1.

Question
An 18-year-old client is admitted with a closed head injury sustained in a
MVA. His intracranial pressure (ICP) shows an upward trend. Which
intervention should the nurse perform first?

 A. Reposition the client to avoid neck flexion.

 B. Administer 1 g Mannitol IV as ordered.
 C. Increase the ventilator’s respiratory rate to 20
breaths/minute.
 D. Administer 100 mg of pentobarbital IV as ordered.

Correct Answer: A. Reposition the client to avoid neck flexion..

2. Question
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV.
Which consideration is mostimportant when administering this dose?

 A. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.

 B. Rapid Dilantin administration can cause cardiac arrhythmias.
 C. Dilantin should be mixed in dextrose in water before administration.
 D. Dilantin should be administered through an IV catheter in the client’s hand.

Correct Answer: B. Rapid Dilantin administration can cause

cardiac arrhythmias.

3. Question
A client with head trauma develops a urine output of 300 ml/hr, dry skin,
and dry mucous membranes. Which of the following nursing interventions
is the most appropriate to perform initially?

 A. Evaluate urine specific gravity.

 B. Anticipate treatment for renal failure.
 C. Provide emollients to the skin to prevent breakdown.
 D. Slow down the IV fluids and notify the physician.

Correct Answer: A. Evaluate urine specific gravity.

4. Question
When evaluating an ABG from a client with a subdural hematoma, the
nurse notes the PaCO2 is 30 mm Hg. Which of the following responses
best describes this result?

 A. Appropriate; lowering carbon dioxide (CO2) reduces

intracranial pressure (ICP).
 B. Emergent; the client is poorly oxygenated.
 C. Normal
 D. Significant; the client has alveolar hypoventilation.

Correct Answer: A. Appropriate; lowering carbon dioxide (CO2) reduces

intracranial pressure (ICP).

5. Question
A client who had a transsphenoidal hypophysectomy should be watched
carefully for hemorrhage, which may be shown by which of the following
signs?

 A. Bloody drainage from the ears

 B. Frequent swallowing
 C. Guaiac-positive stools
 D. Hematuria

Correct Answer: B. Frequent swallowing

Frequent swallowing after brain surgery may indicate fluid or blood
leaking from the sinuses into the oropharynx. In the occurrence of a leak
in the postoperative period, the patient is advised bed rest, and a lumbar
drain is placed. If the leak does not improve in 24 hours, exploration and
closure of the defect are to be done. Worsening of vision as a result of
bleeding or manipulation and arterial hemorrhage are other immediate
complications.

6. Question
After a hypophysectomy, vasopressin is given IM for which of the
following reasons?

 A. To treat growth failure.

  B. To prevent syndrome of inappropriate antidiuretic hormone
(SIADH).
 C. To reduce cerebral edema and lower intracranial pressure.
 D. To replace antidiuretic hormone (ADH) normally
secreted by the pituitary.

Correct Answer: D. To replace antidiuretic hormone (ADH) normally

secreted by the pituitary.

7. Question
A client comes into the ER after hitting his head in an MVA. He’s alert and
oriented. Which of the following nursing interventions should be
done first?

 A. Assess full ROM to determine extent of injuries.

 B. Call for an immediate chest x-ray.
 C. Immobilize the client’s head and neck.
 D. Open the airway with the head-tilt-chin-lift maneuver.

Correct Answer: C. Immobilize the client’s head and neck.

8. Question
A client with a C6 spinal injury would most likely have which of the
following symptoms?

 A. Aphasia
 B. Hemiparesis
 C. Paraplegia
 D. Tetraplegia

Correct Answer: D. Tetraplegia

9. Question
A 30-year-old was admitted to the progressive care unit with a C5 fracture
from a motorcycle accident. Which of the following assessments would
take priority?

 A. Bladder distension
 B. Neurological deficit
  C. Pulse ox readings
 D. The client’s feelings about the injury

Correct Answer: C. Pulse ox readings

10. Question
While in the ER, a client with C8 tetraplegia develops a blood pressure of
80/40, pulse 48, and RR of 18. The nurse suspects which of the following
conditions?

 A. Autonomic dysreflexia
 B. Hemorrhagic shock
 C. Neurogenic shock
 D. Pulmonary embolism

Correct Answer: C. Neurogenic shock

11. Question
A client is admitted with a spinal cord injury at the level of T12. He has
limited movement of his upper extremities. Which of the following
medications would be used to control edema of the spinal cord?

 A. acetazolamide (Diamox)
 B. furosemide (Lasix)
 C. methylprednisolone (Solu-Medrol)
 D. sodium bicarbonate

Correct Answer: C. Methylprednisolone (Solu-Medrol)

12. Question
A 22-year-old client with quadriplegia is apprehensive and flushed, with a
blood pressure of 210/100 and a heart rate of 50 bpm. Which of the
following nursing interventions should be done first?

 A. Place the client flat in bed.

 B. Assess patency of the indwelling urinary catheter.
 C. Give one SL nitroglycerin tablet.
 D. Raise the head of the bed immediately to 90
degrees.
Correct Answer: D. Raise the head of the bed immediately to 90 degrees.

13. Question
A client with a cervical spine injury has Gardner-Wells tongs inserted for
which of the following reasons?

 A. To hasten wound healing.

 B. To immobilize the cervical spine.
 C. To prevent autonomic dysreflexia.
 D. To hold bony fragments of the skull together.

Correct Answer: B. To immobilize the cervical spine.

Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until
surgical stabilization is accomplished. There are several uses for GWT,
including the treatment of cervical spine fractures, patient positioning
inside the operating room, and skeletal traction during spinal deformity
surgery. Aside from GWT, different apparatuses have been utilized for
skeletal traction, including Crutchfield’s caliper, Cone’s caliper,
Blackburn’s caliper, and halo traction.

14. Question
Which of the following interventions describes an appropriate bladder
program for a client in rehabilitation for spinal cord injury?

 A. Insert an indwelling urinary catheter to straight drainage.

 B. Schedule intermittent catheterization every 2 to 4
hours.
 C. Perform a straight catheterization every 8 hours while
awake.
 D. Perform Crede’s maneuver to the lower abdomen before
the client voids.

Correct Answer: B. Schedule intermittent catheterization every 2 to 4

hours.

15. Question
A client who is admitted to the ER for head trauma is diagnosed with an
epidural hematoma. The underlying cause of epidural hematoma is
usually related to which of the following conditions?
  A. Laceration of the middle meningeal artery.
 B. Rupture of the carotid artery.
 C. Thromboembolism from a carotid artery.
 D. Venous bleeding from the arachnoid space.

Correct Answer: A. Laceration of the middle meningeal artery.

16. Question
A 23-year-old client has been hit on the head with a baseball bat. The
nurse notes clear fluid draining from his ears and nose. Which of the
following nursing interventions should be done first?

 A. Position the client flat in bed.

 B. Check the fluid for dextrose with a dipstick.
 C. Suction the nose to maintain airway patency.
 D. Insert nasal and ear packing with sterile gauze.

Correct Answer: B. Check the fluid for dextrose with a dipstick.

When discharging a client from the ER after

1. An interval when the client’s speech is garbled.

head trauma, the nurse teaches the guardian to observe for a lucid
interval. Which of the following statements bestdescribes a lucid interval?

 A. An interval when the client’s speech is garbled.

 B. An interval when the client is alert but can’t recall recent
events.
 C. An interval when the client is oriented but then
becomes somnolent.
 D. An interval when the client has a “warning” symptom, such
as an odor or visual disturbance.

Correct Answer: C. An interval when the client is oriented but then

becomes somnolent.
A lucid interval is described as a brief period of unconsciousness followed
by alertness; after several hours, the client again loses consciousness.
The lucid interval following head trauma and unconsciousness is
described classically in epidural hematomas. The historic emphasis placed
on the lucid interval in cases of extradural hematoma has made this one
of the best-remembered signs of the syndrome. Initial unconsciousness is
thought to be due to the concussive effect of the blow to the head. The
lucid period is the time required for the clot to grow to proportions great
enough to produce compression of the brain.

18. Question
Which of the following clients on the rehab unit is most likely to develop
autonomic dysreflexia?

 A. A client with a brain injury.

 B. A client with a herniated nucleus pulposus.
 C. A client with a high cervical spine injury.
 D. A client with a stroke.

Correct Answer: C. A client with a high cervical spine injury.

19. Question
Which of the following conditions indicates that spinal shock is resolving
in a client with C7 quadriplegia?

 A. Absence of pain sensation in chest

 B. Spasticity
 C. Spontaneous respirations
 D. Urinary continence

Correct Answer: B. Spasticity

20. Question
A nurse assesses a client who has episodes of autonomic dysreflexia.
Which of the following conditions can cause autonomic dysreflexia?

 A. Headache
 B. Lumbar spinal cord injury
 C. Neurogenic shock
 D. Noxious stimuli
Correct Answer: D. Noxious stimuli

21. Question
During an episode of autonomic dysreflexia in which the client becomes
hypertensive, the nurse should perform which of the following
interventions?

 A. Elevate the client’s legs.

 B. Put the client flat in bed.
 C. Put the client in Trendelenburg's position.
 D. Put the client in the high-Fowler’s position.

Correct Answer: D. Put the client in the high-Fowler’s position.

Putting the client in the high-Fowler’s position will decrease cerebral
blood flow, decreasing hypertension. Sitting the patient upright and
removing any tight clothing or constrictive devices will orthostatically help
lower blood pressure by inducing pooling of blood in the abdominal and
lower extremity vessels as well as removing any possible stimuli.

22. Question
A client with a T1 spinal cord injury arrives at the emergency department
with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower
extremities. Which of the following conditions would mostlikely be
suspected?

 A. Autonomic dysreflexia
 B. Hypervolemia
 C. Neurogenic shock
 D. Sepsis

Correct Answer: C. Neurogenic shock

23. Question
A client has a cervical spine injury at the level of C5. Which of the
following conditions would the nurse anticipate during the acute phase?A.
Absent corneal reflex.

 A. Absent corneal reflex.

 B. Decerebrate posturing.
  C. Movement of only the right or left half of the body.
 D. The need for mechanical ventilation.

Correct Answer: D. The need for mechanical ventilation

24. Question
A client with C7 quadriplegia is flushed and anxious and complains of a
pounding headache. Which of the following symptoms would also be
anticipated?

 A. Decreased urine output or oliguria

 B. Hypertension and bradycardia
 C. Respiratory depression
 D. Symptoms of shock

Correct Answer: B. Hypertension and bradycardia

25. Question
A 40-year-old paraplegic must perform intermittent catheterization of the
bladder. Which of the following instructions should be given?

 A. “Clean the meatus from back to front.”

 B. “Measure the quantity of urine.”
 C. “Gently rotate the catheter during removal.”
 D. “Clean the meatus with soap and water.”

Correct Answer: D. “Clean the meatus with soap and water.”

1. Question
An 18-year-old client was hit in the head with a baseball during practice. When discharging him
to the care of his mother, the nurse gives which of the following instructions?

A. “Watch him for a keyhole pupil the next 24 hours.”

B. “Expect profuse vomiting for 24 hours after the injury.”
C. “Wake him every hour and assess his orientation to person, time,
and place.”
D. “Notify the physician immediately if he has a headache.”

2. Question
Which neurotransmitter is responsible for many of the functions of the frontal lobe?

A. Dopamine
B. GABA
C. Histamine
D. Norepinephrine

3. Question
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a
client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for
the nurse to tell family members that the test measures which of the following conditions?

A. Extent of intracranial bleeding.

B. Sites of brain injury.
C. Activity of the brain.
D. Percent of functional brain tissue.
4. Question
client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a
collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

A. Subdural hematoma
B. Subarachnoid hemorrhage
C. Epidural hematoma
D. Contusion

5. Question
After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which
other findings should the nurse expect?

A. Quadriplegia with gross arm movement and diaphragmatic

breathing.
B. Quadriplegia and loss of respiratory function.
C. Paraplegia with intercostal muscle loss.
D. Loss of bowel and bladder control.

6. Question
A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine
injury is suspected. How should the first-responder open the client’s airway for rescue breathing?

A. By inserting a nasopharyngeal airway.

B. By inserting an oropharyngeal airway.
C. By performing a jaw thrust maneuver.
D. By performing the head-tilt, chin-lift maneuver.

7. Question
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the
nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client
reports a severe, pounding headache. Which of the following nursing interventions would be
appropriate for this client? Select all that apply.

A. Elevate the HOB to 90 degrees.

B. Loosen constrictive clothing.
C. Use a fan to reduce diaphoresis.
D. Assess for bladder distention and bowel impaction.
E. Administer antihypertensive medication.
F. Place the client in a supine position with legs elevated.

8. Question
The client with a head injury has been urinating copious amounts of dilute urine through the
Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse
implements a new physician order to administer:

A. desmopressin (DDAVP, Stimate)

B. Dexamethasone (Decadron)
B. Dexamethasone (Decadron) C. ethacrynic acid (Edecrin)
D. mannitol (Osmitrol)

9. Question
The nurse is caring for the client in the ER following a head injury. The client momentarily lost
consciousness at the time of the injury and then regained it. The client now has lost
consciousness again. The nurse takes quick action, knowing this is compatible with:

A. Skull fracture
B. Concussion
C. Subdural hematoma
D. Epidural hematoma

10. Question
The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse
monitors for GI complications by assessing for:

A. A flattened abdomen.
B. Hematest positive nasogastric tube drainage.
C. Hyperactive bowel sounds.
D. A history of diarrhea.

11. Question
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse
would avoid which of the following measures to minimize the risk of recurrence?

A. Strict adherence to a bowel retraining program.

B. Limiting bladder catheterization to once every 12 hours.
C. Keeping the linen wrinkle-free under the client.
D. Preventing unnecessary pressure on the lower limbs.

12. Question
The nurse is planning care for the client in spinal shock. Which of the following actions would
be least helpful in minimizing the effects of vasodilation below the level of the injury?

A. Monitoring vital signs before and during position changes.

B. Using vasopressor medications as prescribed.
C. Moving the client quickly as one unit.
D. Applying Teds or compression stockings.
13. Question
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of
compounding the injury most effectively by:

A. Keeping the client on a stretcher.

B. Logrolling the client on a firm mattress.
C. Logrolling the client on a soft mattress.
D. Placing the client on a Stryker frame.

14. Question
The nurse is evaluating neurological signs of the male client in spinal shock following spinal
cord injury. Which of the following observations by the nurse indicates that spinal shock
persists?

A. Positive reflexes
B. Hyperreflexia
C. Inability to elicit a Babinski’s reflex.
D. Reflex emptying of the bladder.

16. Question
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to
monitor?

A. Unequal pupil size

B. Decreasing systolic blood pressure
C. Tachycardia
D. Decreasing body temperature

17. Question
Which of the following respiratory patterns indicate increasing ICP in the brain stem?

A. Slow, irregular respirations

B. Rapid, shallow respirations
C. Asymmetric chest expansion
D. Nasal flaring

18. Question
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm
Hg?

A. Give the client a warming blanket.

B. Administer low-dose barbiturate.
C. Encourage the client to hyperventilate.
D. Restrict fluids.

19. Question
A client has signs of increased ICP. Which of the following is an early indicator of deterioration
in the client’s condition?

A. Widening pulse pressure

B. Decrease in the pulse rate
C. Dilated, fixed pupil
D. Decrease in LOC

20. Question
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull
out her IV line. Which nursing intervention protects the client without increasing her ICP?

A. Place her in a jacket restraint.

B. Wrap her hands in soft “mitten” restraints.
C. Tuck her arms and hands under the draw sheet.
D. Apply a wrist restraint to each arm.

21. Question
Which of the following describes decerebrate posturing?

A. Internal rotation and adduction of arms with flexion of elbows, wrists,

and fingers.
B. Back hunched over, rigid flexion of all four extremities with supination of
arms and plantar flexion of the feet.
C. Supination of arms, dorsiflexion of feet.
D. Back arched; rigid extension of all four extremities.

22. Question
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after
recent intracranial occipital bleeding. Which action would be most appropriate?

A. Count the rate to be sure the ventilations are deep enough to be

sufficient.
B. Call the physician while another nurse checks the vital signs and
ascertains the patient’s Glasgow Coma score.
C. Call the physician to adjust the ventilator settings.
D. Check deep tendon reflexes to determine the best motor response.

23. Question
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which
of the following is contraindicated when positioning the client?

A. Keeping the client flat on one side or the other.

B. Elevating the head of the bed to 30 degrees.
C. Logrolling or turning as a unit when turning.
D. Keeping the head in a neutral position.

24. Question
A client has been pronounced brain dead. Which findings would the nurse assess? Select all that
apply.

A. Decerebrate posturing
B. Dilated nonreactive pupils
C. Deep tendon reflexes
D. Absent corneal reflex

25. Question
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with
new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s
care will be best to delegate to an LPN/LVN whom you are supervising?

A. Document the onset time, nature of seizure activity, and postictal

behaviors for all seizures.
B. Administer phenytoin (Dilantin) 200 mg PO daily.
C. Teach the patient about the need for good oral hygiene.
D. Develop a discharge plan, including physician visits and referral to the
Epilepsy Foundation.
Question
1 point(s)
A 68-year-old male patient who had a left-sided stroke is admitted
to the hospital. The patient has right-sided weakness and is unable
to perform activities of daily living without assistance. The nurse is
providing oral hygiene to the patient and is preparing to use a
padded tongue blade to open the patient’s mouth. Which nursing
measure is inappropriate when providing oral hygiene to the
patient who had a stroke?

A. Placing the client on the back with a small pillow

under the head.

B. Keeping portable suctioning equipment at the bedside.

C. Opening the client’s mouth with a padded tongue blade.

D. Cleaning the client’s mouth and teeth with a toothbrush.

Question
1 point(s)
A 64-year-old client with a history of hypertension is admitted to the
emergency department with sudden onset right-sided weakness,
facial droop, and difficulty speaking. Which nursing intervention is
the highest priority in the initial management of this client?

A. Prepare to administer recombinant tissue plasminogen

activator (rt-PA).

B. Discuss the precipitating factors that caused the symptoms.

C. Schedule for A STAT computer tomography (CT) scan

of the head.

D. Notify the speech pathologist for an emergency consultation.

Question
1 point(s)
A client arrives in the emergency department with an ischemic
stroke and receives tissue plasminogen activator (t-PA)
administration. Which is the priority nursing assessment?

A. Time of onset of current stroke

B. Complete physical and history

C. Current medications

D. Upcoming surgical procedures

Question
1 point(s)
During the first 24 hours after thrombolytic therapy for ischemic
stroke, the primary goal is to control the client’s:

A. Pulse

B. Respirations

C. Blood pressure
 D. Temperature

Question
1 point(s)
What is a priority nursing assessment in the first 24 hours after
admission of the client with a thrombotic stroke?

A. Cholesterol level

B. Pupil size and pupillary response

C. Bowel sounds

D. Echocardiogram

Question
1 point(s)
What is the expected outcome of thrombolytic drug therapy?

A. Increased vascular permeability

B. Vasoconstriction

C. Dissolved emboli

D. Prevention of haemorrhage

Question
1 point(s)
The client diagnosed with atrial fibrillation has experienced a
transient ischemic attack (TIA). Which medication would the nurse
anticipate being ordered for the client on discharge?

A. A thrombolytic medication
 B. A beta-blocker medication

C. An anti-hyperuricemic medication

D. An oral anticoagulant medication

Question
1 point(s)
Which client would the nurse identify as being most at risk for
experiencing a CVA?

A. A 39-year-old pregnant female.

B. A 67-year-old Caucasian male.

C. An 84-year-old Japanese female.

D. A 55-year-old African American male.

Question
1 point(s)
Which assessment data would indicate to the nurse that the client
would be at risk for a hemorrhagic stroke?

A. A blood glucose level of 480 mg/dl.

B. A right-sided carotid bruit.

C. A blood pressure of 220/120 mmHg.

D. The presence of bronchogenic carcinoma.

Question
1 point(s)
The nurse and unlicensed assistive personnel (UAP) are caring for a
client with right-sided paralysis. Which action by the UAP requires
the nurse to intervene?
 A. The assistant places a gait belt around the client’s waist prior
to ambulating.

B. The assistant places the client on the back with the client’s
head to the side.

C. The assistant places her hand under the client’s right

axilla to help him/her move up in bed.

D. The assistant praises the client for attempting to perform

ADL’s independently.

Question
1 point(s)
A client admitted to the hospital with a subarachnoid hemorrhage
has complaints of severe headache, nuchal rigidity, and projectile
vomiting. The nurse knows lumbar puncture (LP) would be
contraindicated in this client in which of the following
circumstances?

A. Vomiting continues.

B. Intracranial pressure (ICP) is increased.

C. The client needs mechanical ventilation.

D. Blood is anticipated in the cerebrospinal fluid (CSF).

Question
1 point(s)
A client with a subdural hematoma becomes restless and confused,
with dilation of the ipsilateral pupil. The physician orders mannitol
for which of the following reasons?

A. To reduce intraocular pressure.

 B. To prevent acute tubular necrosis.

C. To promote osmotic diuresis to decrease ICP.

D. To draw water into the vascular system to increase blood

pressure.

Question
1 point(s)
A client with subdural hematoma was given mannitol to decrease
intracranial pressure (ICP). Which of the following results would best
show the mannitol was effective?

A. Urine output increases.

B. Pupils are 8 mm and nonreactive.

C. Systolic blood pressure remains at 150 mm Hg.

D. BUN and creatinine levels return to normal.

Question
1 point(s)
Which of the following symptoms may occur with a phenytoin level
of 32 mg/dl?

A. Ataxia and confusion

B. Sodium depletion

C. Tonic-clonic seizure

D. Urinary incontinence

16. Question
1 point(s)
Which of the following signs and symptoms of increased ICP after
head trauma would appear first?

A. Bradycardia

B. Large amounts of very dilute urine

C. Restlessness and confusion

D. Widened pulse pressure

17. Question
1 point(s)
Problems with memory and learning would relate to which of the
following lobes?

A. Frontal

B. Occipital

C. Parietal

D. Temporal

18. Question
1 point(s)
While cooking, your client couldn’t feel the temperature of a hot
oven. Which lobe could be dysfunctional?

A. Frontal

B. Occipital

C. Parietal
 D. Temporal

19. Question
1 point(s)
The nurse is assessing the motor function of an unconscious client.
The nurse would plan to use which of the following to test the
client’s peripheral response to pain?

A. Sternal rub

B. Pressure on the orbital rim

C. Squeezing the sternocleidomastoid muscle

D. Nail bed pressure

20. Question
1 point(s)
The client is having a lumbar puncture performed. The nurse would
plan to place the client in which position for the procedure?

A. Side-lying, with legs pulled up and head bent down

onto the chest.

B. Side-lying, with a pillow under the hip.

C. Prone, in a slight Trendelenburg’s position.

D. Prone, with a pillow under the abdomen.

21. Question
1 point(s)
A nurse is assisting with caloric testing of the oculovestibular reflex
of an unconscious client. Cold water is injected into the left auditory
canal. The client exhibits eye conjugate movements toward the left
followed by a rapid nystagmus toward the right. The nurse
understands that this indicates the client has:

A. A cerebral lesion

B. A temporal lesion

C. An intact brainstem

D. Brain death

22. Question
1 point(s)
The nurse is caring for the client with increased intracranial
pressure. The nurse would note which of the following trends in vital
signs if the ICP is rising?

A. Increasing temperature, increasing pulse, increasing

respirations, decreasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing

respirations, increasing blood pressure.

C. Decreasing temperature, decreasing pulse, increasing

respirations, decreasing blood pressure.

D. Decreasing temperature, increasing pulse, decreasing

respirations, increasing blood pressure.

23. Question
1 point(s)
The nurse is evaluating the status of a client who had a craniotomy
3 days ago. The nurse would suspect the client is developing
meningitis as a complication of surgery if the client exhibits:

A. A negative Kernig’s sign.

 B. A positive Brudzinski’s sign.

C. Absence of nuchal rigidity.

D. A Glascow Coma Scale score of 15.

24. Question
1 point(s)
A client is arousing from a coma and keeps saying, “Just stop the
pain.” The nurse responds based on the knowledge that the human
body typically and automatically responds to pain first with attempts
to:

A. Tolerate the pain.

B. Decrease the perception of pain.

C. Escape the source of pain.

D. Divert attention from the source of pain.

25. Question
1 point(s)
During the acute stage of meningitis, a 3-year-old child is restless
and irritable. Which of the following would be most appropriate to
institute?

A. Limiting conversation with the child.

B. Allowing the child to play in the bathtub.

C. Keeping extraneous noise to a minimum.

 D. Performing treatments quickly.

26. Question
1 point(s)
Which of the following would lead the nurse to suspect that a child
with meningitis has developed disseminated intravascular
coagulation?

A. Hemorrhagic skin rash

B. Edema

C. Cyanosis

D. Dyspnea on exertion
27. Question
1 point(s)
When interviewing the parents of a 2-year-old child, a history of
which of the following illnesses would lead the nurse to suspect
pneumococcal meningitis?

A. Bladder infection

B. Middle ear infection

C. Fractured clavicle

D. Septic arthritis

28. Question
1 point(s)
The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the
child to demonstrate? Select all that apply.
 A. Increased appetite

B. Vomiting

C. Polydipsia

D. Lethargy

E. Head tilt

F. Increased pulse

29. Question
1 point(s)
A lumbar puncture is performed on a child suspected of having
bacterial meningitis. CSF is obtained for analysis. A nurse reviews
the results of the CSF analysis and determines which of the
following results would verify the diagnosis?

A. Cloudy CSF, decreased protein, and decreased glucose.

B. Cloudy CSF, elevated protein, and decreased glucose.

C. Clear CSF, elevated protein, and decreased glucose.

D. Clear CSF, decreased pressure, and elevated protein.

30. Question
1 point(s)
A nurse is planning care for a child with acute bacterial meningitis.
Based on the mode of transmission of this infection, which of the
following would be included in the plan of care?

A. No precautions are required as long as antibiotics have been

started.

B. Maintain enteric precautions.

 C. Maintain respiratory isolation precautions for at least
24 hours after the initiation of antibiotics.

D. Maintain neutropenic precautions.

31. Question
1 point(s)
A nurse is reviewing the record of a child with increased ICP and
notes that the child has exhibited signs of decerebrate posturing. On
assessment of the child, the nurse would expect to note which of
the following if this type of posturing was present?

A. Abnormal flexion of the upper extremities and extension of

the lower extremities.

B. Rigid extension and pronation of the arms and legs.

C. Rigid pronation of all extremities.

D. Flaccid paralysis of all extremities.

32. Question
1 point(s)
Which of the following assessment data indicated nuchal rigidity?

A. Positive Kernig’s sign

B. Negative Brudzinski’s sign

C. Positive homan’s sign

D. Negative Kernig’s sign

33. Question
1 point(s)
Meningitis occurs as an extension of a variety of bacterial infections
due to which of the following conditions?

A. Congenital anatomic abnormality of the meninges.

B. Lack of acquired resistance to the various etiologic

organisms.

C. Occlusion or narrowing of the CSF pathway.

D. Natural affinity of the CNS to certain pathogens.

34.
1 point(s)
Which of the following pathologic processes is often associated with
aseptic meningitis?

A. Ischemic infarction of cerebral tissue.

B. Childhood diseases of viral causation such as mumps.

C. Brain abscesses caused by a variety of pyogenic organisms.

D. Cerebral ventricular irritation from a traumatic brain injury.

35. Question
1 point(s)
You are preparing to admit a patient with a seizure disorder. Which
of the following actions can you delegate to LPN/LVN?

A. Complete admission assessment.

B. Place a padded tongue blade at the bedside.

C. Set up oxygen and suction equipment.

 D. Pad the side rails before the patient arrives.

36. Question
1 point(s)
If a male client experienced a cerebrovascular accident (CVA) that
damaged the hypothalamus, the nurse would anticipate that the
client has problems with:

A. Body temperature control

B. Balance and equilibrium

C. Visual acuity

D. Thinking and reasoning

37. Question
1 point(s)
A female client admitted to an acute care facility after a car
accident develops signs and symptoms of increased intracranial
pressure (ICP). The client is intubated and placed on mechanical
ventilation to help reduce ICP. To prevent a further rise in ICP
caused by suctioning, the nurse anticipates administering which
drug endotracheally before suctioning?

A. phenytoin (Dilantin)

B. mannitol (Osmitrol)

C. lidocaine (Xylocaine)

D. furosemide (Lasix)

38. Question
1 point(s)
After striking his head on a tree while falling from a ladder, a young
man age 18 is admitted to the emergency department. He’s
unconscious and his pupils are nonreactive. Which intervention
would be the most dangerous for the client?

A. Give him a barbiturate.

B. Place him on mechanical ventilation.

C. Perform a lumbar puncture.

D. Elevate the head of his bed.

39. Question
1 point(s)
When obtaining the health history from a male client with retinal
detachment, the nurse expects the client to report:

A. Light flashes and floaters in front of the eye.

B. A recent driving accident while changing lanes.

C. Headaches, nausea, and redness of the eyes.

D. Frequent episodes of double vision.

40. Question
1 point(s)
Which nursing diagnosis takes highest priority for a client with
Parkinson’s crisis?

A. Imbalanced nutrition: Less than body requirements

B. Ineffective airway clearance

C. Impaired urinary elimination

 D. Risk for injury

41. Question
1 point(s)
The nurse has given the male client with Bell’s palsy instructions on
preserving muscle tone in the face and preventing denervation. The
nurse determines that the client needs additional information if the
client states that he or she will:

A. Wrinkle the forehead, blow out the cheeks, and whistle.

B. Massage the face with a gentle upward motion.

C. Perform facial exercises.

D. Exposure to cold and drafts.

42. Question
1 point(s)
A female client is admitted to the hospital with a diagnosis of
Guillain-Barre syndrome. The nurse inquires during the nursing
admission interview if the client has a history of:

A. Seizures or trauma to the brain.

B. Meningitis during the last five (5 years).

C. Back injury or trauma to the spinal cord.

D. Respiratory or gastrointestinal infection during the

previous month.

43. Question
1 point(s)
A female 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 this illness?

A. Giving the client full control over care decisions and

restricting visitors.

B. Providing positive feedback and encouraging active range of

motion.

C. Providing information, giving positive feedback and

encouraging relaxation.

D. Providing intravenously administered sedatives, reducing

distractions and limiting visitors.

44. Question
1 point(s)
A male client has an impairment of cranial nerve II. Specific to this
impairment, the nurse would plan to do which of the following to
ensure the client to ensure client safety?

A. Speak loudly to the client.

B. Test the temperature of the shower water.

C. Check the temperature of the food on the delivery tray.

D. Provide a clear path for ambulation without obstacles.

45. Question
1 point(s)
A female client has a neurological deficit involving the limbic
system. Specific to this type of deficit, the nurse would document
which of the following information related to the client’s behavior.

A. Is disoriented to person, place, and time.

 B. Affect is flat, with periods of emotional lability.

C. Cannot recall what was eaten for breakfast today.

D. Demonstrate inability to add and subtract; does not know who

is the president.

46. Question
1 point(s)
A client is admitted with a diagnosis of Sturge-Weber syndrome.
Which of the following information would you expect to find in this
client?

A. It is a dysfunction of the trigeminal nerve causing a severe

sharp pain in the nose, lips, gums, or across the cheeks.

B. It is a non-progressive neurological disorder of the seventh

cranial nerve causing paralysis of one of the sides of the face.

C. It is a rare degenerative brain disorder characterized by

sudden development of progressive neurological and neuromuscular
symptoms.

D. It is a neurocutaneous disorder with angiomas causing

abnormalities in the skin, brain, and eyes from birth.

47. Question
1 point(s)
A client is admitted to the emergency room with a spinal cord injury.
The client is complaining of lightheadedness, flushed skin above the
level of the injury, and headache. The client’s blood pressure is
160/90 mm Hg. Which of the following is a priority action for the
nurse to take?

A. Loosen tight clothing or accessories

B. Assess for any bladder distention

 C. Raise the head of the bed

D. Administer antihypertensive

48. Question
1 point(s)
A client who had a stroke is seen bumping into things on the side
and is having difficulty picking up the beginning of the next line of
what he is reading. The client is experiencing which of the following
conditions?

A. Visual neglect

B. Astigmatism

C. Blepharitis

D. Homonymous Hemianopsia

49. Question
1 point(s)
Which of the following medical treatments should the nurse
anticipate administering to a client with increased intracranial
pressure due to brain hemorrhage, except?

A. acetaminophen (Tylenol)

B. dexamethasone (Decadron)

C. mannitol (Osmitrol)

D. phenytoin (Dilantin)

E. nitroglycerin (Nitrostat)
 50. Question
1 point(s)
Which of the following symptoms would you expect to a client with a
phenytoin level of 35 mg/dL?

A. Ataxia

B. Potassium deficit

C. Neglect syndrome

D. Tetraplegia

1. 1. Question
1 point(s)
To encourage adequate nutritional intake for a female client with
Alzheimer’s disease, the nurse should:

A. Stay with the client and encourage him to eat.

B. Help the client fill out his menu.

C. Give the client privacy during meals.

D. Fill out the menu for the client.

2. Question
1 point(s)
The nurse is performing a mental status examination on a male client
diagnosed with a subdural hematoma. This test assesses which of the
following?

A. Cerebellar function

B. Intellectual function
 C. Cerebral function

D. Sensory function
3. Question
1 point(s)
Shortly after admission to an acute care facility, a male client with a
seizure disorder develops status epilepticus. The physician orders
diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer
the second dose of diazepam, if needed and prescribed?

A. In 30 to 45 seconds

B. In 10 to 15 minutes

C. In 30 to 45 minutes

D. In 1 to 2 hours

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

A. Parasympathomimetic agent

B. Sympatholytic agent

C. Adrenergic blocker

D. Cholinergic blocker
5. Question
1 point(s)
Emergency medical technicians transport a 27-year-old ironworker to
the emergency department. They tell the nurse, “He fell from a two-
story building. He has a large contusion on his left chest and a
hematoma in the left parietal area. He has a compound fracture of his
left femur and he’s comatose. We intubated him and he’s maintaining
an arterial oxygen saturation of 92% by pulse oximeter with a manual
resuscitation bag.” Which intervention by the nurse has the highest
priority?

Answer : Assessing left leg

6. Question
1 point(s)
An auto mechanic accidentally has battery acid splashed in his eyes.
His coworkers irrigate his eyes with water for 20 minutes, and then
take him to the emergency department of a nearby hospital, where he
receives emergency care for the corneal injury. The physician
prescribes dexamethasone (Maxidex Ophthalmic Suspension), two
drops of 0.1% solution to be instilled initially into the conjunctival sacs
of both eyes every hour; and polymyxin B sulfate (Neosporin
Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of
both eyes every 3 hours. Dexamethasone exerts its therapeutic effect
by:

A. Increasing the exudative reaction of ocular tissue.

B. Decreasing leukocyte infiltration at the site of ocular

inflammation.

C. Inhibiting the action of carbonic anhydrase.

D. Producing a miotic reaction by stimulating and contracting the

sphincter muscles of the iris.

7. Question
1 point(s)
Nurse Amber is caring for a client who underwent a lumbar
laminectomy two (2) days ago. Which of the following findings should
the nurse consider abnormal?

A. More back pain than the first postoperative day.

B. Paresthesia in the dermatomes near the wounds.

C. Urine retention or incontinence.

D. Temperature of 99.2° F (37.3° C).

8. Question
1 point(s)
After an eye examination, a male client is diagnosed with open-angle
glaucoma. The physician prescribes Pilocarpine ophthalmic solution
(Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse
should teach the client or a family member to administer the drug by:

A. Instilling one drop of pilocarpine 0.25% into both eyes daily.

B. Instilling one drop of pilocarpine 0.25% into both eyes

four times daily.

C. Instilling one drop of pilocarpine 0.25% into the right eye daily.

D. Instilling one drop of pilocarpine 0.25% into the left eye four
times daily.

9. Question
1 point(s)
A female client who’s paralyzed on the left side has been receiving
physical therapy and attending teaching sessions about safety. Which
behavior indicates that the client accurately understands safety
measures related to paralysis?

A. The client leaves the side rails down.

 B. The client uses a mirror to inspect the skin.

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

D. The client hangs the left arm over the side of the wheelchair.

10. Question
1 point(s)
A male client in the emergency department has a suspected neurologic
disorder. To assess gait, the nurse asks the client to take a few steps;
with each step, the client’s feet make a half-circle. To document the
client’s gait, the nurse should use which term?

A. Ataxic

B. Dystrophic

C. Helicopod

D. Steppage

11. Question
1 point(s)
A client, age 22, is admitted with bacterial meningitis. Which hospital
room would be the best choice for this client?

A. A private room down the hall from the nurses’ station.

B. An isolation room three doors from the nurses’ station.

C. A semi-private room with a 32-year-old client who has viral

meningitis.

D. A two-bedroom with a client who previously had bacterial

meningitis.
12. Question
1 point(s)
A physician diagnoses a client with myasthenia gravis, prescribing
pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before
administering this anticholinesterase agent, the nurse reviews the
client’s history. Which preexisting condition would contraindicate the
use of pyridostigmine?

A. Ulcerative colitis

B. Blood dyscrasia

C. Intestinal obstruction

D. Spinal cord injury

13. Question
1 point(s)
A female client is admitted to the facility for investigation of balance
and coordination problems, including possible Ménière’s disease. When
assessing this client, the nurse expects to note:

A. Vertigo, tinnitus, and hearing loss.

B. Vertigo, vomiting, and nystagmus.

C. Vertigo, pain, and hearing impairment.

D. Vertigo, blurred vision, and fever.

14. Question
1 point(s)
A male client with a conductive hearing disorder caused by ankylosis of
the stapes in the oval window undergoes a stapedectomy to remove
the stapes and replace the impaired bone with a prosthesis. After the
stapedectomy, the nurse should provide which client instruction?
 A. “Lie in bed with your head elevated, and refrain from blowing
your nose for 24 hours.”

B. “Try to ambulate independently after about 24 hours.”

C. “Shampoo your hair every day for ten (10) days to help prevent
ear infection.”

D. “Don’t fly in an airplane, climb to high altitudes, make

sudden movements, or expose yourself to loud sounds for 30
days.”

15. Question
1 point(s)
Nurse Marty is monitoring a client for adverse reactions to dantrolene
(Dantrium). Which adverse reaction is most common?

A. Excessive tearing

B. Urine retention

C. Muscle weakness

D. Slurred speech

16. Question
1 point(s)
The nurse is monitoring a male client for adverse reactions to atropine
sulfate (Atropine Care) eyedrops. Systemic absorption of atropine
sulfate through the conjunctiva can cause which adverse reaction?

A. Tachycardia

B. Increased salivation

C. Hypotension
 D. Apnea

17. Question
1 point(s)
A male client is admitted with a cervical spine injury sustained during a
diving accident. When planning this client’s care, the nurse should
assign the highest priority to which nursing diagnosis?

A. Impaired physical mobility

B. Ineffective breathing pattern

C. Disturbed sensory perception (tactile)

D. Self-care deficit: Dressing/grooming

18. Question
1 point(s)
A male client has a history of painful, continuous muscle spasms. He
has taken several skeletal muscle relaxants without experiencing
relief. His physician prescribes diazepam (Valium), two (2) mg P.O.
twice daily. In addition to being used to relieve painful muscle spasms,
Diazepam also is recommended for:

A. Long-term treatment of epilepsy.

B. Postoperative pain management of laminectomy clients.

C. Postoperative pain management of diskectomy clients.

D. Treatment of spasticity associated with spinal cord

lesions.

19. Question
1 point(s)
A female client who was found unconscious at home is brought to the
hospital by a rescue squad. In the intensive care unit, the nurse checks
the client’s oculocephalic (doll’s eye) response by:

A. Introducing ice water into the external auditory canal.

B. Touching the cornea with a wisp of cotton.

C. Turning the client’s head suddenly while holding the

eyelids open.

D. Shining a bright light into the pupil.

20. Question
1 point(s)
While reviewing a client’s chart, the nurse notices that the female
client has myasthenia gravis. Which of the following statements about
neuromuscular blocking agents is true for a client with this condition?

A. The client may be less sensitive to the effects of a

neuromuscular blocking agent.

B. Succinylcholine shouldn’t be used; pancuronium may be used in

a lower dosage.

C. Pancuronium shouldn’t be used; succinylcholine may be used in

a lower dosage.

D. Pancuronium and succinylcholine both require cautious

administration.

21. Question
1 point(s)
A male client is color blind. The nurse understands that this client has a
problem with:

A. Rods.
 B. Cones.

C. Lens.

D. Aqueous humor.
Correct
22. Question
1 point(s)
A female client who was trapped inside a car for hours after a head-on
collision is rushed to the emergency department with multiple injuries.
During the neurologic examination, the client responds to painful
stimuli with decerebrate posturing. This finding indicates damage to
which part of the brain?

A. Diencephalon

B. Medulla

C. Midbrain

D. Cortex

23. Question
1 point(s)
The nurse is assessing a 37-year-old client diagnosed with multiple
sclerosis. Which of the following symptoms would the nurse expect to
find?

A. Vision changes

B. Absent deep tendon reflexes

C. Tremors at rest

D. Flaccid muscles
24. Question
1 point(s)
The nurse is caring for a male client diagnosed with a cerebral
aneurysm who reports a severe headache. Which action should the
nurse perform?

A. Sit with the client for a few minutes.

B. Administer an analgesic.

C. Inform the nurse manager.

D. Call the physician immediately.

25. Question
1 point(s)
During recovery from a cerebrovascular accident (CVA), a female client
is given nothing by mouth, to help prevent aspiration. To determine
when the client is ready for a liquid diet, the nurse assesses the client’s
swallowing ability once each shift. This assessment evaluates:

A. Cranial nerves I and II.

B. Cranial nerves III and V.

C. Cranial nerves VI and VIII.

D. Cranial nerves IX and X.

26. Question
1 point(s)
A white female client is admitted to an acute care facility with a
diagnosis of cerebrovascular accident (CVA). Her history reveals
bronchial asthma, exogenous obesity, and iron deficiency anemia.
Which history finding is a risk factor for CVA?

A. Caucasian race
 B. Female sex

C. Obesity

D. Bronchial asthma

27. Question
1 point(s)
The nurse is teaching a female client with multiple sclerosis. When
teaching the client how to reduce fatigue, the nurse should tell the
client to:

A. Take a hot bath.

B. Rest in an air-conditioned room.

C. Increase the dose of muscle relaxants.

D. Avoid naps during the day.

28. Question
1 point(s)
A male client is having tonic-clonic seizures. What should the nurse do
first?

A. Elevate the head of the bed.

B. Restrain the client’s arms and legs.

C. Place a tongue blade in the client’s mouth.

D. Take measures to prevent injury.

29. Question
1 point(s)
A female client with Guillain-Barré syndrome has paralysis affecting the
respiratory muscles and requires mechanical ventilation. When the
client asks the nurse about the paralysis, how should the nurse
respond?

A. “You may have difficulty believing this, but the paralysis

caused by this disease is temporary.”

B. “You’ll have to accept the fact that you’re permanently

paralyzed. However, you won’t have any sensory loss.”

C. “It must be hard to accept the permanency of your paralysis.”

D. “You’ll first regain use of your legs and then your arms.”

30. Question
1 point(s)
The nurse is working on a surgical floor. The nurse must log roll a male
client following a:

A. Laminectomy.

B. Thoracotomy.

C. Hemorrhoidectomy.

D. Cystectomy.

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

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

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

C. Place a cap on the client’s head.

D. Administer a sedative as ordered.

32. Question
1 point(s)
During a routine physical examination to assess a male client’s deep
tendon reflexes, the nurse should make sure to:

A. Use the pointed end of the reflex hammer when striking the
Achilles' tendon.

B. Support the joint where the tendon is being tested.

C. Tap the tendon slowly and softly.

D. Hold the reflex hammer tightly.

33. Question
1 point(s)
A female client is admitted in a disoriented and restless state after
sustaining a concussion during a car accident. Which nursing diagnosis
takes highest priority for this client’s plan of care?

A. Disturbed sensory perception (visual)

B. Self-care deficit: Dressing/grooming

C. Impaired verbal communication

D. Risk for injury

34. Question
1 point(s)
A female client with amyotrophic lateral sclerosis (ALS) tells the nurse,
“Sometimes I feel so frustrated. I can’t do anything without help!” This
comment best supports which nursing diagnosis?

A. Anxiety

B. Powerlessness

C. Ineffective denial

D. Risk for disuse syndrome

35. Question
1 point(s)
For a male client with suspected increased intracranial pressure (ICP),
a most appropriate respiratory goal is to:

A. Prevent respiratory alkalosis.

B. Lower arterial pH.

C. Promote carbon dioxide elimination.

D. Maintain partial pressure of arterial oxygen (PaO2)

above 80 mm Hg.
36. Question
1 point(s)
Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof
of his house. The nurse rushes to the victim and determines the need
to open the airway in this victim by using which method?

A. Flexed position

B. Head tilt-chin lift

C. Jaw-thrust maneuver
 D. Modified head tilt-chin lift

37. Question
1 point(s)
The nurse is assessing the motor function of an unconscious male
client. The nurse would plan to use which of the following to test the
client’s peripheral response to pain?

A. Sternal rub

B. Nail bed pressure

C. Pressure on the orbital rim

D. Squeezing of the sternocleidomastoid muscle

38. Question
1 point(s)
A female client admitted to the hospital with a neurological problem
asks the nurse whether magnetic resonance imaging may be done.
The nurse interprets that the client may be ineligible for this diagnostic
procedure based on the client’s history of:

A. Hypertension

B. Heart failure

C. Prosthetic valve replacement

D. Chronic obstructive pulmonary disorder

39. Question
1 point(s)
A male client is having a lumbar puncture performed. The nurse would
plan to place the client in which position?
 A. Side-lying, with a pillow under the hip.

B. Prone, with a pillow under the abdomen.

C. Prone, in slight-Trendelenburg’s position.

D. Side-lying, with the legs, pulled up and head bent down

onto the chest.

40. Question
1 point(s)
The nurse is positioning the female client with increased intracranial
pressure. Which of the following positions would the nurse avoid?

A. Head midline

B. Head turned to the side

C. Neck in neutral position

D. Head of bed elevated 30 to 45 degrees

41. Question
1 point(s)
A female client has clear fluid leaking from the nose following a basilar
skull fracture. The nurse assesses that this is cerebrospinal fluid if the
fluid:

A. Is clear and tests negative for glucose.

B. Is grossly bloody in appearance and has a pH of 6.

C. Clumps together on the dressing and has a pH of 7.

D. Separates into concentric rings and tests positive for

glucose.
42. Question
1 point(s)
A male client with a spinal cord injury is prone to experiencing
autonomic dysreflexia. The nurse would avoid which of the following
measures to minimize the risk of recurrence?

A. Strict adherence to a bowel retraining program.

B. Keeping the linen wrinkle-free under the client.

C. Preventing unnecessary pressure on the lower limbs.

D. Limiting bladder catheterization to once every 12 hours.

43. Question
1 point(s)
The nurse is caring for the male client who begins to experience
seizure activity while in bed. Which of the following actions by the
nurse would be contraindicated?

A. Loosening restrictive clothing.

B. Restraining the client’s limbs.

C. Removing the pillow and raising padded side rails.

D. Positioning the client to the side, if possible, with the

head flexed forward.

44. Question
1 point(s)
The nurse is assigned to care for a female client with complete right-
sided hemiparesis. The nurse plans care knowing that this condition:

A. The client has complete bilateral paralysis of the arms and legs.
 B. The client has weakness on the right side of the body,
including the face and tongue.

C. The client has lost the ability to move the right arm but can walk
independently.

D. The client has lost the ability to move the right arm but can walk
independently.

45. Question
1 point(s)
The client with a brain attack (stroke) has residual dysphagia. When a
diet order is initiated, the nurse avoids doing which of the following?

A. Giving the client thin liquids.

B. Thickening liquids to the consistency of oatmeal.

C. Placing food on the unaffected side of the mouth.

D. Allowing plenty of time for chewing and swallowing.

46. Question
1 point(s)
The nurse is assessing the adaptation of the female client to changes
in functional status after a brain attack (stroke). The nurse assesses
that the client is adapting most successfully if the client:

A. Gets angry with family if they interrupt a task.

B. Experiences bouts of depression and irritability.

C. Has difficulty with using modified feeding utensils.

D. Consistently uses adaptive equipment in dressing self.

47. Question
1 point(s)
Nurse Kristine is trying to communicate with a client with brain attack
(stroke) and aphasia. Which of the following actions by the nurse would
be least helpful to the client?

A. Speaking to the client at a slower rate.

B. Allowing plenty of time for the client to respond.

C. Completing the sentences that the client cannot finish.

D. Looking directly at the client during attempts at speech.

48. Question
1 point(s)
A female client has experienced an episode of myasthenic crisis. The
nurse would assess whether the client has precipitating factors such
as:

A. Getting too little exercise.

B. Taking excess medication.

C. Omitting doses of medication.

D. Increasing intake of fatty foods.

49. Question
1 point(s)
The nurse is teaching the female client with myasthenia gravis about
the prevention of myasthenic and cholinergic crisis. The nurse tells the
client that this is most effectively done by:

A. Eating large, well-balanced meals.

 B. Doing muscle-strengthening exercises.

C. Doing all chores early in the day while less fatigued.

D. Taking medications on time to maintain therapeutic

blood levels.

50. Question
1 point(s)
A male client with Bell’s Palsy asks the nurse what has caused this
problem. The nurse’s response is based on an understanding that the
cause is:

A. Unknown, but possibly includes ischemia, viral infection,

or an autoimmune problem.

B. Unknown, but possibly includes long-term tissue malnutrition

and cellular hypoxia.

C. Primary genetic in origin, triggered by exposure to meningitis.

D. Primarily genetic in origin, triggered by exposure to

neurotoxins.