Neurology, Fluid and Electrolytes and Disaster Nursing 2011 NURSING PRACTICE IV SET A ________________________________________________________________________ NURSING PRACTICE: Medical Surgical Nursing GENERAL INSTRUCTIONS: 1. This test booklet contains 100 test questions. 2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. 3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES. 5. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is punishable by law. Per RA 8981. ________________________________________________________________________ INSTRUCTIONS: 1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 2. Write the subject title “Nursing Prace: Medical Surgical Nursing” on the box provided. 3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test booklet is Set B. ================================================================================= ============== Situation - Ms. May Mansur encountered vehicular accident on her way to the office and he remains conscious. Police officers brought her to the hospital. 1. You have to observe for increase intracranial pressure. Which of the following is not a sign of increased intracranial pressure? a. Headache b. Vomiting c. Vertigo d. Changes on the level of consciousness 2. Which of the following drug may be given to reduce increase intracranial pressure? a. Scopalamine b. Lanoxin c. Coumadin d. Mannitol 3. Since she medicated to reduce increased intracranial pressure. What nursing measure must be done to prevent further complication? a. Encourage her to observe bed rest b. Check blood pressure every shift c. Observe complete best rest d. Measure intake and output
Transcript
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
NURSING PRACTICE IV SET A________________________________________________________________________NURSING PRACTICE: Medical Surgical Nursing
GENERAL INSTRUCTIONS:
1. This test booklet contains 100 test questions.2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your
answer.4. AVOID ERASURES.5. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is punishable by law. Per
RA 8981.________________________________________________________________________
INSTRUCTIONS:1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.2. Write the subject title “Nursing Prace: Medical Surgical Nursing” on the box provided.3. Shade Set Box “A” on your answer sheet if your test booklet is Set A; Set Box “B” if your test
Situation - Ms. May Mansur encountered vehicular accident on her way to the office and he remains conscious. Police officers brought her to the hospital.
1. You have to observe for increase intracranial pressure. Which of the following is not a sign of increased intracranial pressure? a. Headacheb. Vomiting c. Vertigo d. Changes on the level of consciousness
2. Which of the following drug may be given to reduce increase intracranial pressure? a. Scopalamineb. Lanoxin c. Coumadin d. Mannitol
3. Since she medicated to reduce increased intracranial pressure. What nursing measure must be done to prevent further complication? a. Encourage her to observe bed restb. Check blood pressure every shift c. Observe complete best rest d. Measure intake and output
4. In what manner would you be able to assess accurately her motor strength? a. Observe how he talksb. Instruct her to squeeze her hands c. Allowing him to stand alone d. Pricking her skin with pin
5. Which of the following activities would cause her a risk in the increase of intracranial pressure? a. Coughing b. Readingc. Turning d. Sleeping
Situation: Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.
6. A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first: a. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional helpb. Gently raise Mr. Gabatan to a sitting position to see if the pain eitherc. Roll Mr. Gabatan on his abdomen, place,
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
a pad under his head, and coverhim with any material available d. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
7. Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that: a. Upper extremities are paralyzedb. Lower extremities are paralyzed c. One side of the body is paralyzed d. Both lower and upper extremities are paralyzed
8. The nurse recognizes that the major early problem for Mr. Gabatan will be: a. Bladder control b. Client education c. Quadriceps setting d. Use of aids for ambulation
9. The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to: a. Active exercise b. Deep massage c. Use of tilt board d. Proper positioning
10. Rehabilitation plans for Mr. Gabatan; a. Should be left up to Mr. Gabatan and his familyb. Should be considered and planned for early in his care c. Are not necessary, because he will return to former activitiesd. Are not necessary, because he will probably not able to work again
11. A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse would provide the
most reassurance to the client about the procedure?
a. “Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure”
b. “It is necessary to remove any metal/ metal containing objects before having the MRI done, to avoid the metal being drawn into the magnetic field”
c. “MRI machine is long, hollow, narrow tube, and make you feel somewhat claustrophobic”
d. “You will be able to eat before the procedure unless you get nauseous easily. If so, you should eat lightly”
12. A nurse is providing information to a client scheduled for a lumbar puncture. Which information will the nurse provide to the client?
a. an informed consent form will be required
b. food and fluids will be restricted until after the test
c. there is no need to maintain bed rest after the test
d. the test will probably take about 2 hours
13. A nurse develops a plan of care for a client after a lumbar puncture. Which of the following nursing interventions is not included in the plan of care?
a. assess the client’s ability to void and move extremities
b. inspect puncture site for swelling, redness and drainage
c. maintain client in flat positiond. restrict fluid intake for a period of 2
hours
14. A nurse has formulated a nursing diagnosis of Ineffective Breathing Pattern for a client with neurological disorder. The nurse would avoid including which of the following activities in the care plan for this client?
a. elevate the head of the bed 30 degrees
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
b. keep the client lying in supine position
c. keep the head and neck in good alignment
d. keep suction equipment available at bedside
15. A nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted and stayed in the vicinity of which level?
a. 3 mmHgb. 8 mmHgc. 11 mmHgd. 15 mmHg
16. A client is admitted for overnight observation following a blow to the head during a baseball game. Which of the following assessments warrants immediate nursing action?
a. Widening pulse pressure and bradycardia
b. Narrowing pulse pressure and tachycardia
c. Increasing respiration and irregular pulse rate
d. Narrowing pulse deficit and decreased level of consciousness
17. A client with a spinal cord injury at the level of C5 has weakened respiratory effort and ineffective cough, and is using accessory neck muscles in breathing. The nurse carefully monitors the client, and formulates which of the following nursing diagnosis?
a. Impaired gas exchangeb. ineffective breathing patternc. risk for aspirationd. risk for injury
18. A client is transferring to a chair for the first time following a posterior spinal fusion. To assist the client, the nurse should first
a. secure a mechanical lift to transfer the client from bed to chair.
b. have the client roll on his side, bend his knees, and sit up with assistance without bending his trunk.
c. pull the client to a sitting position using his arms and turn him to dangle on the side of the bed.
d. call physical therapy to supervise the transfer of the client.
19. A nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which of the following as the most critical index of central nervous system dysfunction?
a. Ability to speakb. blood pressurec. level of consciousnessd. temperature
20. A client is experiencing chronic insomnia. The nurse interprets that which of the following areas of the nervous system is involved?
a. hippocampus and frontal lobeb. limbic system and cerebral
21. A nurse is teaching a paraplegic client measures to maintain skin integrity. Which of the following instructions will be least helpful to the client?
a. checking the bottom sheet for wetness & wrinkles
b. shifting weight every 2 hours while in wheelchair
c. using a mirror to inspect for the redness & breakdown twice a week
d. using a pressure relief pad while in a wheelchair
22. A nurse is developing a plan of care for a client with cerebrovascular accident (CVA) who has dysphagia. Which of the following would not be a component of the plan of care?
a. assess for the presence of swallow reflex
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b. place the food on the affected side of the mouth
c. provide ample time for the client to chew and swallow
d. thicken the liquids
23. A nurse is caring for a client with diagnosis of cerebrovascular accident (CVA) with anosognosia. To meet the needs of the client with this deficit, the nurse plans care activities that will:
a. encourage communicationb. increase client’s awareness of the
affected sidec. promote adequate bowel
eliminationd. provide a consistent daily routine
24. The best position for the client who is admitted with risk of increased intracranial pressure from a concussion would be:
a. Trendelenburg.b. Semi-fowler's.c. Sim’s lateral.d. Supine
25. A client with stroke has right sided hemianopsia. The nurse plans to do which of the following to help the client adapt to this visual deficit?
a. ensure that the family brings the client’s eyeglasses to hospital
b. place all objects within the left visual field
c. place all the objects within the right visual field
d. teach the client to scan the environment
26. A client has residual difficulty with chewing food after experiencing a cerebrovascular accident. The nurse interprets that the client has residual dysfunction of which of the following cranial nerves (CN)?
27. The client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety?
a. check the temperature of the food on the dietary tray
b. provide clear path for ambulation without obstacles
c. speak loudly to the clientd. test the temperature of shower
water
28. A nurse is providing instructions to a client with seizure disorder who will be taking phenytoin (Dilantin). Which statement if made by the client indicates that the client understands the information about this medication?
a. “I need to perform good oral hygiene, including brushing and flossing my teeth”
b. “I should monitor for side effects and adjust my medication dose depending on how severe the side effects are”
c. “I should take the medication before coming to the laboratory to have blood level drawn”
d. “I should try to avoid alcohol but if I’m not able to I can drink alcohol in moderation”
29. A nurse is documenting in the record of a client who experienced a tonic clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of seizure?
a. Body stiffeningb. brief flexion of extremitiesc. sudden loss of consciousnessd. violent extension spasm of entire
body
30. A nurse is performing an assessment of a client suspected of having trigeminal neuralgia (tic doloreux). Which of the following assessment questions would elicit data specific to this disorder?
a. “Have you had any numbness and tingling in your face?”
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
b. “Have you had any facial paralysis?”c. “Have you had any sharp pain or
any twitching in any part of your face?”
d. “Have you noticed that your eyelid has been drooping?”
31. A client with trigeminal neuralgia asks the nurse what causes the painful episodes associated with the condition. The nurse’s response is based on an understanding that the symptoms can be triggered by which of the following?
a. hypoglycemic effect on the cranial nerve
b. local reaction to nasal stuffinessc. release of cathecholamines with
infection/ stressd. stimulation of the affected nerve by
pressure & temperature
32. A nurse performing an assessment of a client with a diagnosis of Bell’s palsy, the nurse would expect to observe which of the following in the client?
a. facial droopingb. periorbital edemac. ptosis of eyelidd. twitching on affected side of face
33. Which of the following pathophysiological changes in the brain causes the sign and symptoms of alzheimer’s disease?
a. atrophy of frontal lobeb. degeneration of cholinergic systemc. glucose inadequacyd. intracranial bleeding in limbic
system
34. A client with Alzheimer’s disease becomes extremely agitated. Which of the following initial nursing measures should be implemented to calm the client?
a. Brighten the lightsb. Raise the side railsc. Ambulate the clientd. Play soft music
35. A client with Alzheimer’s disease mumbles incoherently and rambles in a confused
manner. To help redirect the client’s attention, the nurse should encourage the client to:
a. fold towels and pillow casesb. participate in board gamesc. perform an aerobic exercised. play cards with another client
36. A client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
a. excess medicationb. increased intake of fatty foodsc. omitted doses of medicationd. too little exercise
37. A home nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals because of decreased muscle strength. Which of the following suggestions would the nurse avoid giving to the client?
a. cut food into small pieces, chewing thoroughly
b. lift the head while swallowing liquids
c. sit straight up in the chair while eating
d. swallow when the chin is tipped slightly downward to the chest
38. A client with myasthenia gravis received Tensilon test. Which of the following indicates (+) MG?
a. An increase in joint pain following administration of medications
b. an increase in muscle strength within 1-3 minutes
c. a decrease in muscle strengthd. an exacerbation of client’s weakness
39. A nurse has provided instructions to an elderly client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching?
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
a. “I can change the time of my medication on the mornings that I feel stronger”
b. “If I get abdominal cramps and diarrhea, I should call my doctor”
c. “I should cough and deep breathe many times during the day”
d. “I will rest afternoon after my walk”
40. A client is admitted with exacerbation of multiple sclerosis (MS). The nurse is assessing the client for possible precipitating factors. Which of the following factors, if stated by the client, would the nurse assess as being unrelated to the exacerbation?
a. a recent bout of flub. a stressful week at workc. inability to sleep welld. ingestion of more fruits and
vegetables
41. A home health nurse has been discussing interventions to prevent constipation with a client with multiple sclerosis (MS). The nurse would evaluate that the client is using the information most effectively if the client reports which of the following?
a. drinking total of 1500 ml/dayb. initiating a bowel movement every other
day, 45 minutes after largest meal of dayc. taking stool softeners daily,
glycerine suppository once a weekd. use of enema every morning before
breakfast
42. A client with Parkinson’s disease has a nursing diagnosis of Risk for Falls related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait?
a. accelerating with walking on toesb. broad based and waddlingc. shuffling and propulsived. unsteady and staggering
43. A nurse has given instructions to a client with Parkinson’s disease about maintaining mobility. The nurse would evaluate that the
client understood the directions if the client stated he/she should:
a. buy clothes with many buttons to maintain finger dexterity
b. exercise in the evening to combat fatigue
c. rock back and forth to start movement with bradykinesia
d. sit in soft, deep chairs
44. A client with diagnosis of Parkinson’s disease began taking amantadine HCl (Symmetrel) approximately 2 weeks ago. The client reports to the clinic for a follow up evaluation. The nurse would determine that the client is experiencing an adverse effect of this medication if which of the following is noted?
a. Blood pressure of 130/80 mmHgb. complaint of urinary retentionc. decreased akinesiad. decreased rigidity
45. A nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barre syndrome. The client arrives on the nursing unit and the nurse is reviewing the physician’s documentation. The nurse expects to note documentation of which of the following hallmark clinical manifestations of this syndrome?
a. Abrupt onset of fever and headacheb. altered level of consciousnessc. development of progressive muscle
weaknessd. multifocal seizure
46. The client with Guillain Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with his illness?
a. giving client full control over care decisions and restricting visitors
b. providing information, giving positive feedback, and encouraging relaxation
c. providing intravenously administered sedatives, reducing distractions, and limiting visitors
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
d. providing positive feedback and encouraging active range of motion
47. After a cataract surgery, a client is taught to avoid strain on the operative eye. Which of the following statements if made by the client would alert the nurse that further teaching is needed?
a. “I can lie on my operative site”b. “I cannot lift more than 5 lbs”c. “I cannot rub my eye”d. “I need to take stool softeners to
prevent straining”
48. Appropriate nursing diagnosis in client with cataract:
a. alteration in nutritionb. alteration in role
functionc. self care deficitd. sensory perceptual
alterations
49. Which of the following statements by a client who has had a cataract removed would indicate a correct understanding of the nurse’s after-care instructions?
a. “I have to cancel my hairdresser appointment.”
b. “My daughter will be coming over to vacuum for a while.”
c. “I will not have to cancel my golf game.”
d. “I will be able to cook something for tonight.”
50. Normal IOP using tonometer is:
a. 2-7 mmHgb. 7-10 mmHgc. 8-21 mmHgd. 22-30 mmHg
51. The nurse would identify which ocular response as desirable for the client using pilocarpine (Isopto carpine) eye drops:
a. Corneal lubricationb. pupillary constrictionc. pupillary dilationd. mydriasis
52. Which instruction would the nurse include in a discharge teaching plan for a client with a diagnosis of glaucoma:
a. anticipate gradual increase in visual field
b. decrease intake of saturated fats and potassium
c. eye pain and nausea should be reported to physician
d. opacity of the lens is a sign of complication
53. A nurse is performing an admission assessment on a client with diagnosis of detached retina. Which of the following is associated with this eye disorder?
a. pain in the affected eyeb. sense of a curtain falling across the
field of visionc. total loss of visiond. yellow discoloration of sclera
54. A nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment?
a. a reddened conjunctivab. a sudden sharp pain in the eyec. complaints of burst of black spots
or floatersd. total loss of vision
55. A client arrives in an emergency room with a penetrating eye injury from wood chips produced while the client was cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?
a. apply an eye patchb. irrigate the eye with sterile saline c. perform visual acuity testd. remove piece of wood with sterile
eye clamp
56. A client with Meniere’s disease is experiencing vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo?
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
a. avoid sudden head movementsb. increase fluid intake to 3000ml/dayc. increase sodium in the dietd. Lie still and watch the television
57. A six year old has short arm cast place on right extremity. While assessing the fingers during the immediate period after casting, a nurse would report which of the following findings?
a. capillary refill greater than 3 seconds
b. mild edemac. pain on movementd. slight coolness of cast when touched
58. A nurse is giving a client with a left leg cast crutch walking instructions, using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the:
a. crutches and then both legs simultaneously
b. crutches and the right leg, then advance the left leg
c. left leg, right crutch, then right leg and left crutch
d. right crutch, then left leg, then left crutch, then right leg
59. Which of the following is the best way for the nurse to assist a blind client in ambulation?
a. allow client to take nurse’s arm with the nurse walking slightly ahead of the client
b. allow client to walk beside the nurse with the nurse’s hand on the client’s back
c. allow the client to walk down the hall with his/her hand along the wall
d. push the client in a wheelchair
60. A client is admitted post craniotomy . Decadron 4 mg IV is ordered q6h. the nurse understands that decadron is ordered to:
a. decrease cerebral edemab. maintain integrity of gastric mucosac. prevent seizured. stabilize blood sugar
61. A nurse in the emergency room is assessing a client with an open leg fracture. The nurse inquires about the date of the client’s last:
a. Chest radiographb. physical examinationc. tetanus vaccined. tuberculin test
62. A nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. Which of the following assessment findings is not an associated risk factor?
a. family history of osteoporosisb. high calcium diet consumptionc. long term use of corticosteroidd. post menopausal age
63. A nurse is caring for a client in skeletal traction. The nurse is assessing the pin sites and notes the presence of purulent discharge. Which nursing action would be most appropriate?
a. apply antibiotic ointment to the pin sites
b. clean the pin sites more frequently than prescribed
c. document findingsd. notify the physician
64. A nurse is caring for a client with long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment in the:
a. cardiovascular systemb. client’s mobility statusc. neurological and respiratory systemd. renal system
65. A client has been instructed in crutch walking techniques and has been fitted for crutches. Before the client begins ambulation, the nurse checks the fit of the crutches to assure that there is a space between the axilla and the top crutch pad of:
a. ½ -1 inchb. ½ -2 inches
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
c. 2-3 inchesd. 3-4 inches
Situation : Care of client with Thyrotoxicosis requires knowledge and skills to a beginning nurse. The following question will test your knowledge in Thyrotoxicosis and its related care.
66. The nurse is completing a health assessment of 53 year old women with suspected Grave’s Disease. The nurse should assess this client for
a. Anorexia b. Tachycardia c. Weight gain d. Cold skin
67. A female client with thyrotoxicosis would probably report which changes related to the menstrual cycle during initial assessment?
a. Dysmenorrheab. Metrorrhagia c. Oligomenorhead. Menorrhagia
68. Prophylthioracil (PTU) is prescribed for a client with graves disease to decrease the circulating thyroid hormone. The nurse should teach the client to immediately report which of the following signs and symptoms?
a. Sore throat b. Painful excessive menstruationc. Constipation d. Increase urine output
69. The client with thyrotoxicosis says to the nurse. “I am so irritable. I am having problems at work because I lose my temper easily.” Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
a. Your behavior is cause by temporary confusion brought on by illness.
b. Your behavior is cause by excess thyroid hormone in your system.
c. Your worrying is caused by seriousness of your system.
d. Your behavior is cause by stress of trying to manage a career and cope with illness.
70. Serum concentration of thyroid hormones and thyroid stimulating hormones (TSH) are test ordered for the client with thyrotoxicosis. Which of the following laboratory values are indicative of thyrotoxicosis?
a. Elevated thyroid hormone concentration and normal TSH
b. Elevated TSH and normal thyroid hormone concentrations
c. Decrease thyroid hormone concentration and elevated TSH
d. Elevated thyroid hormone concentrations decrease TSH
71. The nurse would teach the client to prevent corneal irritation fro mild exopthalmus by
a. Massaging the eyes at regular intervals b. Instilling an ophthalmic anesthetic as
ordered c. Wearing dark colored glasses d. Covering both eyes with moistened gauze
pads
72. The client is treated with Radioactive Iodine (RAI) in the form of sodium iodide 131 I. which of the following statement by the nurse will explain to the client how the drug works?
a. The radioactive iodine stabilizes the thyroid hormone levels before thyroidectomy
b. The radioactive iodine reduces uptake of thyroxine and thereby improves your condition.
c. The radioactive iodine lowers the levels of thyroid hormones by slowing your bodys production of them.
d. The radioactive iodine destroys thyroid tissue so that the thyroid hormones are no longer produced.
73. After treatment with RAI in the form of sodium iodide 131 I. the nurse teaches the client to
a. Monitor for signs and symptoms of hyperthyroidism
b. Rest for 1 week to prevent complications of the medication.
c. Take the thyroxine replacement for the remainder of the clients life
d. Assess for hypertension and tachycardia resulting from altered thyroid activity
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
74. A client with large goiter is scheduled for subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason in using this drug is to
a. Slow progression of exopthalmos b. Reduce the vascularity of the thyroid gland c. Decrease the ability of the body’s ability to
excrete thyroxine d. Increase the body’s ability to excrete
thyroxine
75. Which of the following symptoms might indicate that a client was developing Tetany after subtotal thyroidectomy ?
a. Pain the joints of hands and feet b. Tingling in the fingers c. Bleeding on the back of the dressing d. Tension on the suture line
Situation: Diabetes Mellitus is the 8th leading cause of death of old age. Care of patient with DM plays an important role in preventing the complication. The following question tackles about DM.
76. The client with type 1 DM is admitted to the emergency department. Which of the following respiration patterns requires immediate action?
a. Deep, rapid respirations with long expiration
b. Shallow respiration alternating with long expirations
c. Regular depth of respiration with frequent pause
d. Short expiration and inspiration
77. The client with type 1 DM is prescribed with the Sulfonyurea compound Tobutamide (Orinase). The patient is concerned about eh diagnosis and says “ I know nothing about Diabetes”. The nurse determines that the client needs teaching and support. The nurse explain that tolbutamide is believed to lower the blood glucose level by which of the following actions?
a. Potentiating the action of insulin b. Lowering the renal threshold of glucose
c. Stimulating insulin release from functioning beta cells in the pancreas
d. Combining with glucose to render it inert
78. The client with type 1 DM is taught to take isophane insulin suspension NPH (Humulin N) at 5 pm each day. The client should be instructed that the greatest risk for hypoglycemia will occur at about what time?
a. 11 am, shortly before lunch b. 1 pm, shortly after lunch c. 6 pm, shortly after dinner d. 1 am, while sleeping
79. The Diabetic client who is taking insulin lispro ( Humalog) injections would be advised to eat
a. Within 10-15 min after injection b. 1 hour after injection c. At any time , because timing of meals with
humalog injections is necessary d. 2 hours before injection
80. The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates impending hypoglycemia?
a. 59 mg/dl b. 75 mg/dl c. 108 mg/dl d. 119 mg/dl
Situation: Care of patient with pituitary adenoma. As a surgical nurse proper assessment and intervention should be initiated to prevent further complication.
81. Galactorrhea is caused by overproduction of which hormone?
a. Prolactin b. Adrenocortocotropic hormone c. Growth hormone d. Thyroid stimulating hormone
82. Before undergoing a transphenodal hypophysectomy for pituitary adenoma, the client ask the nurse how the surgeon will close the incision in the Dura. The nurse
Neurology, Fluid and Electrolytes and Disaster Nursing 2011
would response base on the knowledge that:
a. Dissolve suture are used to close the dura b. Nasal packing provides pressure until
normal wound healing occursc. A patch is made with a piece of facia d. A sybthetic mesh is used to facilitate
healing
83. Initial treatment for CSF leak after transphenoidal hypophysectomy would most likely involve
a. Repacking the nose b. Return the client to surgery c. Enforcing bed rest with the head of the bed
elevated d. Administering high dose corticosteroid
therapy
84. After pituitary surgery the nurse should assess the client for which of the following?
a. Urine specific gravity less than 1.010b. Urine output between 1 and 2 L/day c. Blood glucose level higher than 300
mg/100 ml d. Urine negative for glucose and ketones
85. Vassopressin is administered to the client with diabetes insipidus (DI) because it
a. Decrease blood pressure b. Increase tubular reabsorption of water c. Increase release of insulin from pancreasd. Decrease glucose production from the
liver
Situation – Andrea is admitted to the ER following an assault where she was hit in the
face and head. She was brought to the ER by a police woman. Emergencymeasures were started.
86. As Andrea’s nurse, what will be your priority interventionsA. Insert an intravenous catheter B. Insert an oral or nasopharyngeal airwayC. Obtain arterial blood gasesD. Give 100% oxygen by mask
87. Andrea’s arterial blood gases reflect respiratory acidosis. This is most likely related to:A. Partially obstructed airwayB. Ineffective breathing patternC. Head injury
D. Pain
88. Andrea loses consciousness. You should prepare for which of the following FIRST?A. Placement of a nasogastric tubeB. Placement of a second IV lineC. Endotracheal intubation or surgical airway placementD. CT scan of the head
89. Andrea’s physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP.This is given to:A. promote cerebral-tissue fluid movementB. promote renal perfusionC. correct acid-base imbalancesD. enhance renal excretion of drugs
90. As Andrea’s nurse your goal is to prevent increased intracranial pressure (ICP). Whichof the following independent nursing interventions nursing interventions is NOT suited for her?A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspirationB. Keep head of bed 30-45 degrees elevatedC. Maintain Andrea’s head in straight alignment and prevent hip flexionD. Prevent constipation and increases in intra-abdominal pressure
Situation: Ensuring safety before, during and after a diagnostic procedure is animportant responsibility of the nurse.
91. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice
which of the following prior to the procedure?A. clenching his fist every 2 minutesB. breathing in and out through the nose with his mouth openC. tensing the shoulder muscles while lying on his backD. holding his breath periodically for 30 seconds
92. Following a bronchoscopy, which of the following complains to Fernan should be noted
as a possible complication:A. nausea and vomitingB. shortness of breath and laryngeal stridorC. blood tinged sputum and coughingD. sore throat and hoarseness
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93. Immediately after bronchoscopy, you instructed Fernan to:A. exercise the neck musclesB. breathe deeplyC. retrain from coughing and talkingD. clear his throat
94. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your
most important function during the procedure is to:A. keep the sterile equipment from contaminationB. assist the physicianC. open and close the three-way stopcockD. observe the patient’s vital signs
95. Right after thoracentesis, which of the following is most appropriate intervention?A. instruct the patient not to cough or deep breathe for two hoursB. observe for symptoms of tightness of chest for bleedingC. place an ice pack to the puncture siteD. remove the dressing to check for bleeding
Situation : Nurses have important responsibilities when caring for hospitalized acutely illpatients.
95. Domingo, 80 years old diabetic and hypertensive is admitted in the private ward for
degenerative neurological changes. His physician was considering dementia. Side rails wereplaced to ensure that he will not fall from bed. At 2:00 AM, the call light at his room was on.You came in and saw Domingo slumped on the floor moaning. His daughter told you that hegot out of bed to go to the toilet. He climbed over the side rail but his foot got caught in thebeddings. He has an open wound on his forehead. Which among the following will you doFIRST?A. Transfer him to bedB. Apply restraintsC. Ensure airway, breathing, circulationD. Call his physician
96. Aimee has chest pain and decides to take nitroglycerine en route to the hospital. Based
on the ECG obtained on admission at the ER and clinical findings, the physician gave adiagnosis of myocardial infarction (MI) and prescribed IV morphine to relieve continuing pain.A primary goal of nursing care for Aimee is to recognize life-threatening complications of MI.As Aimee’s nurse, you have to anticipate occurrence of complications. Take note that themajor cause of death after an MI is:A. Cardiac arrhythmias C. Cardiogenic shockB. Heart failure D. Pulmonary embolism
97. The cardiac monitor indicates that Cedric’s heart rate has increased to 150 beats per
minute. Shortly after this increase, you notice Cedric is in ventricular tachycardia. afterreporting this to the physician, you anticipate that the physician will order.A. intracardiac epinephrineB. insertion of a pacemakerC. bolus of LidocaineD. manual cardiopulmonary resuscitation
98. Hermie with a left-sided heart failure complains of increasing shortness of breath and is
agitated and coughing up of pink-tinged foamy sputum. You should recognize this as signsand symptoms of:A. cardiogenic shock C. acute pulmonary edemaB. right-sided heart failure D. pneumonia
99. You are caring for Lulu has acute pulmonary edema. To immediate promote
oxygenation and relief of dyspnea, you should first:A. perform chest physiotherapyB. have her take deep breaths and coughC. place Lulu on high fowler’s positionD. administer oxygen
100. A difficult problem to deal with when caring for a patient with a partial-thickness burns
sustained 3 days ago is:A. alteration in body image C. frequent dressing changeB. maintenance of sterility D. severe pain
