I will schedule appointments late in the morning after his morning bath.”
84. “It is fine if we don’t follow a strict medication schedule on weekends.”

Answer 85

3

Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits.

Question 86

81. The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
82. Crackles in the upper lung fields and jugular vein distention.
83. Muscle weakness in the upper extremities and ptosis.
84. Exaggerated arm swinging and scanning speech.
85. Masklike facies and a shuffling gait.

Answer 86

4

Masklike facies and a shuffling gait are two clinical manifestations of PD.

Question 87

82. Which is a common cognitive problem associated with Parkinson’s disease?
83. Emotional lability.
84. Depression.
85. Memory deficits.
86. Paranoia.

Answer 87

3

Memory deficits are cognitive impairments. The client may also develop a dementia.

Question 88

83. The nurse is conducting a support group for clients diagnosed with Parkinson’s disease and their significant others. Which information regarding psychosocial needs should be included in the discussion?
84. The client should discuss feelings about being placed on a ventilator.
85. The client may have rapid mood swings and become easily upset.
86. “Pill rolling” tremors will become worse when the medication is wearing off.
87. The client may automatically start to repeat what another person says.

Answer 88

2

These are psychosocial manifestations of PD. These should be discussed in the support meeting.

Question 89

84. The nurse is caring for clients on a medical surgical floor. Which client should be assessed first?
85. The 65-year-old client diagnosed with seizures who is complaining of a headache
    that is a 2 on a 1–10 scale.
86. The 24-year-old client diagnosed with a T-10 spinal cord injury who cannot move
    his toes.
87. The 58-year-old client diagnosed with Parkinson’s disease who is crying and
    worried about her facial appearance.
88. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving
    left hemiparesis.

Answer 89

3

Body image is a concern for clients diagnosed with PD. This client is the one client that is not experiencing expected sequelae
of the disease.

Question 90

Neurological Disorders Comprehensive Examination

Answer 90

*

Question 91

3. The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?
4. Bell’s palsy.
5. Right-sided stroke.
6. Tetany.
7. Mononeuropathy.

Answer 91

1

Bell’s palsy, called facial paralysis, is a disorder of the 7th cranial nerve (facial nerve) characterized by unilateral paralysis of
facial muscles.

Question 92

7. The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt- Jakob disease. Which intervention should the nurse implement prior to the procedure?
8. Determine if the client has claustrophobia.
9. Obtain a signed informed consent form.
10. Determine if the client is allergic to egg yolks.
11. Start an intravenous line in both hands.

Answer 92

1

In an MRI, the client is placed in a very narrow tube. If the client is claustrophobic .he or she may need medication or an open
MRI may need to be considered.

Question 93

9. The client calls the clinic and asks the nurse, “What causes Creutzfeldt-Jakob disease?”
   Which statement would be the nurse’s best response?
10. “The person must have been exposed to an infected prion.”
11. “It is mad cow disease, and eating contaminated meat is the cause.”
12. “This disease is caused by a virus that is in stagnant water.”
13. “A fungal spore in the lungs infects the brain tissue.”

Answer 93

2

This is the cause of this disease and would be the best response.

Question 94

10. The client is diagnosed with Creutzfeldt-Jakob disease. Which referral would be the
    most appropriate?
11. Alzheimer’s Association.
12. Creutzfeldt-Jakob Disease Foundation.
13. Hospice Care.
14. A neurosurgeon.

Answer 94

3. This disease is usually fatal within a year, and the symptoms progress rapidly to dementia.

Question 95

12. The client is diagnosed with a brain abscess. Which sign/symptom is the most common?
13. Projectile vomiting.
14. Disoriented behavior.
15. Headaches, worse in the morning.
16. Petit mal seizure activity.

Answer 95

3

The most common and prevailing symptom of a brain abscess is a headache that is worse in the morning because of increased
intracranial pressure as a result of lying flat (gravity).

Question 96

13. The client diagnosed with a brain abscess has become lethargic and difficult to arouse.
    Which intervention should the nurse implement first?
14. Implement seizure precautions.
15. Assess the client’s neurological status.
16. Close the drapes and darken the room.
17. Prepare to administer an IV steroid.

Answer 96

2

Remember, assessment is the first step of the nursing process and should be implemented first whenever there is a change in
the client’s behavior.

Question 97

17. Which finding is considered to be one of the warning signs of developing Alzheimer’s disease?
18. Difficulty performing familiar tasks.
19. Problems with orientation to date, time, and place.
20. Having problems focusing on a task.
21. Atherosclerotic changes in the vessels.

Answer 97

2

Disorientation to time and place is a warning sign.

Question 98

18. Which information should be shared with the client diagnosed with Stage 1 Alzheimer’s disease who is prescribed donepezil (Aricept), a cholinesterase inhibitor?
19. The client must continue taking this medication forever to maintain function.
20. The drug may delay the progression of the disease, but it does not cure it.
21. A serum drug level must be obtained monthly to evaluate for toxicity.
22. If the client develops any muscle aches, the HCP should be notified.

Answer 98

2

This medication does not cure Alzheimer’s, and at some point it will become ineffective as the disease progresses.

Question 99

19. The spouse of a recently retired man tells the nurse, “All my husband does is sit around and watch television all day long. He is so irritable and moody. I don’t want to be
    around him.” Which action should the nurse implement?
20. Encourage the wife to leave the client alone.
21. Tell the wife that he is probably developing Alzheimer’s disease.
22. Recommend that the client see an HCP for an antidepressant medication.
23. Instruct the wife to buy him some arts and crafts supplies.

Answer 99

3

This behavior indicates the client is depressed and should be treated with antidepressants. A major lifestyle change has occurred and he may need short-term medication therapy, depending on how the client adjusts to retirement.

Question 100

20. The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his
    room. Which intervention should the nurse implement first?
21. Insist the client go to the dining room for meals.
22. Notify the family of the change in behavior.
23. Determine if the client wants another roommate.
24. Complete a Geriatric Depression Scale.

Answer 100

4

A change in behavior may indicate depression. The Geriatric Depression Scale measures satisfaction with life’s accomplishment. The elderly should be in Erikson’s generativity versus stagnation stage of life.

Question 101

21. A family member brings the client to the emergency department reporting that the 78- year-old father has suddenly become very confused and thinks he is living in 1942, that
    he has to go to war, and that someone is trying to poison him. Which question should the nurse ask the family member?
22. “Has your father been diagnosed with dementia?”
23. “What medication has your father taken today?”
24. “What have you given him that makes him think it’s poison?”
25. “Does your father like to watch old movies on television?”

Answer 101

2

Drug toxicity and interactions are common
causes of delirium in the elderly.

Question 102

22. The student nurse asks the nurse, “Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?” The nurse would base the response on which scientific rationale?
23. This is part of the routine neurological exam.
24. This is done to determine if the client has diplopia.
25. This assesses the amount of brain damage.
26. This is done to indicate if there is a rebound effect on the brain.

Answer 102

4

When the client hits the front of the head, there is a rebound effect known as “coupcontrecoup” in which the brain hits the back of the skull. The occipital lobe is in the back of the head and an injury to it may be manifested by seeing double.

Question 103

23. The ambulance brings the client with a head injury to the emergency department. The client responds to painful stimuli by muttering and pulling away from the nurse. How would the nurse rate this client on the Glasgow Coma Scale?
24. 3
25. 8
26. 10
27. 15

Answer 103

2

A score of 8 indicates severe increased intracranial pressure, but with appropriate care the client may survive. The nurse
would rate the client at an 8: 1 for opening the eyes; 3 for verbal response; and 4 for motor response.

Question 104

24. Which intervention has the highest priority for the client in the emergency department who has been in a motorcycle collision with an automobile and has a fractured
    left leg?
25. Assessing the neurological status.
26. Immobilizing the fractured leg.
27. Monitoring the client’s output.
28. Starting an 18-gauge saline lock.

Answer 104

1

Assessment is the first step in the nursing process, and a client with a motorcycle accident must be assessed for a head injury.

Question 105

25. The nurse writes the nursing diagnosis “altered body temperature related to damaged temperature regulating mechanism” for a client with a head injury. Which would be
    the most appropriate goal?
26. Administer acetaminophen (Tylenol) for elevated temperature.
27. The client’s temperature will remain less than 100!F.
28. Maintain the hypothermia blanket at 99!F for 24 hours.
29. The basal metabolic temperature will fluctuate no more than two (2) degrees.

Answer 105

2

This is an appropriate goal. It addresses the client, addresses the problem (temperature, elevation), and is measurable.

Question 106

26. Which potential pituitary complication should the nurse assess for in the client diagnosed with a traumatic brain injury (TBI)?
27. Diabetes mellitus type 2 (DM 2).
28. Seizure activity.
29. Syndrome of inappropriate antidiuretic hormone (SIADH).
30. Cushing’s disease.

Answer 106

3

The pituitary gland produces vasopressin, the antidiuretic hormone (ADH), and any injury that causes increased intracranial
pressure will exert pressure on the pituitary gland and can cause the syndrome of inappropriate antidiuretic hormone (SIADH).

Question 107

27. The nurse is discussing seizure prevention with a female client who was just diagnosed with epilepsy. Which statement indicates the client needs more teaching?
28. “I will take calcium supplements daily and drink milk.”
29. “I will see my HCP to have my blood levels drawn regularly.”
30. “I should not drink any type of alcohol while taking the medication.”
31. “I am glad that my periods will not affect my epilepsy.”

Answer 107

4

Women with epilepsy note an increase in the frequency of seizures during menses. This is thought to be linked to the increase
in sex hormones that alter the excitability of the neurons in the brain.

Question 108

28. The unlicensed nursing assistant is caring for a client that is having a seizure. Which action by the assistant would warrant immediate intervention by the nurse?
29. The assistant attempts to insert an oral airway.
30. The assistant turns the client on the right side.
31. The assistant has all the side rails padded and up.
32. The assistant does not leave the client’s bedside.

Answer 108

1

The nurse must intervene to stop the assistant because the client’s jaws are clenched. Attempting to insert anything into the
mouth could cause injury to the client or to
the assistant.

Question 109

29. The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement?
30. Explain that this procedure is not painful.
31. Premedicate the client with a benzodiazepine drug.
32. Instruct the client to shave all facial hair.
33. Tell the client it will cause him to see floaters.

Answer 109

1

This procedure is not painful, although electrodes are attached to the scalp. The client will need to wash the hair after the
procedure.

Question 110

30. Which assessment data indicates that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?
31. The client has flaccid paralysis.
32. The client has purposeful movement.
33. The client has decerebrate posturing with painful stimuli.
34. The client does not move extremities.

Answer 110

2

Purposeful movement indicates the client is getting better and is responding to the treatment.

Question 111

31. The intensive care nurse is caring for the client who has had intracranial surgery.
    Which interventions should the nurse implement? Select all that apply.
32. Assess for deep vein thrombosis.
33. Administer intravenous anticoagulant.
34. Monitor intake and output strictly.
35. Apply warm compresses to the eyes.
36. Perform passive range of motion exercises.

Answer 111

1, 3, 5

1. Assessing for deep vein thrombosis, which
   is a complication of immobility, would be
   appropriate for this client.
2. Anticoagulants may cause bleeding; therefore
   the client who has had surgery would not be
   prescribed this medication.
3. Monitoring of intake and output helps to
   detect possible complications of the pituitary
   gland, which include diabetes insipidus
   and syndrome of inappropriate antidiuretic
   hormone (SIADH).
4. The nurse should apply cool compresses to
   alleviate periocular edema.
5. The nurse does not want the client to be
   active and possibly increase intracranial
   pressure; therefore, the nurse should
   perform passive range of motion for the
   client.

Question 112

32. Which client should the nurse assess first after receiving the shift report?
33. The client diagnosed with a stroke who has right-sided paralysis.
34. The client diagnosed with meningitis who complains of photosensitivity.
35. The client with a brain tumor who has projectile vomiting.
36. The client with epilepsy who complains of tender gums.

Answer 112

3

Projectile vomiting indicates that the increased intracranial pressure is exerting pressure on the vomiting center of the
brain.

Question 113

35. Which assessment data should the nurse expect to observe for the client diagnosed with Parkinson’s disease?
36. Ascending paralysis and pain.
37. Masklike facies and pill rolling.
38. Diplopia and ptosis.
39. Dysphagia and dysarthria.

Answer 113

2

Masklike facies and pill rolling are signs/ symptoms of Parkinson’s disease, along with cog wheeling, postural instability, and
stooped and shuffling gait.

Question 114

36. The client diagnosed with Parkinson’s disease is prescribed carbidopa/levodopa
    (Sinemet). Which intervention should the nurse implement prior to administering the medication?
37. Discuss how to prevent orthostatic hypotension.
38. Take the client’s apical pulse for one (1) full minute.
39. Inform the client that this medication is for short-term use.
40. Tell the client to take the medication on an empty stomach.

Answer 114

1

Because carbidopa/levodopa has been linked to hypotension, teaching a client given the medication ways to help prevent a drop
in blood pressure when standing—orthostatic hypotension—decreases the risks associated with hypotension and falling.

Question 115

42. The client with a history of migraine headaches comes to the clinic and reports that a migraine is coming because the client is experiencing bright spots before the eyes.
    Which phase of migraine headaches is the client experiencing?
43. Prodrome phase.
44. Aura phase.
45. Headache phase.
46. Recovery phase.

Answer 115

2

This is the aura phase, which is characterized by focal neurological symptoms.

Question 116

45. The nurse stops at the scene of a motor vehicle accident and provides emergency first aid at the scene. Which law protects the nurse as a first responder?
46. The First Aid Law.
47. Ombudsman Act.
48. Good Samaritan Act.
49. First Responder Law.

Answer 116

3

The Good Samaritan Act protects the nurse from judgment against them when in an emergency situation in which the nurse
is not receiving compensation for the skills and expertise rendered. The nurse is held to a different standard than a layman; the
nurse must act as any reasonable and prudent nurse would in the same situation.

Question 117

47. The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse
    implement first?
48. Administer the medication in pudding.
49. Check the client’s armband.
50. Crush the tablet and dissolve in juice.
51. Have the client sip some water.

Answer 117

4

Asking the client to sip some water assesses the client’s ability to swallow, which is priority when placing anything in the
mouth of the client who has had a stroke.

Question 118

48. Which client would be most at risk for experiencing a stroke?
49. A 92-year-old client who is an alcoholic.
50. A 54-year-old client diagnosed with hepatitis.
51. A 60-year-old client who has a Greenfield filter.
52. A 68-year-old client with chronic atrial fibrillation.

Answer 118

4

A client with atrial fibrillation is at high risk to have a stroke and is usually given oral anticoagulants to prevent a stroke.

Question 119

49. The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
50. The elderly client who is experiencing a stroke in evolution.
51. The client diagnosed with a transient ischemic attack 48 hours ago.
52. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
53. The client with Alzheimer’s disease who is wandering in the halls.

Answer 119

1

This client is experiencing a progressing stroke, is at risk for dying, and should be cared for by the most experienced nurse.

Question 120

51. The nurse arrives at the scene of a motor vehicle accident and the car is leaking gasoline. The client is in the driver’s seat of the car complaining of not being able to move the legs. Which actions should the nurse implement? List in order of priority.
52. Move the client safely out of the car.
53. Assess the client for other injuries.
54. Stabilize the client’s neck.
55. Notify the emergency medical system.
56. Place client in a functional anatomical position.

Answer 120

In order of priority: 3, 2, 1, 5, 4.

3. Stabilizing the client’s neck is priority
   action to prevent further injury to the
   client, and it must be done prior to moving
   the client.
4. The nurse should assess for any other
   injuries prior to moving the client from the
   vehicle.
5. Because the vehicle is leaking fuel and there
   is potential for an explosion or fire, the
   client should be moved to an area of safety.
6. Placing the client in a functional anatomical
   position is an attempt to prevent further
   spinal cord injury.
7. Because the vehicle is leaking fuel, the
   priority is to remove the client and then
   obtain emergency medical assistance.

Question 121

Arterial Hypertension

Answer 121

*

Question 122

1. The 66-year-old male client has his blood pressure (BP) checked at a health fair. The B/P is 168/98. Which action should the nurse implement first?
2. Recommend that the client have his blood pressure checked in one (1) month.
3. Instruct the client to see his health-care provider as soon as possible.
4. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet.
5. Explain that this B/P is within the normal range for an elderly person.

Answer 122

2

The diastolic blood pressure should be less than 85 according to the American Heart Association; therefore, this client should
see the health-care provider.

Question 123

2. The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing exercise?
3. Walk at least 30 minutes a day on flat surfaces.
4. Perform light weight lifting three (3) times a week.
5. Recommend high-level aerobics daily.
6. Encourage the client to swim laps once a week.

Answer 123

1

Walking 30 to 45 minutes a day will help in reducing blood pressure, weight, and stress and will increase a feeling of overall wellbeing.

Question 124

3. The health-care provider prescribes an ACE inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering
   this medication?
4. ACE inhibitors prevent the beta-receptor stimulation in the heart.
5. This medication blocks the alpha receptors in the vascular smooth muscle.
6. ACE inhibitors prevent vasoconstriction and sodium and water retention.
7. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.

Answer 124

3

Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensinI to angiotensin II, and this, in turn, prevents vasoconstriction and sodium and water retention.

Question 125

4. The nurse is administering a beta blocker to the client diagnosed with essential hypertension.
   Which intervention should the nurse implement?
5. Notify the health-care provider if the potassium level is 3.8 mEq.
6. Question administering the medication if the blood pressure is !90/60 mmHg.
7. Do not administer the medication if the client’s radial pulse is “100.
8. Monitor the client’s blood pressure while he or she is lying, standing, and sitting.

Answer 125

2

The nurse should question administering the beta blocker if the B/P is low because this medication will cause the blood pressure
to drop even lower, leading to hypotension.

Question 126

5. The male client diagnosed with essential hypertension has been prescribed an alphaadrenergic
   blocker. Which intervention should the nurse discuss with the client?
6. Eat at least one (1) banana a day to help increase the potassium level.
7. Explain that impotence is an expected side effect of the medication.
8. Take the medication on an empty stomach to increase absorption.
9. Change position slowly when going from lying to sitting position.

Answer 126

4

Orthostatic hypotension may occur when the blood pressure is decreasing and may lead to dizziness and light-headedness
so the client should change position slowly.

Question 127

6. The nurse just received the A.M. shift report. Which client should the nurse assess first?
7. The client diagnosed with coronary artery disease who has a BP of 170/100.
8. The client diagnosed with deep vein thrombosis who is complaining of chest pain.
9. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%.
10. The client diagnosed with ulcerative colitis who has nonbloody diarrhea.

Answer 127

2

The chest pain could be a pulmonary embolus secondary to deep vein thrombosis and requires immediate intervention by
the nurse.

Question 128

7. The client diagnosed with essential hypertension asks the nurse, “Why do I have high blood pressure?” Which response by the nurse would be most appropriate?
8. “You probably have some type of kidney disease that causes the high BP.”
9. “More than likely you have had a diet high in salt, fat, and cholesterol.”
10. “There is no specific cause for hypertension, but there are many known risk factors.”
11. “You are concerned that you have high blood pressure. Let’s sit down and talk.”

Answer 128

3

There is no known cause for essential hypertension, but many factors, both modifiable (obesity, smoking, diet) and nonmodifiable
(family history, age, gender) are risk factors for essential hypertension.

Question 129

8. The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client
   understands the client teaching concerning the DASH diet?
9. “I should eat at least four (4) to five (5) servings of vegetables a day.”
10. “I should eat meat that has a lot of white streaks in it.”
11. “I should drink no more than two (2) glasses of whole milk a day.”
12. “I should decrease my grain intake to no more than twice a week.”

Answer 129

1

The DASH diet has proved beneficial in lowering blood pressure. It recommends eating a diet high in vegetables and fruits.

Question 130

9. The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse?
10. The telemetry reads normal sinus rhythm.
11. The client has a weight gain of 2 kg within 1–2 days.
12. The client’s blood pressure is 148/92.
13. The client’s serum potassium level is 4.5 mEq.

Answer 130

2

Rapid weight gain—for example, 2 kg in 1–2 days—indicates that the loop diuretic is not working effectively; 2 kg equals 4.4 lbs;
1 L of fluid weighs l kg.

Question 131

10. The client diagnosed with essential hypertension asks the nurse, “I don’t know why the doctor is worried about my blood pressure. I feel just great.” Which statement by the nurse would be the most appropriate response?
11. “Damage can be occurring to your heart and kidneys even if you feel great.”
12. “Unless you have a headache your blood pressure is probably within normal limits.”
13. “When is the last time you saw your doctor? Does he know you are feeling great?”
14. “Your blood pressure reflects how well your heart is working.”

Answer 131

1

Even if the client feels great, the blood pressure can be elevated, causing damage to the heart, kidney, and blood vessels.

Question 132

12. The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation?
13. Include information on retinopathy and nephropathy.
14. Discuss sedentary lifestyle and smoking cessation.
15. Include discussions on family history and gender.
16. Provide information on a low-fiber and high-salt diet.

Answer 132

2

Sedentary lifestyle is discouraged in clients with hypertension, and daily isotonic exercises are recommended. Smoking increases
the atherosclerotic process in vessels; causes vasoconstriction of vessels; and adheres to hemoglobin, decreasing oxygen
levels.

Question 133

Arterial Occlusive Disease

Answer 133

*

Question 134

13. The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document
    in the client’s record?
14. Peripheral vascular disease (PVD).
15. Intermittent claudication.
16. Deep vein thrombosis (DVT).
17. Dependent rubor.

Answer 134

2

This is the classic symptom of arterial occlusive disease.

Question 135

14. Which instruction should be included when a client diagnosed with peripheral arterial disease is being discharged?
15. Encourage the client to use a heating pad on lower extremities.
16. Demonstrate to the client the correct way to apply elastic support hose.
17. Instruct the client to walk daily for at least 30 minutes.
18. Tell the client to check both feet for red areas at least once a week.

Answer 135

3

Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis.

Question 136

15. The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions
    should the nurse include in the teaching? Select all that apply.
16. Wash legs and feet daily in warm water.
17. Apply moisturizing cream to feet.
18. Buy shoes in the morning hours only.
19. Do not wear any type of knee stocking.
20. Wear clean white cotton socks.

Answer 136

1, 2, 4, 5

1. Cold water causes vasoconstriction and
   hot water may burn the client’s feet; therefore,
   warm tepid water should be recommended.
2. Moisturizing prevents drying of the feet.
3. Shoes should be purchased in the afternoon
   when the feet are the largest.
4. This will further decrease circulation to the
   legs.
5. Colored socks have dye and dirty socks may
   cause foot irritation that may lead to breaks
   in the skin.

Question 137

16. Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease?
17. The client has 2! pedal pulses.
18. The client is able to move the toes.
19. The client has numbness and tingling.
20. The client’s feet are red when standing.

Answer 137

3

Numbness and tingling are paresthesia,
which is a sign of a severely decreased
blood supply to the lower extremities.

Question 138

17. Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer?
18. Impaired skin integrity.
19. Activity intolerance.
20. Ineffective health maintenance.
21. Risk for peripheral neuropathy.

Answer 138

1

The client has a foot ulcer, therefore the
protective lining of the body—the skin—
has been impaired.

Question 139

18. The client diagnosed with arterial occlusive disease is one (1) day post-operative right femoral popliteal bypass. Which intervention should the nurse implement?
19. Keep the right leg in the dependent position.
20. Apply sequential compression devices to lower extremities.
21. Monitor the client’s pedal pulses every shift.
22. Assess the client’s leg dressing every four (4) hours.

Answer 139

4

The leg dressing needs to be assessed for hemorrhaging or signs of infection.

Question 140

19. The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first?
20. Complete a neurovascular assessment.
21. Use the Doppler device.
22. Instruct the client to hang the feet off the side of the bed.
23. Wrap the legs in a blanket.

Answer 140

1

An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease, but the nurse must ensure that the feet can be moved and are warm, which indicates adequate blood supply to the feet.

Question 141

20. The wife of a client with arterial occlusive disease tells the nurse, “My husband says he is having rest pain. What does that mean?” Which statement by the nurse would be
    most appropriate?
21. “It describes the type of pain he has when he stops walking.”
22. “His legs are deprived of oxygen during periods of inactivity.”
23. “You are concerned that your husband is having rest pain.”
24. “This term is used to support that his condition is getting better.”

Answer 141

2

Rest pain indicates a worsening of the arterial occlusive disease; the muscles of the legs are not getting enough oxygen when
the client is resting to prevent muscle ischemia.

Question 142

21. The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis?
22. Hairless skin on the legs.
23. Brittle, flaky toe nails.
24. Petechiae on the soles of feet.
25. Nonpitting ankle edema.

Answer 142

1

The decreased oxygen over time causes the loss of hair on top of feet and ascends both legs.

Question 143

22. The health-care provider ordered a femoral angiogram for the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement?
23. Explain that this procedure will be done at the bedside.
24. Discuss with the client that he or she will be on bed rest with bathroom privileges.
25. Inform the client that no intravenous access will be needed.
26. Inform the client that fluids will be increased after the procedure.

Answer 143

4

Fluids will help flush the contrast dye out of the body and help prevent kidney damage.

Question 144

23. Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease?
24. An anticoagulant medication.
25. An antihypertensive medication.
26. An antiplatelet medication.
27. A muscle relaxant.

Answer 144

3

Anti-platelet medications inhibit platelet aggregations in the arterial blood, such as aspirin or clopidogrel (Plavix).

Question 145

24. The nurse and an unlicensed nursing assistant are caring for a 64-year-old client who is four (4) hours post-operative bilateral femoral–popliteal bypass surgery. Which nursing task should be delegated to the unlicensed nursing assistant?
25. Monitor the continuous passive motion machine.
26. Assist the client to the bedside commode.
27. Feed the client the evening meal.
28. Elevate the foot of the client’s bed.

Answer 145

4

After the surgery, the client’s legs will be elevated to help decrease edema. The surgery has corrected the decreased blood
supply to the lower legs.

Question 146

Peripheral Venous Disease

Answer 146

*

Question 147

61. The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency?
62. Arterial thrombosis.
63. Deep vein thrombosis.
64. Venous ulcerations.
65. Varicose veins.

Answer 147

3

Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcerations
to heal, and often clients must be seen in wound care clinics for treatment.

Question 148

62. Which assessment data would support that the client has a venous stasis ulcer?
63. Superficial pink open area on the medial part of the ankle.
64. A deep pale open area over the top side of the foot.
65. A reddened blistered area on the heel of the foot.
66. A necrotic gangrenous area on the dorsal side of the foot.

Answer 148

1

The medial part of the ankle usually ulcerates because of edema that leads to stasis, which, in turn, causes the skin to break
down.

Question 149

63. The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins?
64. Wear low-heeled, comfortable shoes.
65. Wear white, clean, cotton socks.
66. Move the legs back and forth often.
67. Wear graduated compression hose.

Answer 149

4

Graduated compression hose help decrease edema and increase the circulation back to the heart; this helps prevent varicose veins.

Question 150

64. The client with varicose veins asks the nurse, “What caused me to have these?” Which statement by the nurse would be most appropriate?
65. “You have incompetent valves in your legs.”
66. “Your legs have decreased oxygen to the muscle.”
67. “There is an obstruction in the saphenous vein.”
68. “Your blood is thick and can’t circulate properly.”

Answer 150

1

Varicose veins are irregular, tortuous veins with incompetent valves that do not allow the venous blood to ascend the saphenous
vein.

Question 151

65. The nurse is caring for the client with chronic venous insufficiency. Which statement indicates that the client understands the discharge teaching?
66. “I shouldn’t cross my legs for more than 15 minutes.”
67. “I need to elevate the foot of my bed while sleeping.”
68. “I should take a baby aspirin every day with food.”
69. “I should increase my fluid intake to 3000 mL a day.”

Answer 151

2

Elevating the foot of the bed while sleeping helps the venous blood return to the heart and decreases pressure in the lower extremity.

Question 152

66. The unlicensed nursing assistant is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse?
67. Applying compression stockings before going to bed.
68. Taking the client’s blood pressure manually.
69. Assisting the client by opening the milk on the tray.
70. Calculating the client’s shift intake and output.

Answer 152

1

Research shows that removing the compression stockings while the client is in bed promotes perfusion of the subcutaneous tissue. The foot of the bed should be elevated.

Question 153

67. The 80-year-old client is being discharged home after having surgery to debride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for
    the client?
68. Occupational therapist.
69. Social worker.
70. Physical therapist.
71. Cardiac rehabilitation.

Answer 153

2

The social worker would assess the client to determine if home health care services or financial interventions were appropriate
for the client. The client is elderly, immobility is a concern, and wound care must be a concern when the client is discharged
home.

Question 154

68. Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency?
69. Decreased pedal pulses.
70. Cool skin temperature.
71. Intermittent claudication.
72. Brown discolored skin.

Answer 154

4

Chronic venous insufficiency leads to chronic edema that, in turn, causes a brownish pigmentation to the skin.

Question 155

69. Which client would be most at risk for developing varicose veins?
70. A Caucasian female who is a nurse.
71. An African American male who is a bus driver.
72. An Asian female with no children.
73. An elderly male with diabetes.

Answer 155

1

Varicose veins are more common in white females in occupations that involve prolonged standing.

Question 156

70. The client with varicose veins is six (6) hours post-operative vein ligation. Which nursing intervention should the nurse implement first?
71. Assist the client to dangle the legs off the side of the bed.
72. Assess and maintain pressure bandages on the affected leg.
73. Apply a sequential compression device to the affected leg.
74. Administer the prescribed prophylactic intravenous antibiotic.

Answer 156

2

Pressure bandages are applied for up to six (6) weeks after vein ligation to help prevent bleeding and to help venous return from
the lower extremities when in the standing or sitting position.

Question 157

71. The nurse has just received the A.M. shift report. Which client would the nurse assess first?
72. The client with a venous stasis ulcer who is complaining of pain.
73. The client with varicose veins who has dull aching muscle cramps.
74. The client with arterial occlusive disease who cannot move the foot.
75. The client with deep vein thrombosis who has a positive Homans’ sign.

Answer 157

3

The inability to move the foot means that a severe neurovascular compromise has occurred, and the nurse should assess this
client first.

Question 158

72. The nurse is completing a neurovascular assessment on the client with chronic venous
    insufficiency. What should be included in this assessment? Select all that apply.
73. Assess for paresthesia.
74. Assess for pedal pulses.
75. Assess for paralysis.
76. Assess for pallor.
77. Assess for paresthesia.

Answer 158

1, 2, 3, 4, 5,

1. The nurse should determine if the client
   has any numbness or tingling.
2. The nurse should determine if the client
   has pulses, the presence of which indicates
   there is no circulatory compromise.
3. The nurse should determine if the client
   can move the feet and legs.
4. The nurse should determine if the client’s
   feet are pink or pale.
5. The nurse should assess the feet to determine
   if they are cold or warm.

Question 159

Peripheral Vascular Disorders Comprehensive Examination

Answer 159

*

Question 160

9. Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?
10. Walk 15 to 20 minutes three (3) times a day.
11. Keep the legs in the dependent position when sitting.
12. Remove compression bandages before going to bed.
13. Perform Berger-Allen exercises four (4) times a day.

Answer 160

1

After sclerotherapy clients are taught to perform walking activities to maintain blood flow in the leg and enhance dilution of the sclerosing agent.

Question 161

10. The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client? Select all that apply.
11. Wash your feet in antimicrobial soap.
12. Wear comfortable, well-fitting shoes.
13. Cut your toenails in an arch.
14. Keep the area between the toes dry.
15. Use a heating pad when feet are cold.

Answer 161

2, 4

1. Antimicrobial soap is harsh and can dry the
   skin; the client should use mild soap and room temperature water.
2. Shoes must be comfortable to prevent blisters
   or ulcerations of the feet.
3. The toenails should be cut straight across; cutting
   in an arch increases the risk for ingrown
   toenails.
4. Moisture between the toes increases fungal
   growth, leading to skin breakdown.
5. The client with PVD has decreased sensation
   in the feet and should not use a heating pad.

Question 162

11. The unlicensed nursing assistant is applying elastic compression stockings to the client.
    Which action by the assistant would warrant immediate intervention by the nurse?
12. The assistant is putting the stockings on while the client is in the chair.
13. The assistant inserted two (2) fingers under the proximal end of the stocking.
14. The assistant elevated the feet while lying down prior to putting on the stockings.
15. The assistant made sure the toes were warm after putting the stockings on.

Answer 162

1

Stockings should be applied after the legs have been elevated for a period of time when the amount of blood in the leg vein is at its lowest; therefore, the nurse should intervene when the assistant is putting
them on while the client is in the chair.

Question 163

12. The nurse is administering a beta blocker to the client diagnosed with essential hypertension.
    Which data would cause the nurse to question administering the medication?
13. The client’s BP is 110/70.
14. The client’s potassium level is 3.4 mEq/L.
15. The client has a barky cough.
16. The client’s apical pulse is 56.

Answer 163

4

The beta blocker decreases sympathetic stimulation to the beta cells of the heart. Therefore, the nurse should question administering the medication if the apical
pulse is less than 60 beats per minute.

Question 164

14. The nurse is caring for the client on strict bed rest. Which intervention is priority when caring for this client?
15. Encourage the client to drink liquids.
16. Perform active range of motion exercises.
17. Elevate the head of the bed to 45 degrees.
18. Provide a high-fiber diet to the client.

Answer 164

2

Preventing deep vein thrombosis is the priority nursing intervention because the client is on strict bed rest; ROM exercises should be done every four (4) hours.

Question 165

15. The nurse is caring for clients on a medical floor. Which client will the nurse assess
    first?
16. The client with an abdominal aortic aneurysm who is constipated.
17. The client on bed rest who ambulated to the bathroom.
18. The client with essential hypertension who has epistaxis and a headache.
19. The client with arterial occlusive disease who has a decreased pedal pulse.

Answer 165

3

A bloody nose and a headache indicate the client is experiencing very high blood pressure and should be assessed first because of a possible myocardial infarction or stroke.

Question 166

16. The client with peripheral venous disease is scheduled to go to the whirlpool for a
    dressing change. Which is the nurse’s priority intervention?
17. Escort the client to the physical therapy department.
18. Medicate the client 30 minutes before going to whirlpool.
19. Obtain the sterile dressing supplies for the client.
20. Assist the client to the bathroom prior to the treatment.

Answer 166

2

The client’s pain is priority, and the nurse should premedicate prior to treatment.

Question 167

18. The client diagnosed with atherosclerosis asks the nurse, “I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?” Which statement would be the nurse’s best response?
19. “This disease process will not kill you, so don’t worry.”
20. “The blood supply to your brain is being cut off.”
21. “It is what caused you to have your high blood pressure.”
22. “Atherosclerosis is a buildup of plaque in your arteries.”

Answer 167

4

A buildup of plaque in the arteries is occurring in the body when the client has atherosclerosis.

Question 168

25. The client is four (4) hours post-operative femoral–popliteal bypass surgery. Which
    pulse would be best for the nurse to assess for complications related to an occluded
    vessel?
26. radial
27. femoral
    3) popliteal
    4) dorsalis pedal

Answer 168

4

The pedal pulse is the best pulse to assess because it indicates if there is adequate circulation to the most distal site of the extremity. The bypass extends from the midthigh to the mid-calf area.