Exam 3

Question 1

A nurse is assessing a patient with an acoustic neuroma who has been recently admitted
to an oncology unit. What symptoms is the nurse likely to find during the initial
assessment?
A) Loss of hearing, tinnitus, and vertigo
B) Loss of vision, change in mental status, and hyperthermia
C) Loss of hearing, increased sodium retention, and hypertension
D) Loss of vision, headache, and tachycardia

Answer 1

A) Loss of hearing, tinnitus, and vertigo

Question 2

A 25-year-old female patient with brain metastases is considering her life expectancy
after her most recent meeting with her oncologist. Based on the fact that the patient is
not receiving treatment for her brain metastases, what is the nurse’s most appropriate
action?
A) Promoting the patient’s functional status and ADLs
B) Ensuring that the patient receives adequate palliative care
C) Ensuring that the family does not tell the patient that her condition is terminal
D) Promoting adherence to the prescribed medication regimen

Answer 2

B) Ensuring that the patient receives adequate palliative care

Question 3

The nurse is writing a care plan for a patient with brain metastases. The nurse decides
that an appropriate nursing diagnosis is ìanxiety related to lack of control over the
health circumstances.î In establishing this plan of care for the patient, the nurse should
include what intervention?
A) The patient will receive antianxiety medications every 4 hours.
B) The patient’s family will be instructed on planning the patient’s care.
C) The patient will be encouraged to verbalize concerns related to the disease and its
treatment.
D) The patient will begin intensive therapy with the goal of distraction.

Answer 3

C) The patient will be encouraged to verbalize concerns related to the disease and its
treatment.

Question 4

A patient with suspected Parkinson’s disease is initially being assessed by the nurse.
When is the best time to assess for the presence of a tremor?
A) When the patient is resting
B) When the patient is ambulating
C) When the patient is preparing his or her meal tray to eat
D) When the patient is participating in occupational therapy

Answer 4

A) When the patient is resting

Question 5

The clinic nurse caring for a patient with Parkinson’s disease notes that the patient has
been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side
effect of Sinemet would the nurse assesses this patient?
A) Pruritus
B) Dyskinesia
C) Lactose intolerance
D) Diarrhea

Answer 5

B) Dyskinesia

Question 6

The nurse is caring for a boy who has muscular dystrophy. When planning assistance
with the patient’s ADLs, what goal should the nurse prioritize?
A) Promoting the patient’s recovery from the disease
B) Maximizing the patient’s level of function
C) Ensuring the patient’s adherence to treatment
D) Fostering the family’s participation in care

Answer 6

B) Maximizing the patient’s level of function

Question 7

A 37-year-old man is brought to the clinic by his wife because he is experiencing loss
of motor function and sensation. The physician suspects the patient has a spinal cord
tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose
spinal cord compression from a tumor, the nurse will most likely prepare the patient for
what test?
A) Anterior-posterior x-ray
B) Ultrasound
C) Lumbar puncture
D) MRI

Answer 7

D) MRI

Question 8

A patient with Parkinson’s disease is undergoing a swallowing assessment because she
has recently developed adventitious lung sounds. The patient’s nutritional needs should
be met by what method?
A) Total parenteral nutrition (TPN)
B) Provision of a low-residue diet
C) Semisolid food with thick liquids
D) Minced foods and a fluid restriction

Answer 8

C) Semisolid food with thick liquids

Question 9

While assessing the patient at the beginning of the shift, the nurse inspects a surgical
dressing covering the operative site after the patients’ cervical diskectomy. The nurse
notes that the drainage is 75% saturated with serosanguineous discharge. What is the
nurse’s most appropriate action?
A) Page the physician and report this sign of infection.
B) Reinforce the dressing and reassess in 1 to 2 hours.
C) Reposition the patient to prevent further hemorrhage.
D) Inform the surgeon of the possibility of a dural leak.

Answer 9

D) Inform the surgeon of the possibility of a dural leak

Question 10

A patient, diagnosed with cancer of the lung, has just been told he has metastases to the
brain. What change in health status would the nurse attribute to the patient’s metastatic
brain disease?
A) Chronic pain
B) Respiratory distress
C) Fixed pupils
D) Personality changes

Answer 10

D) Personality changes

Question 11

A patient has just been diagnosed with Parkinson’s disease and the nurse is planning the
patient’s subsequent care for the home setting. What nursing diagnosis should the nurse
address when educating the patient’s family?
A) Risk for infection
B) Impaired spontaneous ventilation
C) Unilateral neglect
D) Risk for injury

Answer 11

D) Risk for injury

Question 12

The nurse is caring for a patient with Huntington disease who has been admitted to the
hospital for treatment of malnutrition. What independent nursing action should be
implemented in the patient’s plan of care?
A) Firmly redirect the patient’s head when feeding.
B) Administer phenothiazines after each meal as ordered.
C) Encourage the patient to keep his or her feeding area clean.
D) Apply deep, gentle pressure around the patient’s mouth to aid swallowing.

Answer 12

D) Apply deep, gentle pressure around the patient’s mouth to aid swallowing.

Question 13

A patient has been admitted to the neurologic unit for the treatment of a newly
diagnosed brain tumor. The patient has just exhibited seizure activity for the first time.
What is the nurse’s priority response to this event?
A) Identify the triggers that precipitated the seizure.
B) Implement precautions to ensure the patient’s safety.
C) Teach the patient’s family about the relationship between brain tumors and
seizure activity.
D) Ensure that the patient is housed in a private room.

Answer 13

B) Implement precautions to ensure the patient’s safety.

Question 14

A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When
planning the patient’s care, the nurse should be aware that the effects of the tumor will
primarily depend on what variable?
A) Whether the tumor utilizes aerobic or anaerobic respiration
B) The specific hormones secreted by the tumor
C) The patient’s pre-existing health status
D) Whether the tumor is primary or the result of metastasis

Answer 14

B) The specific hormones secreted by the tumor

Question 15

A male patient with a metastatic brain tumor is having a generalized seizure and begins
vomiting. What should the nurse do first?
A) Perform oral suctioning.
B) Page the physician.
C) Insert a tongue depressor into the patient’s mouth.
D) Turn the patient on his side.

Answer 15

D) Turn the patient on his side.

Question 16

The nurse in an extended care facility is planning the daily activities of a patient with
postpolio syndrome. The nurse recognizes the patient will best benefit from physical
therapy when it is scheduled at what time?
A) Immediately after meals
B) In the morning
C) Before bedtime
D) In the early evening

Answer 16

B) In the morning

Question 17

A patient newly diagnosed with a cervical disk herniation is receiving health education
from the clinic nurse. What conservative management measures should the nurse teach
the patient to implement?
A) Perform active ROM exercises three times daily.
B) Sleep on a firm mattress.
C) Apply cool compresses to the back of the neck daily.
D) Wear the cervical collar for at least 2 hours at a time.

Answer 17

B) Sleep on a firm mattress.

Question 18

A patient has just returned to the unit from the PACU after surgery for a tumor within
the spine. The patient complains of pain. When positioning the patient for comfort and
to reduce injury to the surgical site, the nurse will position to patient in what position?
A) In the high Fowler’s position
B) In a flat side-lying position
C) In the Trendelenberg position
D) In the reverse Trendelenberg position

Answer 18

B) In a flat side-lying position

Question 19

A patient with Huntington disease has just been admitted to a long-term care facility.
The charge nurse is creating a care plan for this patient. Nutritional management for a
patient with Huntington disease should be informed by what principle?
A) The patient is likely to have an increased appetite.
B) The patient is likely to required enzyme supplements.
C) The patient will likely require a clear liquid diet.
D) The patient will benefit from a low-protein diet.

Answer 19

A) The patient is likely to have an increased appetite.

Question 20

A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health
nurse who is creating a care plan. What nursing diagnosis is most likely for a patient
with this condition?
A) Chronic confusion
B) Impaired urinary elimination
C) Impaired verbal communication
D) Bowel incontinence

Answer 20

C) Impaired verbal communication

Question 21

The nurse educator is discussing neoplasms with a group of recent graduates. The
educator explains that the effects of neoplasms are caused by the compression and
infiltration of normal tissue. The physiologic changes that result can cause what
pathophysiologic events? Select all that apply.
A) Intracranial hemorrhage
B) Infection of cerebrospinal fluid
C) Increased ICP
D) Focal neurologic signs
E) Altered pituitary function

Answer 21

C) Increased ICP
D) Focal neurologic signs
E) Altered pituitary function

Question 22

The nurse is caring for a patient newly diagnosed with a primary brain tumor. The
patient asks the nurse where his tumor came from. What would be the nurse’s best
response?
A) ìYour tumor originated from somewhere outside the CNS.
B) ìYour tumor likely started out in one of your glands.
C) ìYour tumor originated from cells within your brain itself.
D) ìYour tumor is from nerve tissue somewhere in your body.

Answer 22

C) ìYour tumor originated from cells within your brain itself.

Question 23

A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who
is experiencing personality changes. The nurse is aware of what factor that is known to
affect the diagnosis and treatment of brain tumors in older adults?
A) The effects of brain tumors are often attributed to the cognitive effects of aging.
B) Brain tumors in older adults do not normally produce focal effects.
C) Older adults typically have numerous benign brain tumors by the eighth decade
of life.
D) Brain tumors cannot normally be treated in patient over age 75.

Answer 23

A) The effects of brain tumors are often attributed to the cognitive effects of aging.

Question 24

A patient who has been experiencing numerous episodes of unexplained headaches and
vomiting has subsequently been referred for testing to rule out a brain tumor. What
characteristic of the patient’s vomiting is most consistent with a brain tumor?
A) The patient’s vomiting is accompanied by epistaxis.
B) The patient’s vomiting does not relieve his nausea.
C) The patient’s vomiting is unrelated to food intake.
D) The patient’s emesis is blood-tinged.

Answer 24

C) The patient’s vomiting is unrelated to food intake.

Question 25

A male patient presents at the free clinic with complaints of impotency. Upon physical
examination, the nurse practitioner notes the presence of hypogonadism. What
diagnosis should the nurse suspect?
A) Prolactinoma
B) Angioma
C) Glioma
D) Adrenocorticotropic hormone (ACTH)ñproducing adenoma

Answer 25

A) Prolactinoma

Question 26

The nurse is planning the care of a patient who has been recently diagnosed with a
cerebellar tumor. Due to the location of this patient’s tumor, the nurse should
implement measures to prevent what complication?
A) Falls
B) Audio hallucinations
C) Respiratory depression
D) Labile BP

Answer 26

A) Falls

Question 27

A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor.
The patient is scheduled to have a tumor resection/removal in the morning. Which of
the following assessment parameters should the nurse include in the initial assessment?
A) Gag reflex
B) Deep tendon reflexes
C) Abdominal girth
D) Hearing acuity

Answer 27

A) Gag reflex

Question 28

A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent
assessment should the nurse prioritize?
A) Assessment of peripheral nervous function
B) Assessment of cranial nerve function
C) Assessment of nutritional status
D) Assessment of respiratory status

Answer 28

C) Assessment of nutritional status

Question 29

A patient with an inoperable brain tumor has been told that he has a short life
expectancy. On what aspects of assessment and care should the home health nurse
focus? Select all that apply.
A) Pain control
B) Management of treatment complications
C) Interpretation of diagnostic tests
D) Assistance with self-care
E) Administration of treatments

Answer 29

A) Pain control
B) Management of treatment complications
D) Assistance with self-care
E) Administration of treatments

Question 30

An older adult has encouraged her husband to visit their primary care provider, stating
that she is concerned that he may have Parkinson’s disease. Which of the wife’s
descriptions of her husband’s health and function is most suggestive of Parkinson’s
disease?
A) ìLately he seems to move far more slowly than he ever has in the past.
B) ìHe often complains that his joints are terribly stiff when he wakes up in the
morning.
C) ìHe’s forgotten the names of some people that we’ve known for years.
D) ìHe’s losing weight even though he has a ravenous appetite.

Answer 30

A) ìLately he seems to move far more slowly than he ever has in the past.

Question 31

A patient, brought to the clinic by his wife and son, is diagnosed with Huntington
disease. When providing anticipatory guidance, the nurse should address the future
possibility of what effect of Huntington disease?
A) Metastasis
B) Risk for stroke
C) Emotional and personality changes
D) Pathologic bone fractures

Answer 31

C) Emotional and personality changes

Question 32

A patient who was diagnosed with Parkinson’s disease several months ago recently
began treatment with levodopa-carbidopa. The patient and his family are excited that he
has experienced significant symptom relief. The nurse should be aware of what
implication of the patient’s medication regimen?
A) The patient is in a ìhoneymoon periodî when adverse effects of levodopacarbidopa
are not yet evident.
B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation
of treatment.
C) The patient’s temporary improvement in status is likely unrelated to levodopacarbidopa.
D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

Answer 32

D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

Question 33

The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of
care that would include what goal?
A) Promoting effective communication
B) Controlling diarrhea
C) Preventing cognitive decline
D) Managing choreiform movements

Answer 33

A) Promoting effective communication

Question 34

The nurse is caring for a patient diagnosed with Parkinson’s disease. The patient is
having increasing problems with rising from the sitting to the standing position. What
should the nurse suggest to the patient to use that will aid in getting from the sitting to
the standing position as well as aid in improving bowel elimination?
A) Use of a bedpan
B) Use of a raised toilet seat
C) Sitting quietly on the toilet every 2 hours
D) Following the outlined bowel program

Answer 34

B) Use of a raised toilet seat

Question 35

A patient with Parkinson’s disease is experiencing episodes of constipation that are
becoming increasingly frequent and severe. The patient states that he has been
achieving relief for the past few weeks by using OTC laxatives. How should the nurse
respond?
A) ìIt’s important to drink plenty of fluids while you’re taking laxatives.î
B) ìMake sure that you supplement your laxatives with a nutritious diet.î
C) ìLet’s explore other options, because laxatives can have side effects and create
dependency.î
D) ìYou should ideally be using herbal remedies rather than medications to promote
bowel function.î

Answer 35

C) ìLet’s explore other options, because laxatives can have side effects and create dependency.

Question 36

A family member of a patient diagnosed with Huntington disease calls you at the clinic.
She is requesting help from the Huntington’s Disease Society of America. What kind of
help can this patient and family receive from this organization? Select all that apply.
A) Information about this disease
B) Referrals
C) Public education
D) Individual assessments
E) Appraisals of research studies

Answer 36

A) Information about this disease
B) Referrals
C) Public education

Question 37

A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed
by his diagnosis and the known complications of the disease. How can the patient best
make known his wishes for care as his disease progresses?
A) Prepare an advance directive.
B) Designate a most responsible physician (MRP) early in the course of the disease.
C) Collaborate with representatives from the Amyotrophic Lateral Sclerosis
Association.
D) Ensure that witnesses are present when he provides instruction.

Answer 37

A) Prepare an advance directive.

Question 38

The nurse is caring for a patient who is scheduled for a cervical discectomy the
following day. During health education, the patient should be made aware of what
potential complications?
A) Vertebral fracture
B) Hematoma at the surgical site
C) Scoliosis
D) Renal trauma

Answer 38

B) Hematoma at the surgical site

Question 39

The nurse responds to the call light of a patient who has had a cervical diskectomy
earlier in the day. The patient states that she is having severe pain that had a sudden
onset. What is the nurse’s most appropriate action?
A) Palpate the surgical site.
B) Remove the dressing to assess the surgical site.
C) Call the surgeon to report the patient’s pain.
D) Administer a dose of an NSAID.

Answer 39

C) Call the surgeon to report the patient’s pain.

Question 40

A nurse is planning discharge education for a patient who underwent a cervical
diskectomy. What strategies would the nurse assess that would aid in planning
discharge teaching?
A) Care of the cervical collar
B) Technique for performing neck ROM exercises
C) Home assessment of ABGs
D) Techniques for restoring nerve function

Answer 40

A) Care of the cervical collar

Question 41

A patient with possible bacterial meningitis is admitted to the ICU. What assessment
finding would the nurse expect for a patient with this diagnosis?
A) Pain upon ankle dorsiflexion of the foot
B) Neck flexion produces flexion of knees and hips
C) Inability to stand with eyes closed and arms extended without swaying
D) Numbness and tingling in the lower extremities

Answer 41

B) Neck flexion produces flexion of knees and hips

Question 42

The nurse is planning discharge education for a patient with trigeminal neuralgia. The
nurse knows to include information about factors that precipitate an attack. What would
the nurse be correct in teaching the patient to avoid?
A) Washing his face
B) Exposing his skin to sunlight
C) Using artificial tears
D) Drinking large amounts of fluids

Answer 42

A) Washing his face

Question 43

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse
the hardest thing to deal with is the fatigue. When teaching the patient how to reduce
fatigue, what action should the nurse suggest?
A) Taking a hot bath at least once daily
B) Resting in an air-conditioned room whenever possible
C) Increasing the dose of muscle relaxants
D) Avoiding naps during the day

Answer 43

B) Resting in an air-conditioned room whenever possible

Question 44

A patient with Guillain-BarrÈ syndrome has experienced a sharp decline in vital
capacity. What is the nurse’s most appropriate action?
A) Administer bronchodilators as ordered.
B) Remind the patient of the importance of deep breathing and coughing exercises.
C) Prepare to assist with intubation.
D) Administer supplementary oxygen by nasal cannula.

Answer 44

C) Prepare to assist with intubation.

Question 45

A patient diagnosed with Bell’s palsy is being cared for on an outpatient basis. During
health education, the nurse should promote which of the following actions?
A) Applying a protective eye shield at night
B) Chewing on the affected side to prevent unilateral neglect
C) Avoiding the use of analgesics whenever possible
D) Avoiding brushing the teeth

Answer 45

A) Applying a protective eye shield at night

Question 46

The nurse is working with a patient who is newly diagnosed with MS. What basic
information should the nurse provide to the patient?
A) MS is a progressive demyelinating disease of the nervous system.
B) MS usually occurs more frequently in men.
C) MS typically has an acute onset.
D) MS is sometimes caused by a bacterial infection.

Answer 46

A) MS is a progressive demyelinating disease of the nervous system.

Question 47

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS.
Which of the following should the nurse include in the patient’s care plan?
A) Encourage patient to void every hour.
B) Order a low-residue diet.
C) Provide total assistance with all ADLs.
D) Instruct the patient on daily muscle stretching.

Answer 47

D) Instruct the patient on daily muscle stretching.

Question 48

A patient with metastatic cancer has developed trigeminal neuralgia and is taking
carbamazepine (Tegretol) for pain relief. What principle applies to the administration of
this medication?
A) Tegretol is not known to have serious adverse effects.
B) The patient should be monitored for bone marrow depression.
C) Side effects of the medication include renal dysfunction.
D) The medication should be first taken in the maximum dosage form to be
effective.

Answer 48

B) The patient should be monitored for bone marrow depression.

Question 49

A male patient presents to the clinic complaining of a headache. The nurse notes that
the patient is guarding his neck and tells the nurse that he has stiffness in the neck area.
The nurse suspects the patient may have meningitis. What is another well-recognized
sign of this infection?
A) Negative Brudzinski’s sign
B) Positive Kernig’s sign
C) Hyperpatellar reflex
D) Sluggish pupil reaction

Answer 49

B) Positive Kernig’s sign

Question 50

The nurse is developing a plan of care for a patient newly diagnosed with Bell’s palsy.
The nurse’s plan of care should address what characteristic manifestation of this
disease?
A) Tinnitus
B) Facial paralysis
C) Pain at the base of the tongue
D) Diplopia

Answer 50

B) Facial paralysis

Question 51

The nurse caring for a patient diagnosed with Guillain-BarrÈ syndrome is planning care
with regard to the clinical manifestations associated this syndrome. The nurse’s
communication with the patient should reflect the possibility of what sign or symptom
of the disease?
A) Intermittent hearing loss
B) Tinnitus
C) Tongue enlargement
D) Vocal paralysis

Answer 51

D) Vocal paralysis

Question 52

The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis.
The nurse should know that the signs and symptoms of the disease are the result of
what?
A) Genetic dysfunction
B) Upper and lower motor neuron lesions
C) Decreased conduction of impulses in an upper motor neuron lesion
D) A lower motor neuron lesion

Answer 52

D) A lower motor neuron lesion

Question 53

A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit.
The nurse would expect what diagnostic test to be ordered for this patient?
A) Cerebral angiography
B) ABG analysis
C) CT
D) EEG

Answer 53

D) EEG

Question 54

To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol
(carbamazepine). What health education should the nurse provide to the patient before
initiating this treatment?
A) Concurrent use of calcium supplements is contraindicated.
B) Blood levels of the drug must be monitored.
C) The drug is likely to cause hyperactivity and agitation.
D) Tegretol can cause tinnitus during the first few days of treatment.

Answer 54

B) Blood levels of the drug must be monitored.

Question 55

A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU.
What medication would the nurse expect the physician to order for the treatment of this
disease process?
A) Cyclosporine (Neoral)
B) Acyclovir (Zovirax)
C) Cyclobenzaprine (Flexeril)
D) Ampicillin (Prinicpen)

Answer 55

B) Acyclovir (Zovirax)

Question 56

A middle-aged woman has sought care from her primary care provider and undergone
diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most
likely to have prompted the woman to seek care?
A) Cognitive declines
B) Personality changes
C) Contractures
D) Difficulty in coordination

Answer 56

D) Difficulty in coordination

Question 57

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of
myasthenia gravis. What approach would be most appropriate for the care and
scheduling of diagnostic procedures for this patient?
A) All at one time, to provide a longer rest period
B) Before meals, to stimulate her appetite
C) In the morning, with frequent rest periods
D) Before bedtime, to promote rest

Answer 57

C) In the morning, with frequent rest periods

Question 58

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To
ensure the patient’s safety, what nursing action should be performed?
A) Ensure that suction apparatus is set up at the bedside.
B) Pad the patient’s bed rails.
C) Maintain bed rest whenever possible.
D) Provide several small meals each day.

Answer 58

A) Ensure that suction apparatus is set up at the bedside.

Question 59

A 33-year-old patient presents at the clinic with complaints of weakness,
incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed
with MS. What sign or symptom, revealed during the initial assessment, is typical of
MS?
A) Diplopia, history of increased fatigue, and decreased or absent deep tendon
reflexes
B) Flexor spasm, clonus, and negative Babinski’s reflex
C) Blurred vision, intention tremor, and urinary hesitancy
D) Hyperactive abdominal reflexes and history of unsteady gait and episodic
paresthesia in both legs

Answer 59

C) Blurred vision, intention tremor, and urinary hesitancy

Question 60

The nurse is developing a plan of care for a patient with Guillain-BarrÈ syndrome.
Which of the following interventions should the nurse prioritize for this patient?
A) Using the incentive spirometer as prescribed
B) Maintaining the patient on bed rest
C) Providing aids to compensate for loss of vision
D) Assessing frequently for loss of cognitive function

Answer 60

A) Using the incentive spirometer as prescribed

Question 61

A 69-year-old patient is brought to the ED by ambulance because a family member
found him lying on the floor disoriented and lethargic. The physician suspects bacterial
meningitis and admits the patient to the ICU. The nurse knows that risk factors for an
unfavorable outcome include what? Select all that apply.
A) Blood pressure greater than 140/90 mm Hg
B) Heart rate greater than 120 bpm
C) Older age
D) Low Glasgow Coma Scale
E) Lack of previous immunizations

Answer 61

B) Heart rate greater than 120 bpm
C) Older age
D) Low Glasgow Coma Scale

Question 62

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain
abscess. What is a priority nursing responsibility in the care of this patient?
A) Maintaining the patient’s functional independence
B) Providing health education
C) Monitoring neurologic status closely
D) Promoting mobility

Answer 62

C) Monitoring neurologic status closely

Question 63

A patient is being admitted to the neurologic ICU with suspected herpes simplex virus
encephalitis. What nursing action best addresses the patient’s complaints of headache?
A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate
B) Administering hydromorphone (Dilaudid) IV as needed
C) Dimming the lights and reducing stimulation
D) Distracting the patient with activity

Answer 63

C) Dimming the lights and reducing stimulation

Question 64

A patient is admitted through the ED with suspected St. Louis encephalitis. The unique
clinical feature of St. Louis encephalitis will make what nursing action a priority?
A) Serial assessments of hemoglobin levels
B) Blood glucose monitoring
C) Close monitoring of fluid balance
D) Assessment of pain along dermatomes

Answer 64

C) Close monitoring of fluid balance

Question 65

The nurse is caring for a 77-year-old woman with MS. She states that she is very
concerned about the progress of her disease and what the future holds. The nurse should
know that elderly patients with MS are known to be particularly concerned about what
variables? Select all that apply.
A) Possible nursing home placement
B) Pain associated with physical therapy
C) Increasing disability
D) Becoming a burden on the family
E) Loss of appetite

Answer 65

A) Possible nursing home placement
C) Increasing disability
D) Becoming a burden on the family

Question 66

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia
gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What
change in status would most clearly suggest a therapeutic benefit of this medication?
A) Increased muscle strength
B) Decreased pain
C) Improved GI function
D) Improved cognition

Answer 66

A) Increased muscle strength

Question 67

The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse
should prioritize what nursing action in the immediate care of this patient?
A) Suctioning secretions
B) Facilitating ABG analysis
C) Providing ventilatory assistance
D) Administering tube feedings

Answer 67

C) Providing ventilatory assistance

Question 68

The nurse caring for a patient in ICU diagnosed with Guillain-BarrÈ syndrome should
prioritize monitoring for what potential complication?
A) Impaired skin integrity
B) Cognitive deficits
C) Hemorrhage
D) Autonomic dysfunction

Answer 68

D) Autonomic dysfunction

Question 69

The nurse is teaching a patient with Guillain-BarrÈ syndrome about the disease. The
patient asks how he can ever recover if demyelination of his nerves is occurring. What
would be the nurse’s best response?
A) ìGuillain-BarrÈ spares the Schwann cell, which allows for remyelination in the
recovery phase of the disease.î
B) ìIn Guillain-BarrÈ, Schwann cells replicate themselves before the disease
destroys them, so remyelination is possible.î
C) ìI know you understand that nerve cells do not remyelinate, so the physician is
the best one to answer your question.î
D) ìFor some reason, in Guillain-BarrÈ, Schwann cells become activated and take
over the remyelination process.î

Answer 69

A) ìGuillain-BarrÈ spares the Schwann cell, which allows for remyelination in the
recovery phase of the disease.î

Question 70

A patient diagnosed with myasthenia gravis has been hospitalized to receive
plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of
treatment for plasmapheresis in a patient with myasthenia gravis is what?
A) Every day for 1 week
B) Determined by the patient’s response
C) Alternate days for 10 days
D) Determined by the patient’s weight

Answer 70

B) Determined by the patient’s response

Question 71

The nurse is discharging a patient home after surgery for trigeminal neuralgia. What
advice should the nurse provide to this patient in order to reduce the risk of injury?
A) Avoid watching television or using a computer for more than 1 hour at a time.
B) Use OTC antibiotic eye drops for at least 14 days.
C) Avoid rubbing the eye on the affected side of the face.
D) Rinse the eye on the affected side with normal saline daily for 1 week.

Answer 71

C) Avoid rubbing the eye on the affected side of the face.

Question 72

A patient diagnosed with Bell’s palsy is having decreased sensitivity to touch of the
involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
A) Blowing up balloons
B) Deliberately frowning
C) Smiling repeatedly
D) Whistling

Answer 72

D) Whistling

Question 73

A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy.
This patient’s nursing care should involve which of the following?
A) Protection of the affected limb from injury
B) Passive and active ROM exercises for the affected limb
C) Education about improvements to glycemic control
D) Interventions to prevent contractures

Answer 73

A) Protection of the affected limb from injury

Question 74

A patient diagnosed with MS has been admitted to the medical unit for treatment of an
MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should
the nurse identify as an expected outcome of this treatment?
A) Reduction in the appearance of new lesions on the MRI
B) Decreased muscle spasms in the lower extremities
C) Increased muscle strength in the upper extremities
D) Decreased severity and duration of exacerbations

Answer 74

B) Decreased muscle spasms in the lower extremities

Question 75

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her
plan of care, the nurse knows to include what in patient teaching? Select all that apply.
A) Inspect the lower extremities for skin breakdown.
B) Footwear needs to be accurately sized.
C) Immediate family members should be screened for the disease.
D) Assistive devices may be needed to reduce the risk of falls.
E) Dietary modifications are likely necessary.

Answer 75

A) Inspect the lower extremities for skin breakdown.
B) Footwear needs to be accurately sized.
D) Assistive devices may be needed to reduce the risk of falls.

Question 76

A 73-year-old man comes to the clinic complaining of weakness and loss of sensation
in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally.
Why would it be a challenge to diagnose a peripheral neuropathy in this patient?
A) Older adults are often vague historians.
B) The elderly have fewer peripheral nerves than younger adults.
C) Many older adults are hesitant to admit that their body is changing.
D) Many symptoms can be the result of normal aging process.

Answer 76

D) Many symptoms can be the result of normal aging process.

Question 77

A patient with MS has been admitted to the hospital following an acute exacerbation.
When planning the patient’s care, the nurse addresses the need to enhance the patient’s
bladder control. What aspect of nursing care is most likely to meet this goal?
A) Establish a timed voiding schedule.
B) Avoid foods that change the pH of urine.
C) Perform intermittent catheterization q6h.
D) Administer anticholinergic drugs as ordered.

Answer 77

A) Establish a timed voiding schedule.

Question 78

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction.
What nursing action should the nurse consequently perform?
A) Arrange for the patient to receive a low residue diet.
B) Position the patient upright during feeding.
C) Suction the patient following each meal.
D) Withhold liquids until the patient has finished eating.

Answer 78

B) Position the patient upright during feeding.

Question 79

A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent
episodes of unilateral face pain. The nurse should recognize what implication of this
diagnosis?
A) The patient will likely require lifelong treatment with anticholinergic
medications.
B) The patient has a disproportionate risk of developing myasthenia gravis later in
life.
C) The patient needs to be assessed for MS.
D) The disease is self-limiting and the patient will achieve pain relief over time.

Answer 79

C) The patient needs to be assessed for MS.

Question 80

A patient presents at the clinic complaining of pain and weakness in her hands. On
assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and
bilateral loss of sensation. The nurse knows that these findings are indicative of what?
A) Guillain-BarrÈ syndrome
B) Myasthenia gravis
C) Trigeminal neuralgia
D) Peripheral nerve disorder

Answer 80

D) Peripheral nerve disorder

Question 81

A patient is brought to the ER following a motor vehicle accident in which he sustained
head trauma. Preliminary assessment reveals a vision deficit in the patient’s left eye.
The nurse should associate this abnormal finding with trauma to which of the following
cerebral lobes?
A) Temporal
B) Occipital
C) Parietal
D) Frontal

Answer 81

B) Occipital

Question 82

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology
department. The nurse who prepares the patient for the MRI should prioritize which of
the following actions?
A) Withholding stimulants 24 to 48 hours prior to exam
B) Removing all metal-containing objects
C) Instructing the patient to void prior to the MRI
D) Initiating an IV line for administration of contrast

Answer 82

B) Removing all metal-containing objects

Question 83

A gerontologic nurse planning the neurologic assessment of an older adult is
considering normal, age-related changes. Of what phenomenon should the nurse be
aware?
A) Hyperactive deep tendon reflexes
B) Reduction in cerebral blood flow
C) Increased cerebral metabolism
D) Hypersensitivity to painful stimuli

Answer 83

B) Reduction in cerebral blood flow

Question 84

The nurse has admitted a new patient to the unit. One of the patient’s admitting orders is
for an adrenergic medication. The nurse knows that this medication will have what
effect on the circulatory system?
A) Thin, watery saliva
B) Increased heart rate
C) Decreased BP
D) Constricted bronchioles

Answer 84

B) Increased heart rate

Question 85

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient’s
foot is abruptly dorsiflexed, it continues to beat two to three times before settling into
a resting position. How would the nurse document this finding?
A) Rigidity
B) Flaccidity
C) Clonus
D) Ataxia

Answer 85

C) Clonus

Question 86

The nurse is doing an initial assessment on a patient newly admitted to the unit with a
diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a
figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What
brain region is primarily involved in this deficit?
A) Temporal lobe
B) Parietal-occipital area
C) Inferior posterior frontal areas
D) Posterior frontal area

Answer 86

B) Parietal-occipital area

Question 87

What term is used to describe the fibrous connective tissue that hugs the brain closely
and extends into every fold of the brain’s surface?
A) Dura mater
B) Arachnoid
C) Fascia
D) Pia mater

Answer 87

D) Pia mater

Question 88

The nurse is caring for a patient with an upper motor neuron lesion. What clinical
manifestations should the nurse anticipate when planning the patient’s neurologic
assessment?
A) Decreased muscle tone
B) Flaccid paralysis
C) Loss of voluntary control of movement
D) Slow reflexes

Answer 88

C) Loss of voluntary control of movement

Question 89

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron
lesion. What entry in the patient’s electronic record is most consistent with this
diagnosis?
A) Patient exhibits increased muscle tone.
B) Patient demonstrates normal muscle structure with no evidence of atrophy.
C) Patient demonstrates hyperactive deep tendon reflexes.
D) Patient demonstrates an absence of deep tendon reflexes.

Answer 89

D) ìPatient demonstrates an absence of deep tendon reflexes.

Question 90

An elderly patient is being discharged home. The patient lives alone and has atrophy of
his olfactory organs. The nurse tells the patient’s family that it is essential that the
patient have what installed in the home?
A) Grab bars
B) Nonslip mats
C) Baseboard heaters
D) A smoke detector

Answer 90

D) A smoke detector

Question 91

The patient in the ED has just had a diagnostic lumbar puncture. To reduce the
incidence of a post-lumbar puncture headache, what is the nurse’s most appropriate
action?
A) Position the patient prone.
B) Position the patient supine with the head of bed flat.
C) Position the patient left side-lying.
D) Administer acetaminophen as ordered.

Answer 91

A) Position the patient prone.

Question 92

The nurse is conducting a focused neurologic assessment. When assessing the patient’s
cranial nerve function, the nurse would include which of the following assessments?
A) Assessment of hand grip
B) Assessment of orientation to person, time, and place
C) Assessment of arm drift
D) Assessment of gag reflex

Answer 92

D) Assessment of gag reflex

Question 93

A nurse is caring for a patient diagnosed with MÈniËre’s disease. While completing a
neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse
would be correct in identifying the function of this nerve as what?
A) Movement of the tongue
B) Visual acuity
C) Sense of smell
D) Hearing and equilibrium

Answer 93

D) Hearing and equilibrium

Question 94

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the
following is the most plausible cause of this patient’s health problem?
A) Cerebellar dysfunction
B) A lesion in the pons
C) Dysfunction of the medulla
D) A hemorrhage in the midbrain

Answer 94

A) Cerebellar dysfunction

Question 95

A patient is being given a medication that stimulates her parasympathetic system.
Following administration of this medication, the nurse should anticipate what effect?
A) Constricted pupils
B) Dilated bronchioles
C) Decreased peristaltic movement
D) Relaxed muscular walls of the urinary bladder

Answer 95

A) Constricted pupils

Question 96

A patient with lower back pain is scheduled for myelography using metrizamide (a
water-soluble contrast dye). After the test, the nurse should prioritize what action?
A) Positioning the patient with the head of the bed elevated 45 degrees
B) Administering IV morphine sulfate to prevent headache
C) Limiting fluids for the next 12 hours
D) Helping the patient perform deep breathing and coughing exercises

Answer 96

A) Positioning the patient with the head of the bed elevated 45 degrees

Question 97

A patient is having a fight or flight response after receiving bad news about his
prognosis. What affect will this have on the patient’s sympathetic nervous system?
A) Constriction of blood vessels in the heart muscle
B) Constriction of bronchioles
C) Increase in the secretion of sweat
D) Constriction of pupils

Answer 97

C) Increase in the secretion of sweat

Question 98

The nurse educator is reviewing the assessment of cranial nerves. What should the
educator identify as the specific instances when cranial nerves should be assessed?
Select all that apply.
A) When a neurogenic bladder develops
B) When level of consciousness is decreased
C) With brain stem pathology
D) In the presence of peripheral nervous system disease
E) When a spinal reflex is interrupted

Answer 98

B) When level of consciousness is decreased
C) With brain stem pathology
D) In the presence of peripheral nervous system disease

Question 99

A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to
the anesthetic. The nurse knows that the area of the brain that regulates body
temperature is which of the following?
A) Cerebellum
B) Thalamus
C) Hypothalamus
D) Midbrain

Answer 99

C) Hypothalamus

Question 100

The nurse is planning the care of a patient with Parkinson’s disease. The nurse should
be aware that treatment will focus on what pathophysiological phenomenon?
A) Premature degradation of acetylcholine
B) Decreased availability of dopamine
C) Insufficient synthesis of epinephrine
D) Delayed reuptake of serotonin

Answer 100

B) Decreased availability of dopamine

Question 101

A patient is admitted to the medical unit with an exacerbation of multiple sclerosis.
When assessing this patient, the nurse has the patient stick out her tongue and move it
back and forth. What is the nurse assessing?
A) Function of the hypoglossal nerve
B) Function of the vagus nerve
C) Function of the spinal nerve
D) Function of the trochlear nerve

Answer 101

A) Function of the hypoglossal nerve

Question 102

A trauma patient was admitted to the ICU with a brain injury. The patient had a change
in level of consciousness, increased vital signs, and became diaphoretic and agitated.
The nurse should recognize which of the following syndromes as the most plausible
cause of these symptoms?
A) Adrenal crisis
B) Hypothalamic collapse
C) Sympathetic storm
D) Cranial nerve deficit

Answer 102

C) Sympathetic storm

Question 103

Assessment is crucial to the care of patients with neurologic dysfunction. What does
accurate and appropriate assessment require? Select all that apply.
A) The ability to select mediations for the neurologic dysfunction
B) Understanding of the tests used to diagnose neurologic disorders
C) Knowledge of nursing interventions related to assessment and diagnostic testing
D) Knowledge of the anatomy of the nervous system
E) The ability to interpret the results of diagnostic tests

Answer 103

B) Understanding of the tests used to diagnose neurologic disorders
C) Knowledge of nursing interventions related to assessment and diagnostic testing
D) Knowledge of the anatomy of the nervous system

Question 104

When caring for a patient with an altered level of consciousness, the nurse is preparing
to test cranial nerve VII. What assessment technique would the nurse use to elicit a
response from cranial nerve VII?
A) Palpate trapezius muscle while patient shrugs should against resistance.
B) Administer the whisper or watch-tick test.
C) Observe for facial movement symmetry, such as a smile.
D) Note any hoarseness in the patient’s voice.

Answer 104

C) Observe for facial movement symmetry, such as a smile.

Question 105

The nurse is caring for a patient who exhibits abnormal results of the Weber test and
Rinne test. The nurse should suspect dysfunction involving what cranial nerve?
A) Trigeminal
B) Acoustic
C) Hypoglossal
D) Trochlear

Answer 105

B) Acoustic

Question 106

The nurse caring for an 80 year-old patient knows that she has a pre-existing history of
dulled tactile sensation. The nurse should first consider what possible cause for this
patient’s diminished tactile sensation?
A) Damage to cranial nerve VIII
B) Adverse medication effects
C) Age-related neurologic changes
D) An undiagnosed cerebrovascular accident in early adulthood

Answer 106

C) Age-related neurologic changes

Question 107

A 72-year-old man has been brought to his primary care provider by his daughter, who
claims that he has been experiencing uncharacteristic lapses in memory. What principle
should underlie the nurse’s assessment and management of this patient?
A) Loss of short-term memory is normal in older adults, but loss of long-term
memory is pathologic.
B) Lapses in memory in older adults are considered benign unless they have
negative consequences.
C) Gradual increases in confusion accompany the aging process.
D) Thorough assessment is necessary because changes in cognition are always
considered to be pathologic.

Answer 107

D) Thorough assessment is necessary because changes in cognition are always
considered to be pathologic.

Question 108

A gerontologic nurse educator is providing practice guidelines to unlicensed care
providers. Because reaction to painful stimuli is sometimes blunted in older adults,
what must be used with caution?
A) Hot or cold packs
B) Analgesics
C) Anti-inflammatory medications
D) Whirlpool baths

Answer 108

A) Hot or cold packs

Question 109

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used
in making the determination of brain death?
A) Magnetic resonance imaging (MRI)
B) Electroencephalography (EEG)
C) Electromyelography (EMG)
D) Computed tomography (CT)

Answer 109

B) Electroencephalography (EEG)

Question 110

A patient is scheduled for CT scanning of the head because of a recent onset of
neurologic deficits. What should the nurse tell the patient in preparation for this test?
A) ìNo metal objects can enter the procedure room.
B) ìYou need to fast for 8 hours prior to the test.
C) ìYou will need to lie still throughout the procedure.
D) ìThere will be a lot of noise during the test.

Answer 110

C) ìYou will need to lie still throughout the procedure.

Question 111

A patient for whom the nurse is caring has positron emission tomography (PET)
scheduled. In preparation, what should the nurse explain to the patient?
A) The test will temporarily limit blood flow through the brain.
B) An allergy to iodine precludes getting the radio-opaque dye.
C) The patient will need to endure loud noises during the test.
D) The test may result in dizziness or lightheadedness.

Answer 111

D) The test may result in dizziness or lightheadedness.

Question 112

A patient is scheduled for a myelogram and the nurse explains to the patient that this is
an invasive procedure, which assesses for any lesions in the spinal cord. The nurse
should explain that the preparation is similar to which of the following neurologic tests?
A) Lumbar puncture
B) MRI
C) Cerebral angiography
D) EEG

Answer 112

A) Lumbar puncture

Question 113

The physician has ordered a somatosensory evoked responses (SERs) test for a patient
for whom the nurse is caring. The nurse is justified in suspecting that this patient may
have a history of what type of neurologic disorder?
A) Hypothalamic disorder
B) Demyelinating disease
C) Brainstem deficit
D) Diabetic neuropathy

Answer 113

B) Demyelinating disease

Question 114

A patient had a lumbar puncture performed at the outpatient clinic and the nurse has
phoned the patient and family that evening. What does this phone call enable the nurse
to determine?
A) What are the patient’s and family’s expectations of the test
B) Whether the patient’s family had any questions about why the test was necessary
C) Whether the patient has had any complications of the test
D) Whether the patient understood accurately why the test was done

Answer 114

C) Whether the patient has had any complications of the test

Question 115

A patient is currently being stimulated by the parasympathetic nervous system. What
effect will this nervous stimulation have on the patient’s bladder?
A) The parasympathetic nervous system causes urinary retention.
B) The parasympathetic nervous system causes bladder spasms.
C) The parasympathetic nervous system causes urge incontinence.
D) The parasympathetic nervous system makes the bladder contract.

Answer 115

D) The parasympathetic nervous system makes the bladder contract.

Question 116

The nurse is performing a neurologic assessment of a patient whose injuries have
rendered her unable to follow verbal commands. How should the nurse proceed with
assessing the patient’s level of consciousness (LOC)?
A) Assess the patient’s vital signs and correlate these with the patient’s baselines.
B) Assess the patient’s eye opening and response to stimuli.
C) Document that the patient currently lacks a level of consciousness.
D) Facilitate diagnostic testing in an effort to obtain objective data.

Answer 116

B) Assess the patient’s eye opening and response to stimuli.

Question 117

In the course of a focused neurologic assessment, the nurse is palpating the patient’s
major muscle groups at rest and during passive movement. Data gleaned from this
assessment will allow the nurse to describe which of the following aspects of
neurologic function?
A) Muscle dexterity
B) Muscle tone
C) Motor symmetry
D) Deep tendon reflexes

Answer 117

B) Muscle tone

Question 118

The neurologic nurse is testing the function of a patient’s cerebellum and basal ganglia.
What action will most accurately test these structures?
A) Have the patient identify the location of a cotton swab on his or her skin with the
eyes closed.
B) Elicit the patient’s response to a hypothetical problem.
C) Ask the patient to close his or her eyes and discern between hot and cold stimuli.
D) Guide the patient through the performance of rapid, alternating movements.

Answer 118

D) Guide the patient through the performance of rapid, alternating movements.

Question 119

During the performance of the Romberg test, the nurse observes that the patient sways
slightly. What is the nurse’s most appropriate action?
A) Facilitate a referral to a neurologist.
B) Reposition the patient supine to ensure safety.
C) Document successful completion of the assessment.
D) Follow up by having the patient perform the Rinne test.

Answer 119

C) Document successful completion of the assessment.

Question 120

A nurse admits a patient who has a fracture of the nose that has resulted in a skin tear
and involvement of the mucous membranes of the nasal passages. The orthopedic nurse
is aware that this description likely indicates which type of fracture?
A) Compression
B) Compound
C) Impacted
D) Transverse

Answer 120

B) Compound

Question 121

A patient has sustained a long bone fracture and the nurse is preparing the patient’s care
plan. Which of the following should the nurse include in the care plan?
A) Administer vitamin D and calcium supplements as ordered.
B) Monitor temperature and pulses of the affected extremity.
C) Perform passive range of motion exercises as tolerated.
D) Administer corticosteroids as ordered.

Answer 121

B) Monitor temperature and pulses of the affected extremity.

Question 122

A nurse’s assessment of a patient’s knee reveals edema, tenderness, muscle spasms, and
ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts
to stand up.î The nurse should plan care based on the belief that the patient has
experienced what?
A) A first-degree strain
B) A second-degree strain
C) A first-degree sprain
D) A second-degree sprain

Answer 122

B) A second-degree strain

Question 123

A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the
following in order to prevent common complications associated with a hip fracture?
A) Avoid requesting analgesia unless pain becomes unbearable.
B) Use supplementary oxygen when transferring or mobilizing.
C) Increase fluid intake and perform prescribed foot exercises.
D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.

Answer 123

C) Increase fluid intake and perform prescribed foot exercises.

Question 124

A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture.
Which of the following is the priority during nursing care?
A) Preventing infection
B) Maintaining spinal alignment
C) Maximizing function
D) Preventing increased intracranial pressure

Answer 124

B) Maintaining spinal alignment

Question 125

A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture.
Which of the following is the priority during nursing care?
A) Preventing infection
B) Maintaining spinal alignment
C) Maximizing function
D) Preventing increased intracranial pressure

Answer 125

B) Maintaining spinal alignment

Question 126

The patient scheduled for a Syme amputation is concerned about the ability to
eventually stand on the amputated extremity. How should the nurse best respond to the
patient’s concern?
A) ìYou will eventually be able to withstand full weight-bearing after the
amputation.î
B) ìYou will have minimal weight-bearing on this extremity but you’ll be taught how
to use an assistive device.î
C) ìYou likely will not be able to use this extremity but you will receive teaching on
use of a wheelchair.î
D) ìYou will be fitted for a prosthesis which may or may not allow you to walk.î

Answer 126

A) ìYou will eventually be able to withstand full weight-bearing after the
amputation.î

Question 127

A patient with a simple arm fracture is receiving discharge education from the nurse.
What would the nurse instruct the patient to do?
A) Elevate the affected extremity to shoulder level when at rest.
B) Engage in exercises that strengthen the unaffected muscles.
C) Apply topical anesthetics to accessible skin surfaces as needed.
D) Avoid using analgesics so that further damage is not masked.

Answer 127

B) Engage in exercises that strengthen the unaffected muscles.

Question 128

Six weeks after an above-the-knee amputation (AKA), a patient returns to the
outpatient office for a routine postoperative checkup. During the nurse’s assessment,
the patient reports symptoms of phantom pain. What should the nurse tell the patient to
do to reduce the discomfort of the phantom pain?
A) Apply intermittent hot compresses to the area of the amputation.
B) Avoid activity until the pain subsides.
C) Take opioid analgesics as ordered.
D) Elevate the level of the amputation site.

Answer 128

C) Take opioid analgesics as ordered.

Question 129

A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The
nurse recognizes the importance of implementing measures that focus on preventing
flexion contracture of the hip and maintaining proper positioning. Which of the
following measures will best achieve these goals?
A) Encouraging the patient to turn from side to side and to assume a prone position
B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation
C) Minimizing movement of the flexor muscles of the hip
D) Encouraging the patient to sit in a chair for at least 8 hours a day

Answer 129

A) Encouraging the patient to turn from side to side and to assume a prone position

Question 130

A nurse is preparing to discharge an emergency department patient who has been fitted
with a sling to support her arm after a clavicle fracture. What should the nurse instruct
the patient to do?
A) Elevate the arm above the shoulder 3 to 4 times daily.
B) Avoid moving the elbow, wrist, and fingers until bone remodeling is complete.
C) Engage in active range of motion using the affected arm.
D) Use the arm for light activities within the range of motion.

Answer 130

D) Use the arm for light activities within the range of motion.

Question 131

The orthopedic nurse should assess for signs and symptoms of Volkmann’s contracture
if a patient has fractured which of the following bones?
A) Femur
B) Humerus
C) Radial head
D) Clavicle

Answer 131

B) Humerus

Question 132

An emergency department nurse is assessing a 17-year-old soccer player who presented
with a knee injury. The patient’s description of the injury indicates that his knee was
struck medially while his foot was on the ground. The nurse knows that the patient
likely has experienced what injury?
A) Lateral collateral ligament injury
B) Medial collateral ligament injury
C) Anterior cruciate ligament injury
D) Posterior cruciate ligament injury

Answer 132

A) Lateral collateral ligament injury

Question 133

A school nurse is assessing a student who was kicked in the shin during a soccer game.
The area of the injury has become swollen and discolored. The triage nurse recognizes
that the patient has likely sustained what?
A) Sprain
B) Strain
C) Contusion
D) Dislocation

Answer 133

C) Contusion

Question 134

Radiographs of a boy’s upper arm show that the humerus appears to be fractured on one
side and slightly bent on the other. This diagnostic result suggests what type of
fracture?
A) Impacted
B) Compound
C) Compression
D) Greenstick

Answer 134

D) Greenstick

Question 135

A nurse is performing a shift assessment on an elderly patient who is recovering after
surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain,
has an increased heart rate, and increased respiratory rate. The nurse further notes that
the patient is febrile and hypoxic, coughing, and producing large amounts of thick,
white sputum. The nurse recognizes that this is a medical emergency and calls for
assistance, recognizing that this patient is likely demonstrating symptoms of what
complication?
A) Avascular necrosis of bone
B) Compartment syndrome
C) Fat embolism syndrome
D) Complex regional pain syndrome

Answer 135

C) Fat embolism syndrome

Question 136

A young patient is being treated for a femoral fracture suffered in a snowboarding
accident. The nurse’s most recent assessment reveals that the patient is
uncharacteristically confused. What diagnostic test should be performed on this patient?
A) Electrolyte assessment
B) Electrocardiogram
C) Arterial blood gases
D) Abdominal ultrasound

Answer 136

C) Arterial blood gases

Question 137

Which of the following is the most appropriate nursing intervention to facilitate healing
in a patient who has suffered a hip fracture?
A) Administer analgesics as required.
B) Place a pillow between the patient’s legs when turning.
C) Maintain prone positioning at all times.
D) Encourage internal and external rotation of the affected leg.

Answer 137

B) Place a pillow between the patient’s legs when turning.

Question 138

A nurse is planning the care of an older adult patient who will soon be discharged home
after treatment for a fractured hip. In an effort to prevent future fractures, the nurse
should encourage which of the following? Select all that apply.
A) Regular bone density testing
B) A high-calcium diet
C) Use of falls prevention precautions
D) Use of corticosteroids as ordered
E) Weight-bearing exercise

Answer 138

A) Regular bone density testing
B) A high-calcium diet
C) Use of falls prevention precautions
E) Weight-bearing exercise

Question 139

A patient is brought to the emergency department by ambulance after stepping in a hole
and falling. While assessing him the nurse notes that his right leg is shorter than his left
leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not
reveal a fracture. Which of the following is the most plausible explanation for this
patient’s signs and symptoms?
A) Subluxated right hip
B) Right hip contusion
C) Hip strain
D) Traumatic hip dislocation

Answer 139

D) Traumatic hip dislocation

Question 140

An emergency department patient is diagnosed with a hip dislocation. The patient’s
family is relieved that the patient has not suffered a hip fracture, but the nurse explains
that this is still considered to be a medical emergency. What is the rationale for the
nurse’s statement?
A) The longer the joint is displaced, the more difficult it is to get it back in place.
B) The patient’s pain will increase until the joint is realigned.
C) Dislocation can become permanent if the process of bone remodeling begins.
D) Avascular necrosis may develop at the site of the dislocation if it is not promptly
resolved.

Answer 140

D) Avascular necrosis may develop at the site of the dislocation if it is not promptly
resolved.

Question 141

The surgical nurse is admitting a patient from postanesthetic recovery following the
patient’s below-the-knee amputation. The nurse recognizes the patient’s high risk for
postoperative hemorrhage and should keep which of the following at the bedside?
A) A tourniquet
B) A syringe preloaded with vitamin K
C) A unit of packed red blood cells, placed on ice
D) A dose of protamine sulfate

Answer 141

A) A tourniquet

Question 142

An elite high school football player has been diagnosed with a shoulder dislocation.
The patient has been treated and is eager to resume his role on his team, stating that he
is not experiencing pain. What should the nurse emphasize during health education?
A) The need to take analgesia regardless of the short-term absence of pain
B) The importance of adhering to the prescribed treatment and rehabilitation
regimen
C) The fact that he has a permanently increased risk of future shoulder dislocations
D) The importance of monitoring for intracapsular bleeding once he resumes playing

Answer 142

B) The importance of adhering to the prescribed treatment and rehabilitation
regimen

Question 143

A patient has presented to the emergency department with an injury to the wrist. The
patient is diagnosed with a third-degree strain. Why would the physician order an x-ray
of the wrist?
A) Nerve damage is associated with third-degree strains.
B) Compartment syndrome is associated with third-degree strains.
C) Avulsion fractures are associated with third-degree strains.
D) Greenstick fractures are associated with third-degree strains.

Answer 143

C) Avulsion fractures are associated with third-degree strains.

Question 144

A 20 year-old is brought in by ambulance to the emergency department after being
involved in a motorcycle accident. The patient has an open fracture of his tibia. The
wound is highly contaminated and there is extensive soft-tissue damage. How would
this patient’s fracture likely be graded?
A) Grade I
B) Grade II
C) Grade III
D) Grade IV

Answer 144

C) Grade III

Question 145

A 25-year-old man is involved in a motorcycle accident and injures his arm. The
physician diagnoses the man with an intra-articular fracture and splints the injury. The
nurse implements the teaching plan developed for this patient. What sequela of intraarticular
fractures should the nurse describe regarding this patient?
A) Post-traumatic arthritis
B) Fat embolism syndrome (FES)
C) Osteomyelitis
D) Compartment syndrome

Answer 145

A) Post-traumatic arthritis

Question 146

A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic
foot ulcer. The patient requires a transmetatarsal amputation. When planning the
patient’s postoperative care, which of the following nursing diagnoses should the nurse
most likely include in the plan of care?
A) Ineffective Thermoregulation
B) Risk-Prone Health Behavior
C) Disturbed Body Image
D) Deficient Diversion Activity

Answer 146

C) Disturbed Body Image

Question 147

A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle
accident. The patient has been placed in traction until his femur can be rodded in
surgery. For what early complications should the nurse monitor this patient? Select all
that apply.
A) Systemic infection
B) Complex regional pain syndrome
C) Deep vein thrombosis
D) Compartment syndrome
E) Fat embolism

Answer 147

C) Deep vein thrombosis
D) Compartment syndrome
E) Fat embolism

Question 148

A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after
fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place.
What factor may have contributed to this complication?
A) Inadequate vitamin D intake
B) Bleeding at the injury site
C) Inadequate immobilization
D) Venous thromboembolism (VTE)

Answer 148

C) Inadequate immobilization

Question 149

An older adult patient has fallen in her home and is brought to the emergency
department by ambulance with a suspected fractured hip. X-rays confirm a fracture of
the left femoral neck. When planning assessments during the patient’s presurgical care,
the nurse should be aware of the patient’s heightened risk of what complication?
A) Osteomyelitis
B) Avascular necrosis
C) Phantom pain
D) Septicemia

Answer 149

B) Avascular necrosis

Question 150

A patient is being treated for a fractured hip and the nurse is aware of the need to
implement interventions to prevent muscle wasting and other complications of
immobility. What intervention best addresses the patient’s need for exercise?
A) Performing gentle leg lifts with both legs
B) Performing massage to stimulate circulation
C) Encouraging frequent use of the overbed trapeze
D) Encouraging the patient to log roll side to side once per hour

Answer 150

C) Encouraging frequent use of the overbed trapeze

Question 151

A patient who has had an amputation is being cared for by a multidisciplinary
rehabilitation team. What is the primary goal of this multidisciplinary team?
A) Maximize the efficiency of care
B) Ensure that the patient’s health care is holistic
C) Facilitate the patient’s adjustment to a new body image
D) Promote the patient’s highest possible level of function

Answer 151

D) Promote the patient’s highest possible level of function

Question 152

A rehabilitation nurse is working with a patient who has had a below-the-knee
amputation. The nurse knows the importance of the patient’s active participation in selfcare.
In order to determine the patient’s ability to be an active participant in self-care,
the nurse should prioritize assessment of what variable?
A) The patient’s attitude
B) The patient’s learning style
C) The patient’s nutritional status
D) The patient’s presurgical level of function

Answer 152

A) The patient’s attitude

Question 153

The nurse is providing care for a patient who has had a below-the-knee amputation. The
nurse enters the patient’s room and finds him resting in bed with his residual limb
supported on pillow. What is the nurse’s most appropriate action?
A) Inform the surgeon of this finding.
B) Explain the risks of flexion contracture to the patient.
C) Transfer the patient to a sitting position.
D) Encourage the patient to perform active ROM exercises with the residual limb.

Answer 153

B) Explain the risks of flexion contracture to the patient.

Question 154

A patient has returned to the postsurgical unit from the PACU after an above-the-knee
amputation of the right leg. Results of the nurse’s initial postsurgical assessment were
unremarkable but the patient has called out. The nurse enters the room and observes
copious quantities of blood at the surgical site. What should be the nurse’s initial
action?
A) Apply a tourniquet.
B) Elevate the residual limb.
C) Apply sterile gauze.
D) Call the surgeon.

Answer 154

A) Apply a tourniquet.

Question 155

A nurse in a busy emergency department provides care for many patients who present
with contusions, strains, or sprains. Treatment modalities that are common to all of
these musculoskeletal injuries include which of the following? Select all that apply.
A) Massage
B) Applying ice
C) Compression dressings
D) Resting the affected extremity
E) Corticosteroids
F) Elevating the injured limb

Answer 155

B) Applying ice
C) Compression dressings
D) Resting the affected extremity
F) Elevating the injured limb

Question 156

A patient who has undergone a lower limb amputation is preparing to be discharged
home. What outcome is necessary prior to discharge?
A) Patient can demonstrate safe use of assistive devices.
B) Patient has a healed, nontender, nonadherent scar.
C) Patient can perform activities of daily living independently.
D) Patientis free of pain.

Answer 156

A) Patient can demonstrate safe use of assistive devices.

Question 157

An older adult patient experienced a fall and required treatment for a fractured hip on
the orthopedic unit. Which of the following are contributory factors to the incidence of
falls and fractured hips among the older adult population? Select all that apply.
A) Loss of visual acuity
B) Adverse medication effects
C) Slowed reflexes
D) Hearing loss
E) Muscle weakness

Answer 157

A) Loss of visual acuity
B) Adverse medication effects
C) Slowed reflexes
E) Muscle weakness

Question 158

A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after
the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do
not relieve the pain. What would be the most appropriate nursing action?
A) Prepare the patient for opening or bivalving of the cast.
B) Obtain an order for a different analgesic.
C) Encourage the patient to wiggle and move the fingers.
D) Petal the edges of the patient’s cast.

Answer 158

A) Prepare the patient for opening or bivalving of the cast.