Detailed Answer Key

Med Surg Neurologic

1. A family of a client who has a medical history of stroke, hyperlipidemia, and peptic ulcer disease arrives at the
memory care clinic with concerns about their loved one. The family states that the client has experienced worsening
memory loss and forgetfulness over the last 6 months. The nurse is concerned the client is experiencing vascular
dementia, due to which of the following factors?

A. The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia by destroying
neuron communication in the stomach.

B. The client's history of hyperlipidemia, because hyperlipidemia can lead to dementia due to blocked neuron
communication throughout the body.

C. The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia due to the loss
of nerve cells in the stomach.

D. The client's history of stroke, because stroke can lead to dementia due to changes in the blood vessels of the
brain.

2. A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the
nurse expect?

A. A lucid period followed by an immediate loss of consciousness

Rationale: The nurse should expect the client who has an epidural hematoma to have a lucid period
followed by an immediate loss of consciousness, which is caused by arterial bleeding into the
space between the dura and skull.

B. A change in the level of consciousness that develops over 48 hr

Rationale: The nurse should expect a client who has an acute subdural hematoma to have a gradual
decrease in alertness that develops over 48 hr.

C. Neurologic deficits that increase up to 2 weeks post-injury

Rationale: The nurse should expect a client who has a subacute subdural hematoma to have neurologic
deficits that increase up to 2 weeks after the initial head injury.

D. Cognitive perception that decreases over several months post-injury

Rationale: The nurse should expect a client who has a chronic subdural hematoma to have decreases in
cognitive perception over several months after the initial head injury.

3. A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of
the following should the nurse identify as the purpose of the medication?

A. Reduce edema of the brain.

Rationale: An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles
into the bloodstream.

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B. Provide fluid hydration.

Rationale: An osmotic diuretic is used to rapidly reduce intracranial edema and is not used to provide fluid
hydration.

C. Increase cell size in the brain.

Rationale: An osmotic diuretic is used to rapidly reduce brain size, not increase the cell size of the brain.

D. Expand extracellular fluid volume.

Rationale: An osmotic diuretic is used to rapidly reduce extracellular fluid volume to decrease brain edema.

4. A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the
nurse expect?

A. Vertigo

Rationale: The nurse should expect a client who has an acoustic neuroma, a benign tumor of cranial nerve
VIII, to manifest mild to moderate vertigo as time progresses.

B. Dysphagia

Rationale: Dysphagia is difficulty swallowing, and the client who has an acoustic neuroma would display
manifestations controlled by the cranial nerve VIII, including hearing and balance.

C. Diplopia

Rationale: Diplopia is double vision, and the client who has an acoustic neuroma would display
manifestations controlled by the cranial nerve VIII, including hearing and balance.

D. Apraxia

Rationale: Apraxia is the inability to perform learned motor skills or commands, and the client who has an
acoustic neuroma would display manifestations controlled by the cranial nerve VIII, including
hearing and balance.

5. A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following
interventions should the nurse take?

A. Elevate the head of the bed to 30&deg.

Rationale: The client who has surgery to treat a supratentorial brain tumor is at risk for increased
intracranial pressure (ICP). Elevation of the head of the bed to 30&deg assists in promoting
venous and CNS fluid drainage from the head to prevent increased ICP.

B. Notify the provider for drainage greater than 80 mL/8hr.

Rationale: The nurse should notify the provider of drainage greater than 50 mL/8hr because this can
indicate a cerebrospinal fluid leak requiring surgical repair.

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C. Place the client in a flat, lateral position.

Rationale: The client who has had surgery to treat an infratentorial brain tumor is placed flat in a side-lying
position to avoid placing pressure on the incision site at the back of the neck and on the surgical
site from the higher brain structures.

D. Provide passive range-of-motion exercises to the neck.

Rationale: The client who has surgery to treat a supratentorial brain tumor is at risk for increased
intracranial pressure (ICP). Extreme neck and hip flexion can cause Increases in ICP. The head
should be kept in a midline, neutral position.

6. A nurse is teaching a group of clients about risk factors for developing age-related macular degeneration (AMD).
Which of the following would be included in the teaching?

A. Light blue colored eyes

B. Exposure to environmental toxins

C. Previous traumatic eye injury

D. Overexposure to UV light

7. Select the four findings that indicate Cushing's Triad and require immediate follow-up.

Answers cannot be displayed for this alternate item format.

Rationale: When recognizing cues, the nurse should identify that the findings of widening pulse pressure,
bradycardia, shallow breathing, and episodes of apnea are signs of increasing intracranial pressure
and require immediate follow-up. The nurse should recognize that if left untreated, this client can
progress to brainstem herniation.

8. A nurse is conducting a health history for a client in the outpatient clinic. Which of the following factors place the
client at greater risk for developing late-onset (sporadic) Alzheimer's disease?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale A:More females than males are diagnosed with late-onset (sporadic) Alzheimer's
disease. This is thought to be because life expectancy for females is longer than for males.
Rationale B:Comorbidities associated with an increased risk of developing Alzheimer's disease
include heart disease, cerebrovascular accident (CVA or stroke), hypertension, diabetes, and
[Link] C:This BMI falls within the obese range according to the CDC. Obesity is a risk
factor associated with the development of Alzheimer's [Link] D:Research suggests that
individuals with more years of formal education are at a lower risk for developing Alzheimer's
disease than those with lower levels of formal [Link] E:Late-onset (sporadic)
Alzheimer's disease, occurs most often in adult clients aged 65 years and [Link] F:
Osteoporosis is not an associated comorbidity to Alzheimer's disease.

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9. A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following
manifestations should the nurse report immediately?

A. Hematuria

B. Swelling of the extremities

C. Chest pain and dyspnea

D. Seizures

10. A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following
behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her
breast?

A. Refusing to look at the dressing or surgical incision

Rationale: Clients who refuse to look at the surgical incision or surgical dressing are having difficulty
adjusting to the loss of a body part or with body disfigurement. This indicates the client is not
yet ready to acknowledge the results of the surgery.

B. Asking for pain medication every 3 hr

Rationale: It is an expectation that clients will have pain postoperatively and will request pain medication
regularly.

C. Asking questions about the information on her postoperative care pamphlet

Rationale: It is an expectation that clients will have questions about postoperative care.

D. Performing arm exercises once or twice a day

Rationale: It is an expectation that clients will have difficulty performing the recommended exercises soon
after surgery, but this client is performing them and the frequency should increase with time
and healing.

11. A nurse is teaching a client who has multiple sclerosis about factors that can worsen their manifestations. Which of
the following factors should the nurse include in the teaching?

A. Flying

B. High altitude travel

C. Working in an office

D. Sunbathing

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12. A nurse is caring for a client who has suspected frontotemporal dementia. Which of the following statements by
the nurse best describes the pathophysiology of frontotemporal dementia?

A. "There is an increased number of proteins in the brain, leading to a loss of neurons."

B. "Deposits of protein found in the brain called Lewy bodies block communication between neurons within the
brain.

C. "There are plaques and tangles, the result of toxins building up, that cause damage to the brain."

D. "There are changes that can occur to the blood vessels in the brain that make it difficult for neurons to
communicate."

13. A nurse is assessing a client who is experiencing a change in vision. Which of the following statements indicates
that the client might be developing cataracts?

A. "My vision is blurry and objects are hazy."

B. "I can't see objects from the sides of my eyes."

C. "There are dark spots moving around in my eye."

D. "I can't see anything in the middle part of my eyes."

14. A nurse is planning care for a client who has a subarachnoid hemorrhage. Which of the following interventions
should the nurse plan to implement?

A. Administer antihypertensives to maintain systolic blood pressure less than 160 mm Hg.

B. Encourage the client to turn, cough, and deep breathe at least 10 times each hour.

C. Reposition the client to supine position.

D. Measure abdom girth every shift.

15. A nurse is meeting with the caregivers of a client who has Alzheimer's disease who is at risk for wandering. Which
of the following are manifestations that put the client at risk for wandering that the nurse should educate their
caregivers about?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale A:Confusion is correct. Physical or psychological changes or changes in the client’s
surroundings can result in confusion, which can lead to the client wandering. This manifestation
can appear in the late afternoon or early evening and is referred to as "sundowning."Rationale B:
Distress is correct. Distress is a behavioral manifestation that can cause the client to wander.
The client could also experience distress brought on by wandering and not knowing where they
are. This manifestation can appear in the late afternoon or early evening and is referred to as
"sundowning."Rationale C:Agitation is correct. Physical or psychological changes occurring for

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the client can result in agitation and can cause the client to wander. This manifestation can appear
in the late afternoon or early evening and is referred to as "sundowning."Rationale D:Depression
is incorrect. Depression can cause several behavioral manifestations that can cause harm to the
client if their safety is not ensured. However, depression is not a risk factor for wandering.
Rationale E:Distraction is incorrect. Difficulty concentrating, or distraction, can result in injury to
the client as this increases the risk for falls or forgetting to turn off the stove, for example.
However, distraction is not a risk factor for wandering.

16. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
(Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Loosen restrictive clothing is correct. Loosening clothing, such as a belt or collar, aids in
respiratory and abdominal expansion. The client should not be [Link] a bite stick into
the client's mouth is incorrect. A bite stick or padded tongue blade can cause an obstruction in
the client's airway or further injury if teeth are broken as a result of the jaw clamping down on the
bite [Link] the client into a supine position is incorrect. If it is possible to do without
causing injury to the client, the nurse should assist the client who is having a seizure into a lateral
position. This position assists with the drainage of saliva and mucus, preventing aspiration, and
allows the tongue to fall forward, preventing airway [Link] a pillow under the client's
head is correct. The nurse should place a pillow or rolled blanket under the client's head to protect
the head from [Link] restraints is incorrect. The nurse should not restrict movement of a
client who is having a seizure. Instead, the nurse should guide the client's movements to prevent
injury and, if possible, assist the client into a lateral position.

17. A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should
indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Headache is correct. A client who has increasing ICP might manifest a [Link] pain and
stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing [Link]
speech is correct. A client who has increasing ICP might manifest slurred [Link]
changes is correct. A client who has increasing ICP might manifest pupillary changes.
Disorientation is correct. A client who has increasing ICP might display disorientation or
confusion.

18. A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires
intervention by the nurse?

A. PaC02 35 mm Hg

Rationale: A PaC02 level of 35 mm Hg is within the expected reference range of 35 to 45 mm Hg.

B. Intracranial pressure (ICP) 18 mm Hg

Rationale: This client's ICP level is above the expected reference range of 10 to 15 mm Hg. ICP increases

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with suctioning, coughing, sneezing, straining, and frequent positioning.

C. Pulse oximetry 96%

Rationale: The client's SpO2 is within the expected reference range.

D. Blood pressure 140/82 mm Hg

Rationale: Although client who is postoperative following a craniotomy is at risk for hypovolemic shock,
this client's blood pressure is not indicative of shock and requires no intervention.

19. A nurse is visiting a client who has Alzheimer's disease in their home. The client's spouse states that the client
gets increasingly agitated and restless in the evening hours and can sometimes be difficult to calm down. Which of
the following behaviors does the nurse recognize that the client is experiencing?

A. Depression

B. Relocation stress syndrome

C. Wandering

D. Sundowning

20. A nurse is caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic
attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

A. Computerized tomography angiography (CTA)

B. Complete blood count (CBC)

C. Prothrombin time (PT)

D. Transesophageal echocardiogram (TEE)

21. A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to
monitor for which of the following complications?

A. Bradycardia

Rationale: The client who has atrial fibrillation has an irregular heartbeat with a rapid ventricular response.

B. Pulmonary embolism

Rationale: Altered atrial contractions can cause blood pooling and thrombus formation. The client is at risk
for developing a pulmonary embolism or embolic stroke. The client should monitor and report
immediately manifestations, such as shortness of breath, or neurological changes.

C. Peripheral vascular disease

Rationale:

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The client who has atrial fibrillation is at risk for developing heart failure because of decrease
ventricular filling and decreased cardiac output.

D. Hypertension

Rationale: A client who has hypertension is at risk for developing atrial fibrillation.

22. A nurse is teaching a group of clients about lifestyle modifications that could decrease risk factors for developing
hearing loss. Which of the following risk factors should the nurse include in the teaching?

A. Increase oral intake of water

B. Limit alcohol to two drinks daily

C. Avoid smoking tobacco products

D. Consume foods high in potassium

23. A nurse is reviewing home medications with a client scheduled for a cataract extraction procedure. Which of the
following medications should the nurse question administering?

A. Clopidogrel

B. Lisinopril

C. Omeprazole

D. Synthroid

24. A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about
the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago.
Which of the following is an appropriate nursing action regarding these findings?

A. Call the anesthesiologist to sedate the client.

Rationale: Mild preoperative anxiety is an expected finding. There is no need to sedate the client at this
time. If the nurse notes extreme anxiety, the nurse should notify the provider because it can
interfere with the client's ability to follow directions.

B. Notify the surgeon of the client's food and fluid consumption.

Rationale: As long as the client has not ingested food or fluids after midnight, there is no need to notify the
surgeon.

C. Witness the surgical consent.

Rationale: The nurse should recognize that the witness signs the consent form at the time the client signs
to verify that the client's signature is authentic. If there was no witness present, the nurse

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should notify the surgeon.

D. Document the findings in the client's medical record.

Rationale: Whenever a nurse collects data from a client, documentation is essential. However, in this
case, all these findings are expectations for a client who is preoperative, so there is no need for
the nurse to take any action other than documenting.

25. A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down
suddenly while walking. Which of the following assessments are the priority for the nurse to complete?

Answers cannot be displayed for this alternate item format.

Rationale: Muscle strength:When using the evidence-based practice priority framework, the nurse should
perform an assessment of muscle strength as sudden weakness or numbness on one side of the
body may be manifestations of stroke. Muscle strength, facial symmetry, vision changes, and
aphasia require more immediate [Link] symmetry:When using the evidence-based
practice priority framework, the nurse should assess facial symmetry as facial drooping may be a
manifestation of stroke. Muscle strength, facial symmetry, vision changes, and aphasia require
more immediate [Link] pulses:The nurse should assess the peripheral pulses of the
client to identify the presence of alterations in perfusion however, there are other manifestations
that the nurse should assess first. Muscle strength, facial symmetry, vision changes, and aphasia
require more immediate [Link] changes:When using the evidence-based practice
priority framework, the nurse should assess for vision changes as alterations in vision may be a
manifestation of stroke. Muscle strength, facial symmetry, vision changes, and aphasia require
more immediate [Link]:When using the evidence-based practice priority framework,
the nurse should perform assessment of speech as aphasia may be a manifestation of stroke.
Muscle strength, facial symmetry, vision changes, and aphasia require more immediate attention.
Smoking history:The nurse should obtain information such as drug, alcohol, and tobacco use in
order to provide more holistic care and gather pertinent information however, muscle strength,
facial symmetry, vision changes, and aphasia are manifestations of stroke and take priority during
the nurse's immediate assessment.

26. A nurse is assessing a client who has Mèniére’s disease. Which of the following manifestations should the nurse
expect?

A. Severe myopia

B. Photopsia

C. Anosmia

D. Vertigo

27. A nurse is preparing an in-service for coworkers about various herbal supplements clients might report using. The
nurse should include in the presentation that which of the following herbal supplements is used to help the client
lose weight?

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A. Licorice

Rationale: Licorice may help relieve gastrointestinal irritation, such as gastric and duodenal ulcers.

B. Feverfew

Rationale: Feverfew may be used to promote wound healing.

C. Comfrey

Rationale: Comfrey may be used to relieve pain due to its anti-inflammatory properties.

D. Ephedra

Rationale: The nurse should identify that ephedra is an extremely dangerous weight loss supplement;
however, clients may still report using it for weight loss.

28. A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should
the nurse take?

A. Teach controlled coughing and deep breathing.

Rationale: The nurse should instruct the client to avoid coughing which increases intracranial pressure.

B. Provide a brightly lit environment.

Rationale: The nurse should provide the client with a nonstimulating environment to limit the risk of
seizure activity.

C. Elevate the head of the bed.

Rationale: The nurse should elevate the head of the bed 30&deg to 45&deg to promote reduction of
intracranial pressure, while monitoring for changes in blood pressure.

D. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.

Rationale: The nurse should place the client on a fluid restriction to avoid increasing intracranial pressure.

29. A client who has a history of migraines comes into the clinic reporting "tingling of the face" and blind spots in the
eyes. Which of the following phases of a migraine is the client experiencing?

A. Postdrome

B. Aura

C. Prodrome

D. Headache

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30. A nurse is providing discharge instruction to the family of a client who has Parkinson's disease and is a fall risk.
Which of the following information should the nurse provide?

Answers cannot be displayed for this alternate item format.

Rationale: Obtain a hospital bed and keep all four siderails [Link] a hospital bed with all four siderails
up will not help prevent falls. Instead, a client at risk for falls should be informed about removing
throw rugs, installing handrails in the bathroom for assistance when getting up from the toilet or out
of the tub, ensuring adequate lighting along walking spaces, and keeping walking areas free of
clutter. These measures would all help to prevent tripping and [Link] all throw rugs from
the home.A client at risk for falls should be informed of the following measures to help prevent
tripping and falling: Removing throw rugs from the home, installing handrails in the bathroom for
assistance when getting up from the toilet or out of the tub, ensuring adequate lighting along
walking spaces, and keeping walking areas free of [Link] handrails in the bathroom.A
client at risk for falls should be informed of the following measures to help prevent tripping and
falling: Removing throw rugs from the home, installing handrails in the bathroom for assistance
when getting up from the toilet or out of the tub, ensuring adequate lighting along walking spaces,
and keeping walking areas free of [Link] adequate lighting along walking spaces.A
client at risk for falls should be informed of the following measures to help prevent tripping and
falling: Removing throw rugs from the home, installing handrails in the bathroom for assistance
when getting up from the toilet or out of the tub, ensuring adequate lighting along walking spaces,
and keeping walking areas free of [Link] walking areas free of clutter.A client at risk for
falls should be informed of the following measures to help prevent tripping and falling: Removing
throw rugs from the home, installing handrails in the bathroom for assistance when getting up from
the toilet or out of the tub, ensuring adequate lighting along walking spaces, and keeping walking
areas free of clutter.

31. A nurse is assessing a client who is experiencing an episode of tinnitus. Which of the following statements from
the client indicates that the tinnitus might be affecting their well-being?

A. "The ringing in my ears is distracting."

B. "I am still able to complete my work in a timely manner."

C. "Hopefully a treatment for this ringing in my ears will help."

D. "I notice the ringing when I'm not concentrating on something."

32. A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to
monitor C4 function?

A. Apply downward pressure while the client shrugs his shoulders upward.

Rationale: This assessment monitors the motor function of C4 to C5.

B. Apply resistance while the client lifts his legs from the bed.

Rationale: This assessment monitors the motor function of L2 to L4.

C. Ask the client to grasp an object and form a fist.

Rationale:

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This assessment monitors the motor function of C8.

D. Apply resistance while the client flexes his arms.

Rationale: This assessment monitors the motor function of C7.

33. A nurse is providing teaching to a group of clients about the changes that occur when clients experience cataracts.
Which of the following statements should the nurse include in the teaching?

A. "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina."

B. "Vision changes occur when the cloudy lens alters the passage of light through the eye."

C. "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor."

D. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye."

34. A nurse is caring for a group of clients in a medical unit. Which of the following clients is at the highest risk for
developing osmotic cerebral edema?

A. A client with an increased hemoglobin A1C

B. A client with an increased creatinine level

C. A client with a decreased serum glucose

D. A client with a decreased potassium level

35. A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech.
Which of the following actions should the nurse take?

A. Obtain the telephone number of the client's provider.

Rationale: This action could delay treatment and result in further injury and disability.

B. Find a location for the client to sit.

Rationale: The nurse should support the client where she is and try to make her comfortable while
ensuring airway patency. But she should not attempt to move her.

C. Call emergency services.

Rationale: The client might have had a stroke, and if she has, she needs emergency medical intervention
and transport to a stroke center.

D. Drive the client to the nearest emergency department.

Rationale: The nurse should support the client where she is and try to make her comfortable while

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ensuring airway patency. But she should not attempt to move her, as doing so could cause
additional injury and disability.

36. A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of
the following therapeutic outcomes should the nurse expect to see?

A. Delay in disease progression

Rationale: Diphenhydramine may be helpful in controlling symptoms in the early stage of the disease;
however, it will not delay disease progression.

B. Improved bladder function

Rationale: Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may cause urinary
retention.

C. Relief of depression

Rationale: Relief of depression is not associated with the use of antihistamines or anticholinergics.

D. Decreased tremors

Rationale: Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty
walking, and problems with balance and coordination. Antihistamines, like diphenhydramine,
have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of
the disease.

37. A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a
patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an
understanding of the teaching?

A. "I should only use the device when it’s absolutely necessary."

Rationale: The client should use the device when the pain begins or starts to increase to maintain a pain
control threshold.

B. "I will ask my family to push the dose button when I am asleep."

Rationale: he client is the only one who should operate the PCA pump. In situations where the client is not
able to do so, the provider may authorize a nurse or a family member to operate the pump.

C. "I’ll be careful about pushing the button so I don’t overdose."

Rationale: A feature of PCA devices is the timing control or lockout mechanism, which enforces a preset
minimum interval between medication doses. This safety feature is one means of preventing an
overdose, as the client cannot self-administer another dose of medication until that time interval
has passed.

D. "I should tell the nurse if I can’t control my pain with this device."

Rationale: PCA is a method of delivering pain medication through an electronic infusion device that allows

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the client to self-administer pain medication on an as-needed basis The client should notify the
nurse if pain control is not achieved. The nurse can initiate a re-evaluation of the client’s pain
management plan.

38. A nurse is providing care to a client who has Parkinson's disease and is having difficulty swallowing. Which of the
following departments should the nurse plan to contact for a consultation?

A. Speech therapy

B. Occupational therapy

C. Nutritional therapy

D. Respiratory therapy

39. A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse
implement first?

A. Prepare for a STAT non-contrast CT scan

B. Perform a thorough health history

C. Administer acetaminophen by mouth for pain control

D. Insert an indwelling urinary catheter to monitor urine output

40. A nurse is planning care for a client who has a mild traumatic brain injury (TBI). Which of the following should the
nurse include in the plan of care?

A. Trousseau's sign

B. Cranial nerve assessment

C. Obstructive sleep apnea

D. Response to noxious stimuli

41. A nurse is preparing a plan of care for a client who is postoperative for retinal detachment. Which of the following
instructions should the nurse include in the plan of care?

A. Driving will be permitted 12 to 24 hr after the procedure.

B. Refrain from lifting objects that weigh over 15 lb.

C. Lie with the face up for 2 weeks following the procedure.

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D. Resume use of contact lenses 48 hr after the procedure.

42. A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition.
Which of the following cues should the nurse recognize as a worsening condition?

Answers cannot be displayed for this alternate item format.

Rationale: A decreasing Glasgow Coma score, changes to pupil size and shape, and swelling of the optic
nerve all indicate a worsening of the client's condition.A decreasing Glasgow Coma score,
changes to pupil size and shape, and swelling of the optic nerve all indicate a worsening of the
client's condition.A decreasing Glasgow Coma score, changes to pupil size and shape, and
swelling of the optic nerve all indicate a worsening of the client's condition.A blood pressure of
108/74 mm Hg is a normal finding and does not indicate a worsening condition. A respiratory rate
of 12/min is a normal finding and does not indicate a worsening condition.

43. A nurse is caring for a client who has advanced-stage cancer and is experiencing disorganized cognition, altered
awareness, and confusion. Which of the following complications of cancer should the nurse understand the client
is experiencing?

A. Concentration problems

B. Neuropathy

C. Delirium

D. Fatigue

44. A nurse is assessing a client who has multiple sclerosis. The client reports that, since the onset of the disease,
there are times when their symptoms are active and then followed by a period with no symptoms. Which of the
following types of multiple sclerosis does this pattern indicate?

A. Clinically isolating syndrome

B. Primary progressive multiple sclerosis

C. Secondary progressive multiple sclerosis

D. Relapsing-remitting multiple sclerosis

45. A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident
(CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

A. Establish the ability to communicate effectively.

Rationale: A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain

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tissue. The left hemisphere is usually dominant for language. Because this client had a left-side
CVA, the nurse should anticipate the client will have some degree of aphasia and will require
speech therapy to establish communication.

B. Compensate for loss of depth perception.

Rationale: A client who has a right-sided lesion experiences a loss of depth perception, proprioception
(recognition of body position), and spatial deficits. The client who has a left-sided lesion will
have an inability to discriminate between words and letters leading to problems reading.

C. Learn to control impulsive behavior.

Rationale: A client with a right-side lesion is likely to be impulsive. Clients with left-side lesions are
typically cautious.

D. Improve left-side motor function.

Rationale: A client with a left-side lesion will demonstrate hemiplegia of the right side due to the fact that
the pyramidal pathway crosses over at the base of the brain.

46. A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at
the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

A. Ability to achieve independent transfer from bed to wheelchair

Rationale: A client who has a transection at the level of C6 or lower should be able to transfer from a bed
to a chair independently.

B. Independent control of bowel and bladder function

Rationale: A client who has a transection in the sacral area might have full or partial bowel and bladder
control; a client who has a cervical transection will not.

C. Use of a wheelchair with a chin or mouth stick

Rationale: A client who has a transection at the level of C5 can use an electric or modified manual
wheelchair.

D. Ability to self-feed with the use of adaptive equipment

Rationale: A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have
full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation
goal for the client is the ability to feed himself with the use of adaptive equipment.

47. A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should
the nurse include as a possible treatment for brain herniation?

A. Hyperventilate the client.

B. Reduce the temperature in the room.

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C. Lower blood pressure.

D. Decrease sedation.

48. A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of
the following manifestations should the nurse expect?

A. Gradual onset of several hours

Rationale: A client who has a thrombotic (ischemic) stroke will have a gradual onset of manifestations
occurring over several minutes to hours. A client who has had a hemorrhagic stroke tends to
have an acute onset.

B. Manifestations preceded by a severe headache

Rationale: A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid
space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A
sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.

C. Maintains consciousness

Rationale: A client who has an ischemic stroke maintains a level of consciousness. A client who has a
hemorrhagic stroke has a decreased level of consciousness, extending from stupor to coma.

D. History of neurologic deficits lasting less than 1 hr

Rationale: A client who has an ischemic stroke might have experienced transient ischemic attacks that
caused neurologic deficits lasting for short periods of time before. These transient attacks are
not present in a client who has had a hemorrhagic stroke.

49. A client who has a history of migraines reports to a clinic with a throbbing headache. Which of the following
questions should the nurse include in the assessment?

Answers cannot be displayed for this alternate item format.

Rationale: "Have you had any nausea and vomiting with your headache?":Nausea and vomiting are
clinical manifestations that can occur with a migraine. Nausea and vomiting, light sensitivity,
strange smells, and feeling weak prior to a headache are manifestations of a migraine."Are you
bothered by the lights in here?":Sensitivity to light is a clinical manifestation that can occur with
a migraine. Nausea and vomiting, light sensitivity, strange smells, and feeling weak prior to a
headache are manifestations of a migraine."Have you noticed any confused or cloudy
thinking?":Confusion and cloudy thinking do not occur with migraines. Instead, nausea and
vomiting, light sensitivity, strange smells, and feeling weak prior to the headache are
manifestations of a migraine."Have you experienced or are you experiencing any strange
smells?":Smelling something strange is a clinical manifestation that can occur with a migraine.
Nausea and vomiting, light sensitivity, strange smells, and feeling weak prior to a headache are
manifestations of a migraine."Did you feel weak before the headache started or do you feel
weak now?":Feeling weak before a headache is a clinical manifestation that can occur with a
migraine. Nausea and vomiting, light sensitivity, strange smells, and feeling weak prior to a
headache are manifestations of a migraine.

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50. A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following
alterations in function should the nurse expect?

A. Difficulty reading

Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A
client who is unable to read following a stroke would have involvement of the left hemisphere.

B. Inability to recognize his family members

Rationale: The right hemisphere is involved with visual and spatial awareness. A client who is unable to
recognize faces would have involvement with the right hemisphere.

C. Right hemiparesis

Rationale: The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the
body reflects damage to the upper motor neurons on the opposite side of the brain. A client
who has right hemiparesis would have involvement of the left hemisphere.

D. Aphasia

Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A
client who is unable to speak or understand language following a stroke would have
involvement of the left hemisphere.

51. A nurse is caring for a client who is being evaluated for multiple sclerosis. Which of the following tests should the
nurse anticipate the provider will order to assist with diagnosis?

A. Troponin level

B. Brain natriuretic peptide

C. Lumbar puncture

D. Myelogram

52. A nurse is teaching a client about health conditions that increase the risk for developing Mèniére's disease. Which
of the following factors should the nurse include in the teaching?

A. Rheumatoid arthritis

B. Bacterial pneumonia

C. Osteoporosis

D. Macular degeneration

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53. A nurse is taking care of a client who has sustained a neurologic injury with increased intracranial pressure and
decreased cerebral perfusion. Which of the following will keep cerebral perfusion pressure constant?

A. Regulation of constriction and dilation of blood vessels in the brain

B. Regulation of how much blood is pumped from the heart

C. Regulation of the amount of carbon dioxide exhaled

D. Regulation of catecholamines circulating throughout the body

54. A nurse is caring for six clients. Which of the following clients are at risk for developing peripheral neuropathy
(PN)?

Answers cannot be displayed for this alternate item format.

Rationale: The client admitted with diabetic ketoacidosis (DKA):Diabetes mellitus is the leading risk factor
for peripheral neuropathy (PN). PN is also associated with autoimmune disorders and chronic
alcohol [Link] client admitted with sleep apnea:Sleep apnea is not associated with an
increased risk of peripheral neuropathy. PN is instead associated with diabetes mellitus,
autoimmune disorders, and chronic alcohol [Link] client admitted with a hypertensive crisis:
Hypertension is not associated with an increased risk for peripheral neuropathy. PN is instead
associated with diabetes mellitus, autoimmune disorders, and chronic alcohol [Link] client
admitted for an exacerbation of Systemic Lupus Erythematosus (SLE):An autoimmune
disorder is associated with an increased risk factor for peripheral neuropathy. PN is also
associated with diabetes mellitus and chronic alcohol [Link] client admitted with untreated
tuberculosis:Tuberculosis is not associated with an increased risk factor for peripheral
neuropathy. PN is instead associated with diabetes mellitus, autoimmune disorders, and chronic
alcohol [Link] client admitted with cirrhosis secondary to chronic alcohol use:Chronic
alcohol use is associated with an increased risk of peripheral neuropathy. PN is additionally
associated with diabetes mellitus and autoimmune disorders.

55. A nurse is collecting data from a client related to changes in vision. Which of the following statements indicates
that the client might be developing a cataract?

A. "My vision is almost gone from the center part of my eye."

B. "I can't see anything from the sides of my eyes."

C. "My contact lenses just don't fit like they used to."

D. "I keep seeing flashes of lights moving around in my eye."

56. A nurse is teaching a client who taking benztropine to treat Parkinson’s disease. The nurse should instruct the
client to report which of the following adverse effects?

A. Excess salivation

Rationale:

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Dry mouth is an adverse effect of benztropine, due to the anticholinergic response of the
medication.

B. Difficulty voiding

Rationale: The nurse should instruct the client to report difficulty voiding, which may indicate urinary
retention, as an adverse effect of benztropine. Benztropine is an anticholinergic medication
that helps decrease the rigidity and tremors of Parkinson’s disease.

C. Diarrhea

Rationale: Constipation is an adverse effect of benztropine, which is due to the anticholinergic response of
the medication that slows peristalsis.

D. Slow pulse

Rationale: Tachycardia is an adverse effect of benztropine, which is due to the anticholinergic response of
the medication.

57. A nurse is teaching a client who has spinal stenosis about exercise. Which of the following statements by the client
indicates they understand the teaching?

A. "I ride my bicycle every day."

B. "I like to jog a half a mile every day."

C. "I have signed up for an aerobics class three times a week."

D. "I enjoy doing circuit training once a week."

58. A nurse is reinforcing discharge instructions with a client following a laminectomy. Which of the following
instructions should the nurse include?

A. "Sit in straight-back chairs."

Rationale: The client should sit in straight-back chairs to provide support to the spine and minimize strain
on the surgical site.

B. "Sleep on a soft mattress."

Rationale: The client should sleep on a firm mattress to promote body alignment and support to the spine.
A soft mattress can cause low-back strain and pain.

C. "Walk around at least every 3 hours when sitting for long periods of time."

Rationale: The client should get up and walk around at least every 2 hr when sitting for long periods of
time to prevent fatigue and pain.

D. "Bend at the waist when lifting objects."

Rationale: Bending at the knees will help the client maintain good body mechanics and prevent strain on

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the spine.

59. A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic
goals?

A. The client will verbalize an understanding of the mode of disease transmission.

Rationale: The client verbalizing an understanding of the mode of disease transmission is done at the time
of initial diagnosis, so this is not a realistic goal.

B. The client will experience a weight gain of one to two pounds per week.

Rationale: The client may not have the desire to eat during the end of life and may experience a weight
loss, so this is not a realistic goal.

C. The client will increase attendance at community social activities.

Rationale: The client may not have the energy or interest to attend community social activities, so this is
not a realistic goal.

D. The client will receive medication to minimize episodes of breakthrough pain.

Rationale: The client should receive medication to minimize episodes of breakthrough pain as a goal for
the end of life care.

60. A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should
the nurse include in the plan? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Provide oral fluids is correct. Adequate hydration will decrease the risk of a spinal headache.
Spinal headaches occur when cerebral spinal fluid (CSF) is decreased suddenly. Adequate
hydration will aid in the replacement of [Link] for nausea is correct. Nausea and vomiting
might occur with an increase in intracranial pressure or meningitis. If the client develops persistent
nausea or vomiting, the nurse should monitor for other manifestations and report the findings to
the provider. Additional findings to report include change in vital signs, headache, change in level
of consciousness, nuchal rigidity, drainage, redness, or swelling at the puncture [Link] fetal
position is incorrect. Following a lumbar puncture (LP), the client should be kept flat and still,
often in a prone position. This helps decrease leakage of cerebral spinal fluid (CSF) from the LP
site. The fetal position is used during the LP procedure, not [Link] level of consciousness
is correct. A change in the client’s level of consciousness (LOC) might indicate meningitis or a loss
of cerebral spinal fluid (CSF).Check sensation in the toes is correct. A lumbar puncture could
cause injury to the spinal cord. The nurse should monitor the client’s neurological status in both
lower extremities. Sensation to touch and position should be checked, as well as the ability to flex
toes and move the feet. The neurological exam should be modified to maintain the client in a flat,
still position. A neurological deficit should be reported.

61. A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the

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nurse identify as a manifestation of increased intracranial pressure?

A. Hypotension

Rationale: The nurse should identify hypertension as a manifestation of increased intracranial pressure.

B. Tachycardia

Rationale: The nurse should identify bradycardia as a manifestation of increased intracranial pressure.

C. Irritability

Rationale: The nurse should monitor the client for behavioral changes, such as confusion, restlessness,
and irritability as manifestations of increased intracranial pressure.

D. Tinnitus

Rationale: The nurse should identify changes in pupillary response as a manifestation of increased
intracranial pressure.

62. A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following
findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Confusion is incorrect. A change in the level of consciousness is an early sign of neurologic
status. This is often manifested as restlessness, irritability, and confusion.
Bradycardia is correct. Bradycardia is one of three findings of Cushing's triad, which is a late
sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have
tachycardia.
Hypotension is incorrect. Severe hypertension is one of three findings of Cushing's triad, which
is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely
to have hypotension.
Nonreactive dilated pupils is correct. Increased intracranial pressure can lead to nonreactive
dilated pupils or constricted nonreactive pupils.
Slurred speech is incorrect. Slowed speech can be an early sign of increased intracranial
pressure. Late manifestations include stupor, progressing to coma, and abnormal motor
responses, including decorticate and decerebrate posturing.

63. A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations
should the nurse expect?

A. Loss of consciousness lasting 30 to 60 min

Rationale: The nurse should expect a client who has a mild traumatic brain injury, such as a concussion,
to have a loss of consciousness lasting 30 min or less.

B. Glasgow Coma Scale score of 11

Rationale: The nurse should expect a client who has a mild traumatic brain injury, such as a concussion,
to have Glasgow Coma Scale score greater than 12. Scores between 9 and 12 indicate a

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moderate traumatic brain injury. Scores between 3 and 8 indicate a severe traumatic brain
injury.

C. Nuchal rigidity

Rationale: Nuchal rigidity is an expected finding for a client who has meningitis.

D. Sensitivity to light

Rationale: The nurse should expect a client who has a mild traumatic brain injury, such as a concussion,
to have sensitivity to light and noise.

64. A nurse in the emergency department is caring for a client following an automobile crash in which the client was
unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from
the client's nose. Which of the following interventions should the nurse take?

A. Obtain a culture of the specimen using sterile swabs.

Rationale: The collection of a culture specimen using any type of swab or suction is contraindicated
because the clear drainage may be an indication of a basilar skull fracture with a leakage of
cerebrospinal fluid. Introducing anything into the nose may cause further injury or infection.

B. Allow the drainage to drip onto a sterile gauze pad.

Rationale: The nurse should allow the drainage to drip onto a sterile gauze pad in order to assess for the
presence of cerebrospinal fluid. This intervention allows for the collection of data without
increasing the risk for further injury.

C. Suction the nose gently with a bulb syringe.

Rationale: Suctioning the nose is contraindicated because the clear fluid may be cerebrospinal fluid
indicating the presence of a basilar skull fracture. Suctioning can result in further trauma to the
brain from aspirating more fluid, or may cause infection of the meninges.

D. Insert sterile packing into the nares.

Rationale: The nurse should avoid placing anything into the nares due to the risk of causing further injury.

65. A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following
findings should the nurse report to the provider?

A. Edematous bruise on forehead

Rationale: A bruised area on the forehead might be evidence of skin trauma from the head injury, but it is
indicative only of soft tissue damage to the epidermis and superficial blood vessels and would
not need to be reported to the provider.

B. Small drops of clear fluid in left ear

Rationale: Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull
fracture. CSF drainage is a serious problem because meningeal infection can occur if

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organisms gain access to the cranial contents. This finding should be reported to the provider.

C. Pupils are 4 mm and reactive to light

Rationale: Normal pupils are characterized by size that is not pinpoint or dilated, and that react bilaterally
to light stimulation and accommodation. This is an expected finding.

D. Glasgow Coma Scale (GCS) score of 12

Rationale: A GCS score between 3 and 8 is considered to be an indication of severe head injury. A score
of 12 would not need to be reported to the provider.

66. A nurse is caring for a client who had a traumatic brain injury (TBI). Which of the following manifestations indicate
a mild TBI?

A. Headache and confusion

B. Seizures and extremity weakness

C. Loss of vision and depression

D. Persistent headache and aggression

67. A nurse is reinforcing teaching with a newly licensed nurse about coup and contrecoup injuries. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?

A. The coup injury is the primary focal injury, and the contrecoup injury occurs on the opposite side of the brain.

B. Contrecoup injuries are less severe and easier to heal from over time.

C. The coup injury occurs secondary to the contrecoup injury but does not affect blood supply to the brain.

D. A contrecoup injury is not considered a "true" injury, and a coup injury can be more devastating.

68. A nurse is educating the family of a client who has Alzheimer's disease. The nurse should be sure to communicate
that which of the following behavioral manifestations can occur in clients with Alzheimer's disease?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale A:Restlessness is correct. The nurse should inform the family that manifestations such
as restlessness, sundowning, and wandering behaviors can occur in clients who have Alzheimer's
disease and are safety [Link] B:Aggression is correct. The nurse should inform the
family that manifestations such as aggression and agitation can occur in clients who have
Alzheimer's disease when they feel out of control or are in a new [Link] C:
Depression is correct. The nurse should inform the family that manifestations such as depression
and hopelessness can occur in clients who have Alzheimer's disease. The family should mention
these manifestations to their health provider should these [Link] D:Hyperactivity is
incorrect. Hyperactivity is not a typical behavioral change in Alzheimer's [Link] E:

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Lethargy is incorrect. Lethargy is not a typical behavioral change in Alzheimer's disease

69. A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following
instructions should the nurse include in the teaching?

A. "Use the pain scale to determine if you need to self-administer."

Rationale: The nurse should instruct the client to use the pain scale to rate his pain level before
self-administering a bolus dose. A bolus dose is the amount of medication received when the
client self-administers the opioid. The nurse should monitor the client to determine is the bolus
dose is too high or low or if the interval is too short or too long.

B. "Ask a family member to push the patient-control button when the client is sleeping."

Rationale: The client is the only person authorized to self-administer using the PCA pump. The provider
may assign a healthcare proxy to administer the bolus medication if the client is unable to push
the button.

C. "There is a 30 minute lock-out limit programmed on your PCA pump."

Rationale: The nurse should instruct the client that the PCA pump lock-out limit is programmed for 1 to 4
hr to prevent overdose. This safety feature is one means of preventing an overdose, as the
client cannot self-administer another dose if the maximum doses of medication are given during
that time period.

D. "Several bolus doses are infused if the button is pushed repeatedly within a 5 to 10 minute timeframe before
lock-out."

Rationale: The nurse should instruct the client that one bolus dose of self-administered medication is
infused within a pre-set 5 min timeframe before lockout.

70. A nurse is teaching a class at a senior center on dementia. Which of the following statements by a client indicates
a need for further teaching?

A. "Even though forgetfulness can happen as I get older, I will need to let my provider know if it starts to happen
frequently."

B. "Dementia can have a big impact on my memory and ability to process information. I should be aware of
forgetfulness."

C. "I should do a crossword puzzle each day. This will keep my brain active and help me keep track of issues I
may be having."

D. "I should speak with my doctor about ordering a brain scan for dementia with my yearly exams so that we
can identify any changes in my memory early."

71. A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become
stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

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A. Pinpoint pupils

Rationale: The nurse should include pupil size as part of an assessment of the cranial nerves during a
neurological examination. Pinpoint pupils may occur as the result of opioid intoxication or a late
sign of neurologic deterioration.

B. Jerking contractions of the head and neck

Rationale: The client who exhibits clonus, or sudden, brief jerking motions of a muscle or group of
muscles, would indicate that the client might be experiencing a seizure.

C. Pronation of the arms

Rationale: Pronation of the arms along with extension of the arms and legs with plantar flexion is identified
as decerebrate posturing and is an indication of injury to the client's brainstem.

D. Dorsiflexion of the great toe

Rationale: Dorsiflexion of the great toe and fanning of the other toes when the plantar reflex is assessed is
an indication of a Babinski's sign, an abnormal response that indicates CNS pathology.

72. A nurse is caring for an older adult client in the emergency department who sustained a head injury due to a fall.
Which of the following are common reasons for head injuries in older adults?

Answers cannot be displayed for this alternate item format.

Rationale: Decreased visual acuity:In the older adult population, decreased visual acuity is a risk factor
associated with head injury due to falls. Different risk factors associated with head injuries affect
the older adult population, such as decreased visual acuity, polypharmacy, weakness, and chronic
[Link] vehicle crashes :Motor vehicle crashes are the most common cause of head
trauma in children and young adults. Different risk factors associated with head injuries affect the
older adult population, such as decreased visual acuity, polypharmacy, weakness, and chronic
[Link] :In the older adult population, polypharmacy is a risk factor
associated with head injury due to falls. Different risk factors associated with head injuries affect
the older adult population, such as decreased visual acuity, polypharmacy, weakness, and chronic
[Link]:In the older adult population, weakness is a risk factor associated with
head injury due to falls. Different risk factors associated with head injuries affect the older adult
population, such as decreased visual acuity, polypharmacy, weakness, and chronic hypertension.
Chronic hypertension:In the older adult population, chronic hypertension is a risk factor
associated with head injury due to falls. Different risk factors associated with head injuries affect
the older adult population, such as decreased visual acuity, polypharmacy, weakness, and chronic
[Link] military experience:Previous military experience is a potential cause of
head trauma in males of all age. Different risk factors associated with head injuries affect the older
adult population, such as decreased visual acuity, polypharmacy, weakness, and chronic
hypertension.

73. A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic
hormone (SIADH). Which of the following manifestations should the nurse anticipate?

A. Hypernatremia

Rationale:

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The nurse should expect hyponatremia, due to the development SIADH.

B. Oliguria

Rationale: The nurse should expect a client who has developed SIADH following a craniotomy to manifest
oliguria. The decrease in urine output can be dramatic with output less than 20 mL/hr.

C. Weight loss

Rationale: The nurse should expect weight gain, due to water retention from SIADH.

D. Increased thirst

Rationale: The nurse should expect a loss of thirst, due to the development of SIADH.

74. A nurse is assessing a client who is recovering from subarachnoid hemorrhage following a fall. Which of the
following medications should the nurse understand is a potential reason for the fall?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale ABlood pressure medications, antipsychotics, sedating medications, and

antidepressants can increase the risk of falls in clients following a neurological [Link] B
Blood pressure medications, antipsychotics, sedating medications, and antidepressants can
increase the risk of falls in clients following a neurological [Link] CDonepezil is a
cholinesterase inhibitor to treat Alzheimer's disease and does not increase the risk of falls.
Rationale DBlood pressure medications, antipsychotics, sedating medications, and
antidepressants can increase the risk of falls in clients following a neurological [Link] E
Blood pressure medications, antipsychotics, sedating medications, and antidepressants can
increase the risk of falls in clients following a neurological injury.

75. A nurse is caring for a client who has multiple sclerosis and is experiencing progressive multifocal
leukoencephalopathy (PML). Which of the following medications should the nurse recognize is associated with the
development of PML?

A. Furosemide

B. Metoprolol

C. Natalizumab

D. Pregabalin

76. A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments
will give the nurse information about the function of cranial nerve III?

A. Instruct the client to look up and down without moving his head.

Rationale: The nurse should observe the client's extraocular eye movements by instructing him to look at

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the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III
(Oculomotor).

B. Observe the client's ability to smile and frown.

Rationale: The nurse should observe the client's ability to smile and frown as part of an evaluation of the
function of cranial nerve VII (Facial).

C. Have the client stand with eyes his closed and touch his nose.

Rationale: The nurse should observe the client's ability to stand with his eyes closed and touch his nose
while evaluating equilibrium as part of an evaluation of the function of cranial nerve VIII
(Vestibulocochlear).

D. Ask the client to shrug his shoulders against passive resistance.

Rationale: The nurse should observe the client's ability to shrug his shoulders against passive resistance
as part of an evaluation of the function of cranial nerve XI (Accessory).

77. A nurse is preparing a presentation about ginkgo biloba to a group of clients. Which of the following information
should the nurse include in the teaching?

A. "Ginkgo biloba can help reduce feelings of restlessness."

Rationale: Valerian may reduce feelings of restlessness by increasing the amount of gamma-aminobutyric
acid (GABA) at the synapses in the CNS.

B. "Ginkgo biloba may enhance wound healing."

Rationale: Echinacea is an herbal preparation that can enhance wound healing by stimulating the
T-lymphocyte proliferation and proinflammatory enzymes.

C. "Ginkgo biloba can improve memory."

Rationale: Ginkgo biloba can improve memory by improving blood flow due to ginkgo-induced
vasodilation.

D. "Ginkgo biloba relieves pain and inflammation of the mouth."

Rationale: St. John’s wort may be beneficial in treating oral inflammation and pain.

78. A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following nursing
interventions should the nurse implement?

A. Allow bathroom privileges.

Rationale: The nurse should not allow bathroom privileges. Activity can cause an increase in blood
pressure, resulting in a rupture of the aneurysm.

B. Encourage exhaling through mouth during defecation.

Rationale:

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The nurse should encourage the client to exhale through her mouth when defecating to
decrease strain.

C. Allow natural sunlight in the room.

Rationale: The nurse should not allow natural sunlight in the room because the client might have
photophobia.

D. Encourage visitation from family and friends.

Rationale: The nurse should not encourage visitors because excess stimulation can increase blood
pressure and intracranial pressure.

79. A nurse is reinforcing teaching to a group of high school students about how penetrating traumatic brain injuries
cause damage to the brain. Which of the following statements should the nurse include in the teaching?

A. "Damage to the brain is related to the size, route, and rate of speed of the object entering the brain."

B. "Damage occurs from the penetrating object shattering the skull and causing an infection."

C. "Damage occurs from the penetrating injury causing leakage of cerebrospinal fluid."

D. "Damage to the brain is related to coup and contrecoup injuries."

80. A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse
recognizes these manifestations are likely related to a condition with which of the following characteristics?

A. Reversible

B. Unique

C. Permanent

D. Isolated

81. A nurse is planning care for a client who states he is anxious concerning abdominal surgery. Which of the
following actions should the nurse take?

A. Explain to the client that all patients feel that way prior to surgery.

Rationale: The nurse provides false reassurance by not acknowledging the client’s negative emotions,
which closes the opportunity for therapeutic communication.

B. Suggest the client talk to the provider.

Rationale: The nurse refusing to discuss the client’s negative emotions causes the client to feel rejected,
which closes the opportunity for therapeutic communication.

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C. Ask the client what to expect tomorrow.

Rationale: The nurse changes the subject by not acknowledging the client’s negative emotions, which
closes the opportunity for therapeutic communication.

D. Encourage the client to express negative emotions.

Rationale: The nurse is acknowledging the client’s negative emotions, therefore providing open
therapeutic communication.

82. A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning
care, the nurse should anticipate which of the following types of disability?

A. Paresthesia

Rationale: Paresthesia refers to a burning or tingling sensation due to pressure on nerves, circulatory
impairment, or peripheral neuropathy. It is not a form of paralysis associated with a transected
spinal cord.

B. Hemiplegia

Rationale: Hemiplegia, or paralysis of an arm and leg on the same side of the body, is seen after a
cerebral vascular accident or stroke.

C. Quadriplegia

Rationale: Quadriplegia, or paralysis of all four extremities, is seen with spinal cord injuries in the cervical
vertebrae above C7.

D. Paraplegia

Rationale: Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

83. A nurse is assessing a client who has multiple sclerosis. Which of the following assessment findings should the
nurse anticipate?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale AClients who have multiple sclerosis have multiple manifestations that include
paresthesia, dysphagia, spasticity, and [Link] BThe nurse should not anticipate
nausea and vomiting because they are not associated with multiple [Link] CClients
who have multiple sclerosis have multiple manifestations that include paresthesia, dysphagia,
spasticity, and [Link] DClients who have multiple sclerosis have multiple
manifestations that include paresthesia, dysphagia, spasticity, and [Link] EClients who
have multiple sclerosis have multiple manifestations that include paresthesia, dysphagia,
spasticity, and vertigo.

84. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

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Answers cannot be displayed for this alternate item format.

85. A nurse is assisting with the plan of care for a client who has a spinal cord injury and spasm-induced incontinence.
Which of the following medications should the nurse anticipate a prescription for?

A. Oxybutynin

B. Glatiramer acetate

C. Montelukast sodium

D. Dulaglutide

86. A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of
the following outcomes based on this score?

A. The client needs total nursing care.

Rationale: A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will
require total nursing care.

B. The client is alert and oriented.

Rationale: A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state.

C. The client is in a deep coma.

Rationale: A client who has a score of 3 on the Glasgow Coma Scale is in a deep coma or is completely
unresponsive.

D. Indicates stable neurologic status

Rationale: A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state.

87. A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following
instructions should the nurse include?

A. Sleep on the abdomen to facilitate wound healing.

Rationale: The client should be instructed to sleep on the back or the unaffected side to lessen pressure
on the affected eye. Sleeping on the abdomen is not recommended.

B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.

Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure.
Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10
lb) for 1 week following surgery.

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C. Bend at the waist to pick objects up from the floor.

Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure, such
as bending at the waist. The client should bend at the knees to pick objects up from the floor.

D. Notify the surgeon if white drainage develops on the eyelids.

Rationale: White, crusty drainage on the eye lid is an expected finding. The client should notify the
surgeon if she has green or yellow drainage on the eyelids or eyelashes.

88. A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of
the following instructions should the nurse include in the plan of care?

A. Resume your exercise routine.

B. Lie on your back when sleeping.

C. Lie on your back when sleeping.

D. Wash your hair 24 hr after surgery.

89. An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that
the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe
when assessing the client?

A. Extension of the arms

Rationale: Extension of the extremities is an indicator of decerebrate posturing rather than decorticate
posturing.

B. Pronation of the hands

Rationale: Pronation of the hands is an indicator of decerebrate posturing rather than decorticate
posturing.

C. Plantar flexion of the legs

Rationale: Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the
corticospinal tracts.

D. External rotation of the lower extremities

Rationale: Internal rotation rather than external rotation of the lower extremities is an indicator of
decorticate posturing.

90. A nurse is reviewing the medication administration records of four clients who have a prescription for morphine
PRN. Which of the following findings should the nurse identify as a contraindication to this medication?

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A. The client is experiencing a myocardial infarction.

Rationale: Morphine sulfate is routinely used for clients experiencing a myocardial infarction to decrease
oxygen demand and the workload on the heart. A history of recent MI is not a contraindication
to the administration of morphine.

B. The client who is 24 hr postoperative following hip arthroplasty.

Rationale: Morphine sulfate is used for preoperative and postoperative pain by mimicking the actions of
endogenous opioid peptides at the mu receptors.

C. The client who has bronchitis pleurisy.

Rationale: The client who is experiencing bronchitis with pleurisy is not a contraindication for administering
morphine, but may help to suppress the cough reflex when administered to treat the pain from
the pleurisy.

D. The client has a paralytic ileus.

Rationale: Morphine is contraindicated in clients who have a paralytic ileus because morphine suppresses
the propulsive contractions of the intestinal tract and inhibits secretion of fluids into the
intestinal tract.

91. A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and
reports a loss of consciousness immediately after the accident. Which of the following additional manifestations
should the nurse assess the client for?

Answers cannot be displayed for this alternate item format.

Rationale: Pupillary dilation:Assessing for pupillary dilation is important as it can be a manifestation of a

moderate to severe head injury. Manifestations such as persistent headache and difficulty waking
should be assessed after a moderate to severe head [Link] headache:Assessing for
persistent headache is important as it can be a manifestation of a moderate to severe head injury.
Manifestations such as pupillary dilation and difficulty waking should be assessed after a moderate
to severe head [Link] of hand tremors:Hand tremors are a manifestation of Parkinson's
disease. Manifestations such as pupillary dilation, persistent headache, and difficulty waking
should be assessed after a moderate to severe head [Link] waking:Assessing for
difficulty waking is important as it can be a manifestation of a moderate to severe head injury.
Manifestations such as pupillary dilation and persistent headache should be assessed after a
moderate to severe head [Link] drop:Foot drop is a manifestation of peripheral neuropathy.
Assessing for pupillary dilation, persistent headache, and difficulty waking are manifestations of a
moderate to severe head injury.

92. A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma.
Which of the following interventions should the nurse include in the plan?

A. Apply restraints.

Rationale: The nurse should pad the rails of the bed and apply mitts to the client's hands if needed to
protect the client from self-injury. The nurse should avoid applying restrains, which can
increase the client's intracranial pressure.

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B. Administer opioids.

Rationale: The nurse should avoid administering opioids because they can suppress respiratory rate,
constrict pupillary reaction, and alter responsiveness.

C. Darken the room.

Rationale: The nurse should provide adequate lighting in the client's room to prevent visual hallucinations.

D. Reduce stimuli.

Rationale: The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and
creating a quiet environment.

93. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.

Answers cannot be displayed for this alternate item format.

Rationale: The nurse should implement seizure precautions and dim the lights in the client's room because
the client has manifestations of meningitis, such as headache, elevated temperature, lethargy,
vomiting, rash, and photosensitivity. The nurse should assess the client's neurologic status and the
client's temperature every 2 to 4 hr to monitor for changes that can indicate an increase in the
client's intracranial pressure and worsening of the infection.

94. A nurse is caring for a client who has Mèniére's disease. The nurse identifies that which of the following
manifestations is caused by an excessive accumulation of endolymph fluid?

A. Vertigo

B. Presbycusis

C. Myopia

D. Photophobia

95. Which of the following findings are consistent with spinal cord injury, multiple sclerosis, or degenerative disc
disease?For each assessment finding, click to specify if the assessment finding is consistent with spinal cord
injury, multiple sclerosis, or degenerative disc disease. Each finding might support more than one disease
process.

Answers cannot be displayed for this alternate item format.

Rationale: When analyzing cues, the nurse should recognize that heterotopic ossification impacting the joints
and loss of sensation and motor movement are conditions that affect clients who have spinal cord
[Link] analyzing cues, the nurse should recognize that changes in mobility, loss of bowel
and bladder control, and paresthesia might affect clients who have spinal cord injury, multiple

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sclerosis, and degenerative disc [Link] analyzing cues, the nurse should recognize that
optic neuritis and dysphagia might affect clients who have multiple sclerosis.

96. A nurse is planning care for a client who has neurogenic shock following a spinal cord injury. Which of the
following provider prescriptions should the nurse anticipate? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: The nurse should anticipate treatment of hypotension with a vasopressor, dopamine, and fluid
[Link] nurse should anticipate treatment of hypotension with a vasopressor, dopamine,
and fluid [Link] nurse should anticipate treatment of hypotension with a vasopressor,
dopamine, and fluid [Link] should not be given for neurogenic shock because it
decreases blood [Link] should not be given for neurogenic shock because it
decreases blood pressure.

97. A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances
Act. Which of the following medication prescriptions should the nurse include under Schedule II?

A. Buprenorphine hydrochloride

Rationale: Buprenorphine is under Schedule III prescription medication, which may be oral, written, or
electronically prescribed by the provider.

B. Morphine

Rationale: The charge nurse should include in the teaching that morphine is under Schedule II
prescription medications, which requires the provider to complete a written prescription with a
signature.

C. Hydrocodone bitartrate

Rationale: Hydrocodone is under Schedule III prescription medication, which may be oral, written, or
electronically prescribed by the provider.

D. Diazepam

Rationale: Diazepam is a Schedule IV prescription medication, which may be oral, written, or electronically
prescribed by the provider.

98. A nurse is providing teaching to a group of clients about the changes that occur in the eye when clients experience
retinal detachment. Which of the following statements should the nurse include in the teaching?

A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow."

B. "Vision changes occur when the cloudy lens alters the passage of light through the eye."

C. "Vision changes occur when the retina begins to breakdown and collect bits of debris."

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D. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye."

99. A nurse is teaching a student about cerebral edema. The student nurse asks, "What type of cerebral edema is
associated with a client who has a stroke?" Which of the following is the best response from the nurse?

A. Vasogenic cerebral edema

B. Osmotic cerebral edema

C. Cellular cerebral edema

D. Interstitial cerebral edema

100.A nurse is preparing a poster about chronic traumatic encephalopathy (CTE) for a local community health fair.
Which of the following activities should the nurse include on the poster as increasing the risk for CTE?

A. Football, military service, and physical abuse

B. Basketball, office jobs, and listening to loud music

C. Golfing, working in construction, and horse roping

D. Swimming, working as a nurse, and painting

101.A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

A. Speak to the client about one idea at a time.

Rationale: The nurse should speak using sentences that contain one clear thought or idea for better
communication and understanding.

B. Ask the client to multi-task.

Rationale: The nurse use simple one-step directions, rather than ask the client to multi-task.

C. Limit questions to yes and no answers.

Rationale: The nurse should avoid asking questions that stimulate "yes" and "no" responses because the
client might give automatic responses that are not correct.

D. Focus on a single form of communication.

Rationale: The nurse should include a variety of aids to assist with communication.

102.A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following

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information should the nurse include in the teaching?

A. "Syncope episodes may occur when taking this medication."

Rationale: The nurse should inform the family to monitor for syncope, which places the client at risk for
falling.

B. "This medication may cause tachycardia."

Rationale: The nurse should inform the family the medication may cause bradycardia, which places the
client at risk for falling.

C. "You should administer the medication each morning."

Rationale: The nurse should instruct the family to administer the medication at bedtime, not in the
morning, to avoid daytime sedation and improve effectiveness.

D. "You will need to monitor for constipation."

Rationale: The nurse should inform the family to monitor for diarrhea because of the cholinergic effect,
not constipation.

103.A nurse is providing teaching to a group of clients about changes that occur when clients experience open-angle
glaucoma. Which of the following statements should the nurse include in the teaching?

A. "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina."

B. "Vision changes occur when the cloudy lens alters the passage of light through the eye."

C. "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor."

D. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye."

104.A nurse is providing care for a client who was in a motor-vehicle accident. The client has been on a ventilator for
3 weeks and has no brain activity on an electroencephalogram (EEG). The family is requesting that all care be
provided to the client. Which of the following interventions should the nurse perform?

A. Consult the ethics committee.

B. Discontinue the ventilator.

C. Ignore the family's request.

D. Consult the social worker.

105.A nurse is caring for a client who has headaches. In determining a diagnosis, which of the following precipitating
factors is common in both tension-type headaches and cluster headaches?

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A. Stress

B. Poor posture

C. Depression

D. Smoking

[Link] 5 diagnostic tests that the nurse should anticipate the provider to order to assist in determining
the etiology of this client's condition.

Answers cannot be displayed for this alternate item format.

Rationale: Rationale:When analyzing cues to determine the cause of the client's peripheral neuropathy, the
nurse anticipates the following provider prescriptions:-Check hemoglobin A1C given the client's
history of diabetes mellitus and likelihood that this condition may contribute to the client's
symptoms. The incidence of peripheral neuropathy is more frequent in individuals who have
diabetes. In 2019, the American Diabetes Association estimated that 50% of individuals who have
diabetes will experience some time of peripheral neuropathy.-Check vitamin B12 level because
macrocytic anemia can cause peripheral neuropathy.-Check ANA for specific autoimmune
diseases known to cause peripheral neuropathies such as Sjogren's syndrome, lupus, and
rheumatoid arthritis.-Check TSH level because hypothyroidism can cause neuropathy.-Perform a
nucleic acid test (NAT) to determine the presence of human immunodeficiency virus (HIV).The
causes of peripheral neuropathy are numerous and include diabetes mellitus, chronic alcohol
use, vitamin deficiencies, including deficiencies in vitamins BI, B6, B9, B12, E, and folic acid,
autoimmune diseases, inflammatory conditions, chemotherapy, exposure to heavy metals,
tumors, genetic conditions such as amyloidosis, Fabry disease, and Charcot-Marie-Tooth
disease, infections such as HIV, Lyme disease, shingles, and Hansen's disease, trauma and
surgery due to nerve damage, and vascular conditions.

107.A nurse is teaching the caregiver of a client who has dementia. Which of the following behaviors should the nurse
identify as increasing with the progression of the disorder?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale A:Hallucinations is correct. As dementia worsens, some clients can experience
hallucinations, which can contribute to increased stress and additional burdens for caregivers as
the amount of supervision necessary to keep the client safe [Link] B:Paranoia is
correct. As dementia worsens, some clients can experience paranoia, which can contribute to
increased stress and additional burdens for caregivers as the amount of supervision necessary to
keep the client safe [Link] C:Lethargy is incorrect. Dementia does not affect
consciousness. Changes in the client's level of consciousness can be manifestations of a
different [Link] D:Impulsivity is correct. As dementia worsens, some clients can act
impulsively, which can contribute to increased stress and additional burdens for caregivers as the
amount of supervision necessary to keep the client safe [Link] E:Disregard for the
caregiver's feelings is correct. As dementia worsens, some clients can act without regard for the
caregiver's feelings, which can contribute to increased stress and additional burdens for
caregivers.

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108.A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following
actions should the nurse take?

A. Prepare the client for mechanical ventilation.

Rationale: The client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory
function. The nurse should closely monitor the client's respiratory status and prepare for
possible mechanical ventilation.

B. Administer prescribed sedatives.

Rationale: The client who is experiencing a myasthenic crisis should not receive sedative medications
during a myasthenic crisis. These medications can cause hypoxia and respiratory and cardiac
depression.

C. Instruct the client to perform pursed lip breathing.

Rationale: Myasthenia gravis is an autoimmune illness that results in progressive muscular weakness. A
client who is experiencing myasthenic crisis is at risk for respiratory failure and will not benefit
from pursed lip breathing.

D. Prepare to administer a vasoconstrictor.

Rationale: A client who is experiencing myasthenic crisis will be hypertensive rather than hypotensive.

109.A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent
drainage from the affected eye. Which of the following actions is the nurse's priority?

A. Notify the surgeon.

Rationale: Purulent draining is a manifestation of infection and should be reported to the surgeon
immediately.

B. Instill an antibiotic solution in both eyes.

Rationale: The client will likely have a prescription for antibiotic, but another action is the priority.

C. Clean eye from inner to outer canthus.

Rationale: The nurse should keep the eye clean. However, another action is the priority.

D. Apply a non-pressure patch to the affected eye.

Rationale: A patch is often applied to the eye following surgery. However, another action is the priority.

110.A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral
perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

A. Provide warming measures for the client.

Rationale: The nurse should provide cooling measures to reduce brain metabolism.

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B. Hyperextend the client's neck.

Rationale: The nurse should keep the client's neck midline, in a neutral position to reduce the client's
ICP.

C. Flex the client's hip.

Rationale: The nurse should avoid flexing the client’s hips to reduce the client's ICP.

D. Adjust the client's head of bed.

Rationale: The nurse should adjust the client's head of bed to keep CPP greater than 70 mm Hg.

[Link] the following sentence by using the lists of options.

Answers cannot be displayed for this alternate item format.

[Link] the following sentence by using the lists of options.

Answers cannot be displayed for this alternate item format.

Rationale: When using the evidence-based practice priority framework, the nurse should determine that the
priority hypothesis is the client developing progressive multifocal leukoencephalopathy (PML) as
evidenced by the client's loss of coordination, ataxia, increasing weakness, difficult speech,
confusion, and visual changes. The client had started Natalizumab which is known to potentially
cause PML.

113.A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely
monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?

A. Nuchal rigidity

Rationale: Neck stiffness or nuchal rigidity, along with myalgia and altered reflexes, is a manifestation of
meningeal inflammation.

B. Pupils reactive to light

Rationale: Cranial nerve III is responsible for pupil constriction, so changes in pupillary reaction is a
definite cause for concern, but reactivity does not indicate increased ICP.

C. Widened pulse pressure

Rationale: A widened pulse pressure is a manifestation of increased ICP. Other manifestations include
bradycardia, vomiting, and decreased level of consciousness.

D. Elevated temperature

Rationale: Fever, sometimes accompanied by chills, is a manifestation of bacterial infection.

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114.A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse
identify as an indication of increased intracranial pressure (ICP)?

A. Tachycardia

Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and
bradycardia (termed Cushing’s triad) are signs of increased ICP.

B. Amnesia

Rationale: The client who has a traumatic brain injury may experience a loss of consciousness along with
a lack of memory of events prior to or following the injury, but does not indicate an increase in
ICP.

C. Hypotension

Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and
bradycardia (termed Cushing’s triad) are signs of increased ICP.

D. Restlessness

Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid
or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP
include restlessness, irritability and confusion along with a change in level of consciousness,
or a change in speech pattern.

115.A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic–clonic seizure. Which of
the following actions should the nurse take?

A. Insert a padded tongue blade into the client’s mouth.

Rationale: The nurse should avoid placing anything in the client’s mouth during a seizure due to the risk
for injury and airway occlusion.

B. Place a pillow under the client’s head.

Rationale: The nurse should place a small pillow or other soft padding under the client’s head to protect
the client from injury during the seizure, and turn his head to the side to keep the airway clear.

C. Gently restrain the client’s extremities.

Rationale: The nurse should avoid restraining the client’s extremities during a seizure due to the risk for
injury.

D. Apply a face mask for oxygen administration.

Rationale: The nurse should avoid placing anything on the client during a seizure due to the risk for
injury. During the postictal phase the nurse should assess the client’s oxygenation status and
administer supplemental oxygen if necessary.

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116.A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks
the nurse what to expect during the procedure. Which of the following statements should the nurse make?

A. "An MRI scan is not distorted by movement, so you do not have to lie still."

Rationale: An MRI scan is distorted by movement. It is important that the client is informed of the need to
lie still during the procedure.

B. "An MRI scan is a short procedure and should take no longer than 30 minutes."

Rationale: An MRI scan is a lengthy procedure that lasts between 60 and 90 min.

C. "The MRI contrast dye contains iodine and can cause your skin to itch."

Rationale: MRI contrast dye does not contain iodine and therefore is not subject to hypersensitivity
reactions like contrast dye used in a traditional CT scan.

D. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

Rationale: The nurse should instruct the client that many clients report being disconcerted by the loud
thumping and humming noises produced by the scanner, and for that reason, earplugs are
offered to reduce the discomfort.

117.A nurse is caring for a client who has a subarachnoid hemorrhage and asks why they are having a CT
angiography. Which of the following should the nurse understand about CT angiography?

A. A CT angiogram will reveal any decreased blood flow related to vasospasm.

B. A CT angiogram will reveal any fractures within the skull or spine.

C. A CT angiogram will reveal any edema within the brain tissue.

D. A CT angiogram will reveal any overproduction of cerebrosp fluid (CSF).

118.A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation
device. Which of the following statements should the nurse make?

A. "Turn the screws on the device once each day."

Rationale: The nurse should instruct the client and family that the screws are not to be adjusted except
by the provider. Pin loosening is a complication and should be reported to the provider
immediately.

B. "The purpose of this device is to immobilize the cervical spine."

Rationale: A client who has an injury to the cervical spine can have a halo fixation device to provide
immobilization of the head and neck for a period of 8 to 12 weeks.

C. "Apply talcum powder under the vest to limit friction."

Rationale: The nurse should instruct the client and family to avoid placing powder under the vest

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because this can result in skin breakdown.

D. "The purpose of this device is to allow for neck movement during the healing process."

Rationale: A client who has a halo fixation device in place is unable to move or rotate the neck in order to
prevent further injury.

119.A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction
procedure. Which of the following client statements require further investigation by the nurse?

A. "I took my blood pressure meds with a sip of water."

B. "I stopped taking aspirin last week."

C. "I did not put my contact lenses in this morning."

D. "I had a cough and runny nose a couple days ago."

120.A nurse is caring for a client who has multiple sclerosis. Which of the following assessment findings should the
nurse anticipate with this client?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale APhotosensitivity is not an assessment finding associated with multiple sclerosis.
Rationale BDifficulty acquiring, retaining, and retrieving memories is a common manifestation of
multiple [Link] CLhermitte's sign is a finding associated with multiple sclerosis.
Lhermitte's sign is a brief, electrical-shock pain that extends from the back of the head down the
spine and can affect the extremities. This type of pain is experienced when the client who has
multiple sclerosis bends their neck forward. It indicates damage to the cervical [Link] D
Seizures are not an assessment finding associated with multiple [Link] EOptic
neuritis is a common finding in multiple sclerosis that results in central vision loss and pain with
eye movement.

121.A nurse is caring for a client who has a spinal cord injury and has absent bowel sounds in the lower abdominal
quadrants. Which of the following actions should the nurse perform?

A. Place the client on clear liquids.

B. Force the intake of fluids.

C. Insert a nasogastric tube.

D. Perform a hemoccult blood test.

122.A nurse is caring for a client who experienced severe head trauma. The client's partner asks the nurse why they

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are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of
the following?

A. Cerebral blood flow

B. Regulation of blood pressure

C. Resorption of cerebrospinal fluid

D. The client's intake and output needs

123.A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following
interventions should the nurse implement first to prevent client injury?

A. Administer antipsychotic medications as prescribed.

B. Arrange for one-on-one observation for the client.

C. Apply soft restraints to wrists and chest.

D. Administer sedative medications as prescribed.

124.A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for
suspicion of cataracts. The nurse should expect the client to report

A. loss of central vision.

Rationale: Clients who have macular degeneration experience a loss of central vision.

B. having a loss of peripheral vision.

Rationale: Loss of peripheral vision is an initial symptom of open angle glaucoma.

C. seeing bright flashes of light and floaters.

Rationale: Bright flashes of light, especially in the peripheral visual field, and floaters, which are
translucent specks of various shapes in the visual field, are associated with retinal
detachment.

D. having a decreased ability to perceive colors.

Rationale: Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive
colors.

125.A nurse is providing discharge information to a client who has Parkinson's disease and their family members.
Which of the following instructions should the nurse include in the discharge information?

Answers cannot be displayed for this alternate item format.

Rationale:

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Encourage the client to walk [Link] a hospital bed with all four siderails up will not
help prevent falls. Instead, a client at risk for falls should be informed about removing throw rugs,
installing handrails in the bathroom for assistance when getting up from the toilet or out of the tub,
ensuring adequate lighting along walking spaces, and keeping walking areas free of clutter.
These measures would all help to prevent tripping and [Link] the client with fresh
fruits and vegetables.A client at risk for falls should be informed of the following measures to
help prevent tripping and falling: Removing throw rugs from the home, installing handrails in the
bathroom for assistance when getting up from the toilet or out of the tub, ensuring adequate
lighting along walking spaces, and keeping walking areas free of [Link] fluids to 800
mL/day.A client at risk for falls should be informed of the following measures to help prevent
tripping and falling: Removing throw rugs from the home, installing handrails in the bathroom for
assistance when getting up from the toilet or out of the tub, ensuring adequate lighting along
walking spaces, and keeping walking areas free of [Link] exposure to outside
activities.A client at risk for falls should be informed of the following measures to help prevent
tripping and falling: Removing throw rugs from the home, installing handrails in the bathroom for
assistance when getting up from the toilet or out of the tub, ensuring adequate lighting along
walking spaces, and keeping walking areas free of [Link] the client how to use a walker.
A client at risk for falls should be informed of the following measures to help prevent tripping and
falling: Removing throw rugs from the home, installing handrails in the bathroom for assistance
when getting up from the toilet or out of the tub, ensuring adequate lighting along walking spaces,
and keeping walking areas free of clutter.

126.A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the
following information should the nurse include?

A. "Bloodshot eyes on the day of surgery should be reported to the provider."

Rationale: Bloodshot eyes are an expected finding on the day of surgery.

B. "Warm compresses should be applied to the eye three times daily."

Rationale: Cold compresses should be applied to the eye.

C. "Photophobia is expected for 2 to 3 days."

Rationale: Photophobia is not an expected finding and should be immediately reported to the provider.

D. "Vision will be greatly improved on the day of surgery."

Rationale: Vision should be greatly improved on the day of surgery. This information should be included
in the teaching.

127.A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which
of the following actions should the nurse take?

A. Instruct the client to cough and deep breathe.

Rationale: A client who has increased ICP is at risk for brain herniation, a potentially life-threatening
condition. Actions, such as deep breathing, coughing, and blowing the nose, can increase
ICP. The nurse should take measures to maintain or reduce the client's ICP.

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B. Place the client in a supine position.

Rationale: An important intervention for ICP is positioning the client in a neutral position with the head of
the bed elevated to 30&deg to 45&deg. This placement allows the cerebral spinal fluid to flow
freely through the brain and spinal cord, minimizes pressure within the central nervous
system, and prevents aspiration.

C. Place a warming blanket on the client.

Rationale: A client who has increased ICP can develop a fever in response to systemic trauma, the
presence of blood in the cranium, infection, or as a generalized inflammatory response to the
brain injury. Therapeutic cooling is often initiated, even in the absence of fever, in order to
slow the brain's metabolism and prevent secondary brain injury.

D. Use log rolling to reposition the client.

Rationale: Treatment of increased ICP focuses on decreasing the pressure. An important intervention
includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In
order to avoid hip flexion, the client should be log rolled when repositioned.

128.A nurse is admitting a client to the hospital unit. Which one of the following elements of the client's history and
physical assessment increases the risk for the development of delirium?

A. History of drug and alcohol use

B. Female sex

C. History of lymphoma

D. Lack of medical insurance

129.A nurse in a primary care office is teaching a client about the nervous system. Which of the following
neurotransmitters should the nurse include in the teaching as having an inhibitory action on the cell?

A. GABA

B. Acetylcholine

C. Serotonin

D. Dopamine

130.A nurse is preparing to administer valproic acid 400 mg PO bid for migraine headaches. Available is valproic acid
250 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL

Correct Rationale:

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<b>Follow these steps for the Ratio and Proportion method of calculation:</b>Step 1:
What is the unit of measurement the nurse should calculate? mL Step 2: What is the
dose the nurse should administer? Dose to administer = Desired 400 mg Step 3: What is
the dose available? Dose available = Have 250 mg Step 4: Should the nurse convert the
units of measurement? No Step 5: What is the quantity of the dose available? 5 mL Step
6: Set up an equation and solve for X. <i>Have</i><i>Desired<i/><hr>&#160 =
&#160<hr><i>Quantity<i/><i>X</i></br></br>250 mg400 mg<hr>&#160 = &#160<hr>5
mL<i>X</i> mL</br></br><i>X</i> mL = 8 mLStep 7: Round if necessary. Step 8:
Reassess to determine whether the amount to administer makes sense. If there are 250
mg/5 mL and the prescription reads 400 mg, it makes sense to administer 8 mL. The
nurse should administer valproic acid 8 mL PO per dose.<b>Follow these steps for the
Desired Over Have method of calculation:</b>Step 1: What is the unit of measurement
the nurse should calculate? mL Step 2: What is the dose the nurse should administer?
Dose to administer = Desired 400 mg Step 3: What is the dose available? Dose
available = Have 250 mg Step 4: Should the nurse convert the units of measurement?
No Step 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation
and solve for X. <i>Desired<i/> &#215 <i>Quantity</i><i>X</i>&#160 =
&#160<hr><i>Have<i/></br></br>400 <s>mg &#215 5 mL<i>X</i> mL&#160 =
&#160<hr>250 <s>mg</br></br><i>X</i> mL = 8 mLStep 7: Round if necessary. Step 8:
Reassess to determine whether the amount to administer makes sense. If there are 250
mg/5 mL and the prescription reads 400 mg, it makes sense to administer 8 mL. The
nurse should administer valproic acid 8 mL PO per dose. <b>Follow these steps for the
Dimensional Analysis method of calculation:</b>Step 1: What is the unit of
measurement the nurse should calculate? (Place the unit of measure being calculated
on the left side of the equation.) <i>X</i> mL = Step 2: Determine the ratio that contains
the same unit as the unit being calculated. (Place the ratio on the right side of the
equation, ensuring that the unit in the numerator matches the unit being calculated.) 5
mL<i>X</i> mL&#160 = &#160<hr>250 mg</br></br>Step 3: Place any remaining ratios
that are relevant to the item on the right side of the equation, along with any needed
conversion factors, to cancel out unwanted units of measurement. 5 mL400
<s>mg<i>X</i> mL&#160 = &#160<hr>&#160 &#215 &#160<hr>250 <s>mg1
dose</br></br>Step 4: Solve for X. <i>X</i> mL = 8 mLStep 5: Round if necessary. Step
6: Reassess to determine whether the amount to administer makes sense. If there are
250 mg/5 mL and the prescription reads 400 mg, it makes sense to administer 8 mL.
The nurse should administer valproic acid 8 mL PO per dose.

InCorrect Rationale: <b>Follow these steps for the Ratio and Proportion method of calculation:</b>Step 1:
What is the unit of measurement the nurse should calculate? mL Step 2: What is the
dose the nurse should administer? Dose to administer = Desired 400 mg Step 3: What
is the dose available? Dose available = Have 250 mg Step 4: Should the nurse
convert the units of measurement? No Step 5: What is the quantity of the dose
available? 5 mL Step 6: Set up an equation and solve for X.
<i>Have</i><i>Desired<i/><hr>&#160 =
&#160<hr><i>Quantity<i/><i>X</i></br></br>250 mg400 mg<hr>&#160 =
&#160<hr>5 mL<i>X</i> mL</br></br><i>X</i> mL = 8 mLStep 7: Round if
necessary. Step 8: Reassess to determine whether the amount to administer makes
sense. If there are 250 mg/5 mL and the prescription reads 400 mg, it makes sense to
administer 8 mL. The nurse should administer valproic acid 8 mL PO per
dose.<b>Follow these steps for the Desired Over Have method of
calculation:</b>Step 1: What is the unit of measurement the nurse should calculate?
mL Step 2: What is the dose the nurse should administer? Dose to administer =
Desired 400 mg Step 3: What is the dose available? Dose available = Have 250 mg
Step 4: Should the nurse convert the units of measurement? No Step 5: What is the
quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X.
<i>Desired<i/> &#215 <i>Quantity</i><i>X</i>&#160 =
&#160<hr><i>Have<i/></br></br>400 <s>mg &#215 5 mL<i>X</i> mL&#160 =
&#160<hr>250 <s>mg</br></br><i>X</i> mL = 8 mLStep 7: Round if necessary. Step

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:</b>Step 1: What is the unit of measurement the nurse should calculate? mL Step 2:
What is the dose the nurse should administer? Dose to administer = Desired 400 mg
Step 3: What is the dose available? Dose available = Have 250 mg Step 4: Should the
nurse convert the units of measurement? No Step 5: What is the quantity of the dose
available? 5 mL Step 6: Set up an equation and solve for X.
<i>Have</i><i>Desired<i/><hr>&#160 =
&#160<hr><i>Quantity<i/><i>X</i></br></br>250 mg400 mg<hr>&#160 =
&#160<hr>5 mL<i>X</i> mL</br></br><i>X</i> mL = 8 mLStep 7: Round if
necessary. Step 8: Reassess to determine whether the amount to administer makes
sense. If there are 250 mg/5 mL and the prescription reads 400 mg, it makes sense to
administer 8 mL. The nurse should administer valproic acid 8 mL PO per
dose.<b>Follow these steps for the Desired Over Have method of
calculation:</b>Step 1: What is the unit of measurement the nurse should calculate?
mL Step 2: What is the dose the nurse should administer? Dose to administer =
Desired 400 mg Step 3: What is the dose available? Dose available = Have 250 mg
Step 4: Should the nurse convert the units of measurement? No Step 5: What is the
quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X.
<i>Desired<i/> &#215 <i>Quantity</i><i>X</i>&#160 =
&#160<hr><i>Have<i/></br></br>400 <s>mg &#215 5 mL<i>X</i> mL&#160 =
&#160<hr>250 <s>mg</br></br><i>X</i> mL = 8 mLStep 7: Round if necessary. Step
8: Reassess to determine whether the amount to administer makes sense. If there are
250 mg/5 mL and the prescription reads 400 mg, it makes sense to administer 8 mL.
The nurse should administer valproic acid 8 mL PO per dose. <b>Follow these steps
for the Dimensional Analysis method of calculation:</b>Step 1: What is the unit of
measurement the nurse should calculate? (Place the unit of measure being calculated
on the left side of the equation.) <i>X</i> mL = Step 2: Determine the ratio that
contains the same unit as the unit being calculated. (Place the ratio on the right side of
the equation, ensuring that the unit in the numerator matches the unit being
calculated.) 5 mL<i>X</i> mL&#160 = &#160<hr>250 mg</br></br>Step 3: Place any
remaining ratios that are relevant to the item on the right side of the equation, along
with any needed conversion factors, to cancel out unwanted units of measurement. 5
mL400 <s>mg<i>X</i> mL&#160 = &#160<hr>&#160 &#215 &#160<hr>250 <s>mg1
dose</br></br>Step 4: Solve for X. <i>X</i> mL = 8 mLStep 5: Round if necessary.
Step 6: Reassess to determine whether the amount to administer makes sense. If
there are 250 mg/5 mL and the prescription reads 400 mg, it makes sense to
administer 8 mL. The nurse should administer valproic acid 8 mL PO per dose.

131.A nurse in the emergency department is caring for a client who has an epidural hematoma following a
motor-vehicle crash. Which of the following is an expected finding for this client?

A. Narrowing pulse pressure

Rationale: The client who has an epidural hematoma can exhibit a widening pulse pressure as a result of
increasing intracranial pressure.

B. Drainage of clear fluid from the ears

Rationale: Drainage of clear fluid from the ears can indicate a leak of cerebrospinal fluid but is not an
indication of an epidural hematoma.

C. Alternating periods of alertness and unconsciousness

Rationale: Alternating periods of alertness and unconsciousness is a common manifestation of an

epidural hematoma.

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D. Extensive bruising in the mastoid area

Rationale: Extensive bruising in the mastoid area, also known as "battle sign," is a possible manifestation
of a skull fracture rather than an epidural hematoma.

132.A nurse is planning care for a client who has multiple sclerosis and is receiving methylprednisolone. Which of the
following adverse effects should the nurse anticipate? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Adverse effects associated with methylprednisolone include pheochromocytomas, depression,

euphoria, hypertension, decreased wound healing, hirsutism, adrenal suppression,
hyperglycemia, leukocytosis, thromboembolism, osteoporosis, and Cushingoid
[Link] effects associated with methylprednisolone include pheochromocytomas,
depression, euphoria, hypertension, decreased wound healing, hirsutism, adrenal suppression,
hyperglycemia, leukocytosis, thromboembolism, osteoporosis, and Cushingoid
[Link] effects associated with methylprednisolone include pheochromocytomas,
depression, euphoria, hypertension, decreased wound healing, hirsutism, adrenal suppression,
hyperglycemia, leukocytosis, thromboembolism, osteoporosis, and Cushingoid
[Link] can cause hypertension, not hypotension, as an adverse
[Link] is not associated with the adverse effect of bladder spasms.

133.A nurse is caring for a client who is newly diagnosed with Parkinson's disease. The client states, "I have no idea
why I got this." Which of the following is the most important question the nurse should ask this client while
performing the assessment?

A. "What kind of work do you do?"

B. "When did you have your last physical?"

C. "Do you have any family members with Parkinson's disease?"

D. "How much coffee do you drink every day?"

134.A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should
the nurse plan to include in the plan of care?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale ATo minimize further neurological decline, the nurse should plan to monitor the client's
volume status, ensure the ventriculostomy transducer level is correct, and manage sedation.
Rationale BEndotracheal suctioning should be limited due to the possibility of increasing
intracranial [Link] CTo minimize further neurological decline, the nurse should plan
to monitor the client's volume status, ensure the ventriculostomy transducer level is correct, and
manage [Link] DTo minimize further neurological decline, the nurse should plan to
monitor the client's volume status, ensure the ventriculostomy transducer level is correct, and
manage [Link] EThe head of the bed should be elevated at least 30° for clients with
increased intracranial pressure.

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135.A nurse is performing preoperative assessments on a client who has a suspected detached retina. Which of the
following should the nurse expect to find?

A. Tonometer intraocular pressure reading 8 mm Hg

B. Smooth retina edges identified on slit-lamp biomicroscope examination

C. Lens and cornea appear intact during ophthalmoscope exam

D. Visual acuity of 20/20 using the Snellen eye chart

136.A nurse is teaching a group of clients about causes for developing hearing loss. Which of the following risk
factors should the nurse include in the teaching?

A. Exposure to environmental toxins

B. Prolonged exposure to loud noises

C. Alcohol use disorder

D. Contact with excessive heat

137.A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the
following actions should the nurse take?

A. Monitor sensory perception of the lower extremities.

Rationale: The nurse should perform neurologic assessments focusing on sensory perception of the
lower extremities every 4 hr. Any decrease in sensation by the client requires immediate
notification of the provider.

B. Assist the client into a knee-chest position to manage postoperative discomfort.

Rationale: A client who is postoperative following a laminectomy needs to maintain a straight back.

C. Maintain strict bed rest for the first 48 hr postoperative.

Rationale: The nurse should assist the client to get out of bed with assistance in the evening following
surgery.

D. Position the client in a high-Fowler's position if clear drainage is noted on the dressing.

Rationale: The nurse should place a client who has clear drainage on the surgical dressing in a supine
position and notify the provider immediately.

138.A nurse is caring for a client following cataract surgery. Which of the following comments from the client should

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the nurse report to the client's provider?

A. "My eye really itches, but I'm trying not to rub it."

Rationale: Itching is common after cataract surgery. The nurse should remind the client not to rub or
place pressure on the eyes.

B. "I need something for the pain in my eye. I can't stand it."

Rationale: Following cataract surgery, the client should expect only mild pain and should immediately
report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain
after surgery might indicate increased intraocular pressure or hemorrhage.

C. "It's hard to see with a patch on one eye. I'm afraid of falling."

Rationale: Clients who wear an eye patch lose their depth perception and part of their peripheral vision,
temporarily decreasing visual acuity.

D. "The bright light in this room is really bothering me."

Rationale: The client may find that exposure to bright light is uncomfortable after cataract surgery.
Wearing sunglasses can prevent most of the client's discomfort.

139.A nurse is caring for a client who has chemotherapy- induced peripheral neuropathy. The nurse should expect
the client to report having experienced which of the following symptoms?

A. Extremities that turned blue when exposed to cold

Rationale: Extremities that turn blue when exposed to cold is a symptom of Raynaud's phenomenon, a
disorder that causes constriction of the blood vessels in the fingers, toes, ears, and nose.

B. Tingling feeling in the extremities

Rationale: Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral
nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a
side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to
experience pain, numbness, tingling, burning, or a loss of feeling in the extremities.

C. Jerking movements of the extremities

Rationale: Jerking movements, such as ataxia, may be seen with many neurologic conditions affecting
the client's ability to produce a smooth movement.

D. Spasms of the extremities

Rationale: Involuntary spasms may be found with such conditions as cerebral palsy, trauma, cerebral
infection, and certain degenerative disorders.

140.A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following secondary conditions
should the nurse anticipate the client might develop?

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A. Loss of sensation and cognition difficulties

B. Development of emotional disorders and acute pain

C. Decreased appetite and a lack of sleep

D. Body dysmorphia and neurofibrillary tangles

141.A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the
following interventions should the nurse include? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at
the bedside to provide oral suctioning as needed following the seizure to prevent aspiration.
Elevate the side rails near the head when the client is in bed is correct. The nurse should
raise the side rails near the head of the bed to help keep the client in the bed. The nurse should
check the facility policy for specific guidelines because raising all side rails can be considered a
restraint. Elevate the rails of the bed to prevent a fall during a seizure.
Place the bed in the lowest position is correct. The nurse should place the bed in the lowest
position to prevent injury if a fall should occur during a seizure.
Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen
saturation during a seizure and provide supplemental oxygen as prescribed.
Furnish restraints at the bedside is incorrect. The nurse should not plan to restrain a client
during a seizure, as this can cause harm to the client's muscles and limbs.

[Link] nurse knows that a secondary spinal cord injury might occur. Which of the following indicates the client is
experiencing this condition?Select all that apply.

Answers cannot be displayed for this alternate item format.

Rationale: When analyzing cues, the nurse should anticipate inflammation, hemorrhage, edema, and
hypovolemic shock, which decreases perfusion to the spinal cord during the secondary injury
following a spinal cord injury. This client's vital signs suggest hypovolemic shock with hypotension
and tachycardia.

143.A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently.
Which of the following responses should the nurse make?

A. "Yes, you are free to move around as you wish."

Rationale: This response creates a safety concern for a client who is at risk of falling.

B. "No, you are on strict bedrest and must not be up."

Rationale: This response is not appropriate because the client is not on strict bed rest and should be able
to move around with assistance.

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C. "Please ring for assistance when you wish to get out of bed."

Rationale: This response is appropriate. With assistance, the client can ambulate safely. Tinnitus,
one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can
increase the client's risk of falls when ambulating.

D. "We will have to get a prescription from your provider."

Rationale: The nurse can make judgments and decisions regarding safety and fall risk without a
prescription from the provider.

144.A nurse is collecting neurologic data on a client who has a neurological injury and notes changes suggestive of
Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that might prevent
which of the following conditions?

A. Brainstem ischemia

B. Chest pain

C. Agonal breathing

D. Tachycardia

145.A nurse is teaching a client who is to start taking warfarin about herbal supplements. The nurse should inform
the client that which of the following herbal supplements can interact adversely with warfarin?

A. Valerian

Rationale: Valerian can increase the actions of other CNS depressant medication, such as
benzodiazepines, barbiturates, opioids, muscle relaxants, and antihistamines.

B. Black cohosh

Rationale: Black cohosh increases the hypotensive effect when using antihypertensive medication and
the hypoglycemic effects of insulin and other diabetic medication.

C. Echinacea

Rationale: Echinacea can decrease the effects of immunosuppressant medication.

D. St. John’s wort

Rationale: The nurse should instruct the client that St. John’s wort can decrease anticoagulation when
taking warfarin.

146.A nurse is obtaining an admission history on a client who is experiencing a loss of hearing. Which of the following
communication techniques should the nurse use when interviewing the client?

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A. Talk in a loud voice.

B. Speak directly into the client's ear.

C. Face the client when talking.

D. Speak with the client's significant other.

147.A nurse is evaluating the plan of care during a postoperative visit for a client who had a retinal reattachment
procedure. Which of the following statements indicates the client is following the instructions in the plan of care?

A. "I will be relieved once I can drive myself to the store."

B. "I can't wait to be able to take a bath."

C. "I get bored only being able to watch television."

D. "I'm glad that I can work remotely from my computer."

148.A nurse is teaching a client who has macular degeneration about how to use an Amsler grid. Which of the
following statements should the nurse include in the teaching?

A. "Check to see if the lines on the grid are blurry or distorted."

B. "Note if you see any flashing bright lights on the grid."

C. "Monitor for the lines on the grid to change in color or brightness."

D. "Watch for floating dark spots on the grid."

149.A nurse is planning care for a client who has a spinal cord injury and spasm-induced incontinence. Which of the
following medications should the nurse anticipate a prescription for?

A. Oxybutynin

B. Glatiramer acetate

C. Montelukast sodium

D. Dulaglutide

150.A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on
a scale from 0 to 10. Which of the following actions should the nurse take first?

A. Administer a bolus of medication.

Rationale:

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The nurse should administer a bolus of medication to achieve a more rapid desired outcome
for pain control; however, there is another action the nurse should take first.

B. Check the display on the PCA pump.

Rationale: The first action the nurse should take using the nursing process is to assess the client;
therefore, the nurse should assess the display on the PCA pump to determine the amount of
medication administered. Some clients are fearful of developing an addiction to narcotics and
may be reluctant to use the PCA.

C. Obtain an order for another pain medication for breakthrough pain.

Rationale: The nurse should obtain an order for another pain medication for breakthrough pain if needed;
however, there is another action the nurse should take first.

D. Encourage the client to administer a demand dose.

Rationale: The nurse should encourage the client to administer a demand dose of medication to increase
the blood level of medication for pain control; however, there is another action the nurse
should take first.

151.A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following
information should the nurse include in the teaching?

A. Provide client supervision.

Rationale: Because the client's voluntary motor control is affected by the disease, the nurse should
recommend that the family provide client supervision to create a safe and respectful
environment.

B. Limit client physical activity.

Rationale: The nurse should recommend an exercise program, alternated with periods of rest, to improve
the client's mobility.

C. Speak loudly to the client.

Rationale: The speech patterns of clients who have Parkinson's disease are often affected with slurring
or hesitation, but not their hearing.

D. Leave the television on continuously.

Rationale: The nurse should recommend decreasing excess environmental stimuli to increase the client's
ability to concentrate on listening.

152.A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing
interventions is of highest priority?

A. Perform passive range of motion on each extremity.

Rationale: The nurse should perform passive range of motion for the client who is unconscious, to help

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prevent complications of impaired physical mobility; however, this is not the highest priority
intervention according to the safety and risk reduction priority setting framework.

B. Monitor the client’s electrolyte levels.

Rationale: The nurse should monitor the electrolyte levels for the client who is unconscious, to help
identify complications of increased intracranial pressure and to limit the risk of cardiac
dysrhythmia; however, this is not the highest priority intervention according to the safety and
risk reduction priority setting framework.

C. Suction saliva from the client’s mouth.

Rationale: The unconscious client is unable to independently maintain a clear airway and is at risk for
ineffective airway clearance. According to the safety and risk reduction priority setting
framework, maintaining the client’s airway, breathing, and circulation is the highest priority.

D. Record the client’s intake and output.

Rationale: The nurse should record the intake and output for the client who is unconscious, to help
identify complications of altered neurological status and increased intracranial pressure;
however, this is not the highest priority intervention according to the safety and risk reduction
priority setting framework.

153.A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions
should the nurse take first?

A. Turn the client's head to the side.

Rationale: The first action the nurse should take when using the airway, breathing, circulation approach
to client care is to turn the client's head to the side. This action keeps the client's airway clear
of secretion to prevent aspiration.

B. Check the client's motor strength.

Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment
following the seizure; however, there is another action the nurse should take first.

C. Loosen the clothing around the client's waist.

Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury;
however, there is another action the nurse should take first.

D. Document the time the seizure began.

Rationale: The nurse should document the time the seizure began and ended to provide information to
the provider about the severity of the seizure; however, there is another action the nurse
should take first.

154.A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports
symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are
appropriate?

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A. “Wear an eye patch on the right eye at all times.”

Rationale: The nurse should instruct the client to alternate every two hours an eye patch to improve
diplopia, not leave on the right eye continually.

B. "Plan to relax in a hot tub spa each day."

Rationale: The nurse should instruct the client to avoid extreme temperature changes because they can
exacerbate the manifestations of MS.

C. "Engage in a vigorous exercise program."

Rationale: The nurse should instruct the client to develop a tolerable exercise program. A vigorous
exercise program can exacerbate the manifestations of MS.

D. "Implement a schedule to include periods of rest."

Rationale: The nurse should assist the client in developing a schedule that includes periods of exercise
followed by periods of rest to maintain muscle strength and coordination.

155.A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse
several questions about what the provider might be planning to do. Which of the following nursing responses
should the nurse make?

A. Provide the client with articles from the Internet that explain colon cancer stages.

Rationale: This action does not address the client's question.

B. Assure the client that the provider will explain what has been planned.

Rationale: This response by the nurse blocks communication by putting the client's concern on hold and
giving false reassurance.

C. Explain the various options available for treatment based on the cancer stage.

Rationale: It is not within the nurse's scope of practice to discuss treatment options with the client.

D. Encourage the client to write down questions to ask the provider.

Rationale: The nurse does not know the answers to the client's questions, so helping the client to
prepare questions for the provider addresses the client's needs.

156.A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following
clients to be at greatest risk for developing delirium?

A. A client who has been NPO for 3 hours, receiving IV fluids, and has not been prescribed any medications

B. A client who is 4 days postoperative following knee surgery and scheduled for discharge home later this
morning

C. A client who has been on the medical unit for a week following a car accident and is waiting for transfer to a

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rehab facility when a bed becomes available

D. A client transferred to the medical unit 1 hour ago, after staying 3 days in the ICU for severe blood pressure
issues

157.A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which
of the following findings should the nurse expect during the initial assessment?

A. Lethargy

Rationale: A serum calcium level of 12.3 mg/dL is above the expected reference range. The nurse
should monitor the client for lethargy, generalized weakness, and confusion.

B. Hyperactive deep tendon reflexes

Rationale: A client who has a serum calcium level below the expected reference range is more likely to
have hyperactive deep tendon reflexes. The nurse should expect this client to have depressed
deep tendon reflexes.

C. Prolonged ST segment

Rationale: Calcium plays a role in the electrical conduction of the heart by controlling depolarization and
action potentials within cells. A client who has a serum calcium level below the expected
reference range is more likely to have a shortened ST segment and shortened QT intervals.

D. Hyperactive bowel sounds

Rationale: A client who has a serum calcium level below the expected reference range is more likely to
have hyperactive bowel sounds and diarrhea. The nurse should expect this client to have
constipation, anorexia, nausea, vomiting, and abdominal distention.

[Link] to highlight the modifiable risk factors in the client's history for the condition found by the CT scan. To
deselect a finding, click on the finding again.

Answers cannot be displayed for this alternate item format.

Rationale: Rationale:When recognizing cues for a client with ischemic stroke, the nurse recognizes that
hypertension, exercise, smoking, and obesity are modifiable risk factors for ischemic stroke.
Non-modifiable factors include age, sex, and ethnicity.

159.A nurse is assessing a client who has Alzheimer's disease, who arrived at the memory clinic with their caregiver.
The nurse recognizes the caregiver of the client is at an increased risk for experiencing which of the following
types of stress?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale A:Financial is correct. Caregivers of clients who have Alzheimer's disease often are
unpaid and experience more financial stress than caregivers of clients who do not have a

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cognitive [Link] B:Emotional is correct. Caregivers of clients who have

Alzheimer's disease provide emotional support and manage other medical conditions and
experience more emotional stress than caregivers of clients who do not have a cognitive
[Link] C:Spiritual is incorrect. Spiritual stress has not been identified as
significant in caring for clients with Alzheimer’[Link] D:Physical is correct. Caregivers of
clients who have Alzheimer's disease provide many different ADL’s and experience more
physical stress than caregivers of clients who do not have a cognitive [Link] E:
Social is incorrect. Caregivers do not report social stress as significant when caring for a client
who has Alzheimer’s disease.

160.A nurse is caring for a client in the intensive care unit who was admitted with severe head trauma and cerebral
edema. The client opens their eyes spontaneously, is oriented, and obeys commands. Which of the following
findings indicate the client is experiencing a decline in their condition?

Answers cannot be displayed for this alternate item format.

Rationale: Client responds to name:A client responding to their name demonstrates orientation, therefore,
this is not a decline in condition. There are other more appropriate findings, such as confusion
and mumbling inappropriate words, that do indicate a decline in the client's [Link] open
to painful stimuli:Eyes opening to painful stimuli is a decline from eyes opening spontaneously,
therefore, this finding indicates a decline in client condition. Client confusion, the client mumbling
inappropriate words, and the client's eyes not opening when hearing their name are also findings
that indicate the client is experiencing a decline in their [Link] states day of the week:
The client who states the day of the week demonstrates orientation, therefore, this is not a
decline in condition. There are other more appropriate findings, such as confusion and mumbling
inappropriate words, that indicate a decline in the client's [Link] is confused:Client
confusion is a decline from the client being oriented, therefore, this finding indicates a decline in
client condition. The client's eyes opening to painful stimulus, the client mumbling inappropriate
words, and the client's eyes not opening when hearing their name are also findings that indicate
the client is experiencing a decline in their [Link] mumbles inappropriate words:
Client mumbling inappropriate words demonstrates a decline in verbal response, therefore, this
finding indicates a decline in client condition. The client's eyes opening to painful stimulus, client
confusion, and the client's eyes not opening when hearing their name are also findings that
indicate the client is experiencing a decline in their [Link] do not open to name:The
client's eyes not opening when hearing their name is a decline in eye response, therefore, this
finding indicates a decline in client condition. The client's eyes opening to painful stimulus, client
confusion, and the client mumbling inappropriate words are also findings that indicate the client is
experiencing a decline in their condition.

161.A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the
nurse expect with neurogenic shock? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Clients who have spinal cord injuries can develop neurogenic shock, which results from a
reduction in sympathetic tone in the blood vessels and leads to significant hypotension,
bradycardia, and hypothermia, due to an imbalance in the parasympathetic system.A blood
pressure of 184/88 mm Hg is not a finding in neurogenic shock. Blood pressure with neurogenic
shock will be [Link] who have spinal cord injuries can develop neurogenic shock, which
results from a reduction in sympathetic tone in the blood vessels and leads to significant
hypotension, bradycardia, and hypothermia, due to an imbalance in the parasympathetic

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system.A respiratory rate of 12/min is within normal limits and is not a finding of neurogenic
shock.A calcium level of 7.0 mg/dL is low, but it is not a finding in neurogenic shock. Normal
range for calcium is 9.0 to 10.5 mg/dL.

162.A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse
understand is a possible consequence of a TBI?

A. Disruption of cellular function and blood vessel damage

B. Increased synaptic connections from pressure

C. Increased blood supply and edema to the area of injury

D. Damage to brain tissue from decreased pressure shock waves

163.A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that
enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

A. Bacterial translocation

B. Deep vein thrombosis

C. Myocardial infarction

D. Pulmonary embolus

[Link] of the following findings should the nurse identify as requiring immediate follow-up?Select the "3"
findings that require immediate follow-up.

Answers cannot be displayed for this alternate item format.

Rationale: When recognizing cues, the nurse should identify that inflammation and irritation of the right calf,
4+ edema on right calf, and warmth on the right calf are manifestations of a venous
thromboembolism and require immediate follow-up to prevent possible embolization of the clot to
the lungs or brain.

165.A nurse is admitting a client who has suspected retinal detachment. Which of the following questions should the
nurse include when gathering a client history?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale ATrauma to the eye can cause retinal [Link] BThe nurse should
identify that performing heavy lifting can be a risk factor for retinal [Link] C
Clients who have Mèniére’s disease should decrease their sodium intake. Sodium intake does
not play a part in retinal [Link] DClients should wear sunglasses when they are

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in the direct sunlight to prevent [Link] EUsing steroids is a risk factor for the
development of cataracts.

166.A nurse is reinforcing teaching to a newly licensed nurse about risk factors for subarachnoid hemorrhage (SAH).
Which of the following should the nurse include in the teaching?

A. Marfan's syndrome

B. Male sex

C. Alzheimer's disease

D. Parkinson's disease

167.A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following groups should the
nurse understand has a higher risk of sustaining a TBI?

A. People who are in their 30's

B. People who live in rural areas

C. People who abstain from alcohol

D. People who play contact sports

168.A nurse is caring for a client who has a suspected brain tumor. Which of the following diagnostic tests should the
nurse understand is most frequently used to diagnose brain tumors?

A. Blood test for tumor markers

B. Cholangiopancreatography

C. Fecal occult blood test (FOBT)

D. Computerized tomography (CT) scan

169.A nurse is caring for a critically ill client who is experiencing sudden confusion and disorientation, inattention, and
restlessness. Which assessment instrument should the nurse use to aid in the diagnosis of delirium?

A. Richmond Agitation-Sedation Scale.

B. Confusion Assessment Method for the Intensive Care Unit.

C. Vanderbilt Assessment Scale.

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D. Critical-Care Pain Observation Tool.

170.A nurse is providing care to a client who presents with manifestations consistent with bacterial meningitis. After
evaluating the client and completing a head CT scan, the provider delays performing a lumbar puncture and
orders a corticosteroid combined with antibiotics. The nurse knows that the lumbar puncture has most likely been
delayed for what reason?

A. The client has experienced a seizure.

B. The client has elevated intracranial pressure.

C. The provider wants to avoid lasting health complications.

D. The provider already knows which pathogen the client has.

[Link] to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding
again.

Answers cannot be displayed for this alternate item format.

Rationale: The nurse should recognize cues that indicate the client is experiencing a change in behavior in
the evening hours, which indicates sundowning. This evening the client is agitated and pacing the
room, will not follow commands, and is oriented only to person. Heart rate is elevated, which is
consistent with agitation and behavior. Client does not recognize where they are or the people
they are with, one of whom is a family member. Client's laboratory results rule out other possible
causes for change in behavior, such as drugs, infection, and electrolyte imbalance.

172.A nurse is assessing a client who has a chronic illness and the caregiver is concerned that the client might
develop dementia. The nurse should explain to the caregiver that which of the following chronic illnesses can lead
to dementia?

A. HIV infection

B. Arthritis

C. Asthma

D. Psoriasis

[Link] spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to
the spouse regarding the client's plan of care. Which of the following responses by the spouse indicates a need
for further teaching?

A. "I notified our family members that they should not come visit for a while, until they are better."

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B. "I am not worried. This sort of thing happens all the time to us 'old people.'”

C. "I brought an updated list of all the medications he takes at home to help you and the doctors determine
what the cause of this could be."

D. "I am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."

174.A nurse is planning care for a client who has a severe traumatic brain injury (TBI). Which of the following should
the nurse include in the plan of care?

Answers cannot be displayed for this alternate item format.

Rationale: For a client who has a severe TBI, the nurse should plan to assess for abnormal posturing,
Cushing's Triad, cough reflex, and the ability to follow simple [Link] a client who has a
severe TBI, the nurse should plan to assess for abnormal posturing, Cushing's Triad, cough
reflex, and the ability to follow simple [Link] palmar reflex is a newborn reflex and
should not be assessed for this [Link] a client who has a severe TBI, the nurse should plan to
assess for abnormal posturing, Cushing's Triad, cough reflex, and the ability to follow simple
commands.

175.A nurse is caring for a client who has chronic migraine headaches. The client asks the nurse if it could be a
cerebral aneurysm. Which of the following responses should the nurse use?

A. "If you have a cerebral aneurysm, you will experience nausea and vomiting."

B. "If you have a cerebral aneurysm, you typically will have no symptoms."

C. "If you have a cerebral aneurysm, you would be having seizures."

D. "If you had a cerebral aneurysm, you would have a stiff neck."

176.A nurse is caring for a client who has multiple sclerosis. Which of the following factors should the nurse anticipate
have been identified as contributing to the development of multiple sclerosis?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale AThere are three kinds of factors that have been linked to the development of multiple
sclerosis: genetic, environmental, and autoimmune [Link] BThere are three kinds of
factors that have been linked to the development of multiple sclerosis: genetic, environmental,
and autoimmune [Link] CUpper respiratory infections have not been linked to multiple
[Link] DThere are three kinds of factors that have been linked to the development
of multiple sclerosis: genetic, environmental, and autoimmune [Link] EUrinary tract
infections have not been linked to multiple sclerosis.

177.A nurse is caring for a client in the intensive care unit. Which of the following laboratory values could contribute to

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an episode of delirium?

A. Potassium level of 4.1 mEq/L

B. Blood glucose level of 254 mg/dL

C. White blood cell level of 5,900 mm3

D. Hemoglobin level of 14.2 g/dL

178.A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following
surgical removal of a cataract. Which of the following should the nurse include in the teaching?

A. Take ibuprofen for eye discomfort.

Rationale: The nurse should instruct the client to avoid NSAIDs, such as ibuprofen, as these can cause
bleeding at the surgical site. The client should use acetaminophen, along with cool
compresses, to treat discomfort.

B. Creamy white drainage is an indication of infection.

Rationale: The nurse should instruct the client that creamy white drainage is an expected finding
following cataract surgery. Drainage that is green or yellow in color should be reported to the
provider immediately.

C. Notify the provider immediately if the operative eye itches.

Rationale: The nurse should remind the client that mild itching is a normal occurrence following cataract
surgery. The client should be instructed to contact the provider if eye pain occurs with nausea
and vomiting as this can indicate an increase in intraocular pressure.

D. The client should wear dark glasses while outdoors.

Rationale: The nurse should instruct the client and his spouse that he should wear dark glasses when
outside or in bright light until pupil reaction returns.

179.A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX
and X. Which of the following actions should the nurse take?

A. Place suction equipment at the client's bedside.

Rationale: Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate,
larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making
it necessary for the nurse to have access to suction for the client.

B. Apply an eye patch to the client's right eye.

Rationale: Cranial nerve III (Oculomotor) is responsible for eye movement, pupil constriction, and eyelid
elevation. It is not affected by an acoustic neuroma.

C. Avoid the use of warm water to wash the client's face.

Rationale:

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The temperature of the water does not affect clients with an acoustic neuroma and impairment
of cranial nerves IX and X. The nurse should bathe the client with water at a temperature that
promotes client comfort.

D. Provide range-of-motion exercises to the client's neck and shoulders.

Rationale: Cranial nerve XI (Accessory) innervates the sternocleidomastoid and trapezius muscles. It is
not affected by an acoustic neuroma.

180.A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions
should the nurse take?

A. Keep the room darkened.

Rationale: It is appropriate for the nurse to cover the eyes of a client who has a loss of the corneal reflex,
but the room does not need to be dark

B. Apply lubricating eye drops.

Rationale: The nurse should apply lubricating drops to the eyes of a client who has a loss of corneal
reflexes to prevent a corneal abrasion, due to the client's inability to blink.

C. Alternate warm saline compresses to the eyes.

Rationale: The nurse should place cold compresses to the eyes of a client who has a loss of corneal
reflexes.

D. Clean the eyes with a mild soap.

Rationale: The nurse should wash the eyes of a client who has a loss of corneal reflexes with plain water
or sterile 0.9% sodium chloride. Even a mild soap can irritate the eyes.

181.A nurse is caring for a group of four clients. Which of the following clients would the nurse conclude is most at risk
for developing Alzheimer's disease?

A. A male client

B. An 87-year-old client

C. A client who smokes cigarettes

D. A client with limited mobility

182.A nurse is collecting data from an admission history for a client who reports being tackled while playing football
and is now seeing bright flashes of light and dark floating spots. Which of the following conditions should the
nurse expect the client to be experiencing?

A. Mèniére’s disease

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B. Macular degeneration

C. Open-angle glaucoma

D. Retinal detachment

183.A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for
gabapentin. Which of the following statements should the nurse include in the teaching?

A. "Take this medication with an antacid to reduce gastric irritation."

Rationale: The nurse should instruct the client that gabapentin and antacids should be taken 2 hr apart.

B. "You may experience drowsiness while taking this medication."

Rationale: The nurse should instruct the client that drowsiness can occur while taking this medication
and to exercise caution while performing activities that require alertness.

C. "You should take this medication with meals."

Rationale: The nurse should instruct the client that this medication can be taken without regard to meals.

D. "You may continue to breastfeed while taking this medication."

Rationale: The nurse should instruct the client to avoid breastfeeding while taking this medication.

184.A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following
interventions should the nurse include in the care plan?

A. Keep lights turned to medium level in the evening.

B. Reposition the client every shift.

C. Maintain the head of the bed between 30° and 45°.

D. Administer hypotonic intravenous solutions.

185.A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which
of the following instructions should the nurse include in the teaching? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Stool softeners should be administered routinely with stimulants and enemas as needed to keep
bowel movements regular and prevent [Link] cord injury clients should be
encouraged to drink fluids. This will not cause the client to have [Link] should be taught
clean intermittent self-catheterization to prevent bladder retention. Clients who have a complete
spinal cord injury require rectal stimulation daily to achieve and maintain bowel
[Link] catheters are typically reserved for clients who are unable to perform

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self-catheterization.

186.A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has
a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of
which of the following conditions?

A. Mastoiditis

Rationale: Manifestations of mastoiditis include pain and swelling behind the ear, fever, hearing loss, and
ear drainage.

B. Ménière's disease

Rationale: Manifestations of Ménière's disease include tinnitus, hearing loss, vertigo and nystagmus.

C. Acoustic neuroma

Rationale: Acoustic neuroma is a benign tumor of the eighth cranial nerve. Manifestations include
tinnitus, and hearing loss.

D. Perforated tympanic membrane

Rationale: The client has manifestations of otitis media with a perforated tympanic membrane (eardrum).
Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation.

187.A nurse is caring for a client who has multiple sclerosis and reports a tightening feeling around their torso. Which
of the following conditions should the nurse recognize this finding indicates?

A. Lhermitte's sign

B. Trigeminal neuralgia

C. MS hug

D. Paroxysmal spasms

188.A nurse is teaching a group of older adult clients at the senior center about chronic illnesses. Which of the
following acronyms should the nurse teach to the clients to help them remember common manifestations of a
stroke?

A. TALK

B. FLIP

C. RACE

D. FAST

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189.A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client
experiences a seizure. Which of the following instructions should the nurse include in the teaching?

A. "Insert a padded tongue blade into the client's mouth."

Rationale: The nurse should instruct the family not to insert anything into the client's mouth during a
seizure to prevent causing injuring to the client.

B. "Restrain the client."

Rationale: The nurse should instruct the family not to restrain the client to reduce the risk of causing
injury to the client.

C. "Place the client on his back."

Rationale: The nurse should instruct the family to place the client on his side to decrease the risk for
aspiration.

D. "Move objects away from the client."

Rationale: The nurse should instruct the family to move objects away from the client to reduce the risk of
injury to the client.

190.A nurse is providing discharge instructions to a client who has epilepsy. Which of the following instructions should
be included in the nurse's teaching?

Answers cannot be displayed for this alternate item format.

Rationale: Refrain from climbing ladders:This instruction should be included in the teaching as clients who
have epilepsy should refrain from performing activities that might be dangerous. Clients at risk for
seizures should refrain from performing dangerous tasks, such as climbing ladders or using
power tools, and should not swim without a partner or take a bath without supervision. In addition,
a client who is having a seizure should be placed on their left side on the floor away from any
hazards if [Link] not go swimming without a partner:Clients should not take baths or
swim without supervision, therefore, this instruction should be included in the client teaching.
Clients at risk for seizures should refrain from performing dangerous tasks, such as climbing
ladders or using power tools, and should not swim without a partner or take a bath without
supervision. In addition, a client who is having a seizure should be placed on their left side on the
floor away from any hazards if [Link] from driving unless seizure-free for 3 months:
Clients must refrain from driving unless they are seizure-free for 6 to 12 months, therefore,
refraining from driving unless seizure-free for 3 months should not be included as an instruction.
Clients at risk for seizures should refrain from performing dangerous tasks, such as climbing
ladders or using power tools, and should not swim without a partner or take a bath without
supervision. In addition, a client who is having a seizure should be placed on their left side on the
floor away from any hazards if [Link] using power tools:Avoiding using power tools
should be included in the teaching as clients who have epilepsy should refrain from performing
activities that might be dangerous. Clients at risk for seizures should refrain from performing
dangerous tasks, such as climbing ladders or using power tools, and should not swim without a
partner or take a bath without supervision. In addition, a client who is having a seizure should be
placed on their left side on the floor away from any hazards if [Link] client on the floor
when having a seizure:Placing the client on the floor away from hazards when having a seizure
should be included in the client teaching. Clients at risk for seizures should refrain from

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performing dangerous tasks, such as climbing ladders or using power tools, and should not swim
without a partner or take a bath without supervision. In addition, a client who is having a seizure
should be placed on their left side on the floor away from any hazards if [Link] client on
their back when they are recovering from a seizure:Placing the client on their back when
recovering from a seizure should not be included in the client teaching. If possible, the client
should be positioned on their left side on the floor and away from any hazards. Clients at risk for
seizures should refrain from performing dangerous tasks, such as climbing ladders or using
power tools, and should not swim without a partner or take a bath without supervision. In addition,
a client who is having a seizure should be placed on their left side on the floor away from any
hazards if possible.

191.A nurse is caring for a client recently diagnosed with Alzheimer's disease and is providing teaching to the client
and their family. Which of the following statements by a family member indicates the need for further teaching?

A. "I read that protein deposits block communication in the brain, and that causes memory loss."

B. "I read that there are these plaques and tangles because of toxins building up in the brain, and they
damage the brain."

C. "I read that there are changes that occur in the body, like inflammation and high cholesterol, that ultimately
lead to tangles in the brain that cause memory loss."

D. "I read that there is a possibility that a lack of oxygen to the brain is causing the changes in behavior we are
seeing."

192.A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should
identify which of the following findings as an adverse effect of the medication?

A. Sleepy, but arousing when her name is called

Rationale: A client who is sleepy, but easily aroused does not indicate an adverse effect of morphine.

B. Respiratory rate 8/min

Rationale: A respiratory rate of 8/min represents an adverse effect of the morphine and the nurse should
notify the provider. Expected respiratory rate is 12/min or greater.

C. Pain level of 6 on a scale from 0 to 10

Rationale: Pain level of 6 does not indicate an adverse effect of morphine.

D. SaO2 94%

Rationale: SaO2 94% does not indicate an adverse effect of morphine.

193.A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations
should the nurse immediately report to the provider?

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A. A change in the Glasgow Coma Scale score from 13 to 11

Rationale: In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a
decrease in level of consciousness and that the client is risk of a deteriorating neurologic
status. Therefore, this finding is the priority to report to the provider.

B. Diplopia

Rationale: In a client who has mild TBI, diplopia indicates a risk for damage to the optic tract and should
be reported to the provider; however, another finding is the priority to report.

C. A drop in heart rate from 76 to 70/min

Rationale: In a client who has mild TBI, a decrease in heart rate indicates that the client is at risk for
increasing intracranial pressure, but this client's heart rate has not dropped below 60/min.
Therefore, another finding is the priority to report.

D. Ataxia

Rationale: In a client who has mild TBI, ataxia indicates a risk for brainstem or cerebellar injury and
should be reported to the provider; however, another finding is the priority.

194.A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the
following actions should the nurse take first?

A. Evaluate the client's neurological status.

Rationale: Manifestations of a headache and stiff neck (nuchal rigidity) are indications that the client
might have meningitis. The greatest risk to the client is injury from increased intracranial
pressure, which can lead to brain herniation and death. Therefore, the nurse should complete
a neurological assessment as a baseline. If the client does have meningitis, neurological
checks should be completed every 2 to 4 hr.

B. Perform a complete blood count.

Rationale: The nurse should obtain a venous sample for a complete blood count from clients who report
symptoms of meningitis in order to evaluate the white blood cell count, which is elevated in
clients who have meningitis, and the electrolyte values to determine whether any imbalances
exist. However, there is another action that is the nurse's priority.

C. Check the client's temperature.

Rationale: Clinical manifestations of meningitis include fever, photophobia, phonophobia (noise

sensitivity), myalgia, and nausea and vomiting in addition to the headache and stiff neck. The
nurse should check the client's temperature and other vital signs because hyperthermia and
tachycardia can occur and should be treated. However, there is another action that is the
nurse's priority.

D. Administer an oral analgesic.

Rationale: The nurse should administer prescribed analgesics for clients who report symptoms of
meningitis in order to provide relief of symptoms. However, there is another action that is the
nurse's priority.

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195.A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which
of the following action should the nurse take?

A. Provide the client with water to test the gag reflex.

Rationale: The nurse should not give the client anything to eat or drink in case the client's gag reflex is
impaired, as this could cause aspiration. Assessment of swallowing ability can be performed
when the client is stable and equipment to suction the client's airway is available.

B. Perform carotid massage.

Rationale: The nurse should understand carotid massage is used to correct atrioventricular tachycardia.
The technique will not improve the client's condition and could cause harm if the client has
carotid stenosis.

C. Notify emergency management services.

Rationale: The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to administering
appropriate treatment; therefore, the nurse should call the emergency management services.

D. Drive the client to the nearest medical facility.

Rationale: The nurse should not attempt to drive the client away from the scene. The nurse should
position the client to maintain an open airway.

196.A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the
client’s ability to safely ambulate?

A. Observe for the presence of Kernig’s sign.

Rationale: The nurse should check for Kernig’s sign in a client who has possible meningitis.

B. Perform a Romberg’s test.

Rationale: The nurse should perform a Romberg’s test to check the client’s ability to maintain an upright
position without swaying when standing with feet close together, with eyes open and with eyes
closed. The nurse must stand close enough to prevent the client from falling.

C. Check the function of cranial nerve V.

Rationale: The nurse should check cranial nerve V to assess sensory nerve function of the face.

D. Inspect for the presence of clubbing.

Rationale: The nurse should inspect for the presence of digital clubbing in clients who have chronic
cardiopulmonary disorders.

197.A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following
medications should the nurse plan to administer?

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A. Epinephrine

Rationale: The nurse should not administer epinephrine to reverse the effects of an opioid overdose.
Epinephrine is an agonist that activates receptors that affect the cardiovascular system in a
client at risk for cardiac collapse.

B. Protamine

Rationale: The nurse should plan to administer protamine to a client who has a prolonged aPTT from the
infusion of heparin. Protamine is an antagonist that binds with heparin and makes it
ineffective.

C. Flumazenil

Rationale: The nurse should administer flumazenil if the client has a benzodiazepine overdose, not an
opioid overdose. Flumazenil is an antagonist that reverses the adverse effects of
benzodiazepine at the GABA/benzodiazepine receptor site.

D. Naloxone

Rationale: The nurse should plan to administer naloxone, which is an opiate antagonist that competes
with opioids at opiate receptor sites making the opioid ineffective.

198.A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the
nurse expect?

A. Pruritus

Rationale: The nurse should expect to find oily skin, which results from autonomic dysfunction, rather
than pruritus, which results from dry skin.

B. Hypertension

Rationale: The nurse should expect to find orthostatic hypotension, which results from autonomic
dysfunction.

C. Bradykinesia

Rationale: The nurse should expect to find bradykinesia or difficulty moving in a client who has
Parkinson's disease.

D. Xerostomia

Rationale: The nurse should expect to find uncontrolled drooling, especially at night, instead of
xerostomia or dry mouth in a client who has Parkinson's disease.

199.A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following
actions should the nurse take?

A. Provide a low-sodium diet.

Rationale:

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The most common complication following a lumbar puncture is a spinal headache. This is
caused by leakage of cerebral spinal fluid (CSF) from the puncture hole in the dura mater and
subsequent tension on the brain, which can cause a severe headache. Treatment for a spinal
headache includes placing the client on flat bed rest to decrease tension on the brain and
increasing the client’s fluid intake to replenish the volume of CSF. There is no need to
encourage the client to decrease sodium intake.

B. Administer sumatriptan.

Rationale: Sumatriptan is a medication used to treat migraine headaches. It is not administered to clients
experiencing a headache following a lumbar puncture.

C. Place in high-Fowler’s position.

Rationale: A spinal headache is the most common complication following a lumbar puncture (LP). The
headache is caused by leakage of cerebral spinal fluid. A spinal headache usually occurs
within 12 to 24 hr following an LP. Sitting upright causes more tension on the brain and
therefore makes the headache worse. Clients are encouraged to maintain flat bed rest as
much as possible for the first 24 hr after this procedure to decrease the risk of a spinal
headache. If the client does experience a spinal headache, he should not be placed in the
high-Fowler’s position because this would increase the tension on the brain and exacerbate
pain.

D. Encourage oral fluids.

Rationale: A lumbar puncture (LP) is a diagnostic test of the cerebral spinal fluid. During an LP, a needle
is inserted through the dura mater that surrounds the spinal cord. Cerebral spinal fluid (CSF)
is aspirated and sent to a lab for diagnostic testing. The most common complication following
an LP is a spinal headache. This is caused by leakage of CSF from the puncture hole in the
dura mater and subsequent tension on the brain. A spinal headache usually occurs within 12
to 24 hr following an LP. Treatment for a spinal headache includes placing the client in a flat
position to decrease tension on the brain and increasing the client’s fluid intake to replace
CSF volume.

200.A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of
the following factors should the nurse identify as a possible cause of myasthenic crisis?

A. Developing a respiratory infection

Rationale: The most common triggers of myasthenic crises are respiratory infection, not taking, or taking
too little, of the prescribed medication, surgery, and high environmental temperatures.

B. Taking too much prescribed medication

Rationale: Not taking, or taking too little, of the prescribed medication is more likely to trigger a
myasthenic crisis. Taking an excess amount of medication can cause a cholinergic crisis.

C. Diet high in protein

Rationale: A diet high in protein should be avoided in the client who has renal failure; however, there is
no correlation between dietary intake and the development of myasthenic crisis.

D. Not exercising enough

Rationale:

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Vigorous physical activity, such as exercising excessively, can trigger a myasthenic crisis.

201.A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI.
Which of the following foods should the nurse eliminate?

A. Fresh fish

Rationale: The nurse does not need to eliminate fresh fish from the diet of a client prescribed selegiline.
Cured meats that contain tyramine should be eliminated.

B. Cheddar cheese

Rationale: The nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline.
Cheddar cheese contains tyramine, which can cause a hypertensive crisis.

C. Cherries

Rationale: The nurse does not need to eliminate cherries from the diet of a client prescribed selegiline.

D. Chicken

Rationale: The nurse does not need to eliminate chicken from the diet of a client prescribed selegiline.
Cured meats that contain tyramine should be eliminated.

202.A nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after
surgery. Which of the following statements by the client indicates an understanding of the teaching?

A. "I'll splint my incision with a pillow to cough."

Rationale: The client should use a pillow to splint the incision to reduce the pain and discomfort of
coughing.

B. "I'll ask for pain medication after I do the exercises."

Rationale: The client should receive pain medication around the clock or before performing exercises or
activities.

C. "I'll use the incentive spirometer when I can get out of bed."

Rationale: The client should use the incentive spirometer whether he is in bed or ambulatory.

D. "I'll breathe deeply and cough every 4 hours."

Rationale: The client should breathe deeply and cough at least every 2 hr.

203.A nurse is caring for a client who has Alzheimer’s disease and is going to transition from home to a skilled
nursing facility. Which of the following interventions should the nurse incorporate into the plan of care to help the
client with this transition and avoid relocation stress syndrome?

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A. Inform the client about the need to move prior to the actual event.

B. Limit the members of the team who can help the client while transitioning, to avoid adding confusion or
uneasiness.

C. Provide opportunities for education and continually evaluate the client’s preferences and goals for care.

D. Leave the client alone while ensuring safety, to allow the client to work through behaviors and feelings
during the transition period.

204.A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for
which of the following manifestations of increased intracranial pressure?

A. Decreased level of consciousness

Rationale: As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness,
decrease. Other manifestations include severe headache, irritability, and pupils that are slow
to react or are unreactive to light.

B. Tachypnea

Rationale: As intracranial pressure increases, the respiratory rate decreases or becomes erratic.

C. Bilateral weakness of extremities

Rationale: As intracranial pressure increases, one-sided weakness of an extremity is a common early

manifestation.

D. Hypotension

Rationale: As intracranial pressure increases, blood pressure also increases.

205.A nurse is assessing a client who reports hearing loss. Which of the following statements indicates that the
hearing loss is affecting the client's ability to perform activities of daily living (ADLs)?

A. "I get dizzy when I nod my head."

B. "I walk my dog at least twice a day."

C. "I wash my hair every other day."

D. "I can't eat as much as I used to."

206.A nurse is caring for a client who has a traumatic brain injury and is being mechanically ventilated. Which of the
following can cause unfavorable outcomes for this client?

A. Hyperoxia

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B. Hemoglobin 16 g/dL

C. Platelet count 250,000/mm3

D. Glasgow Coma Scale 16

207.A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic
during knee surgery. For which of the following findings should the nurse notify the provider?

A. Pulse oximetry changed from 98% to 96%

Rationale: SpO2 of 96% is well above the critical level of 91% and does not warrant notifying the
provider. It likely represents shallow respirations and should be continually monitored.

B. Client reports knee pain, changed from 4/10 to 6/10

Rationale: As the anesthetic metabolizes, the client’s sensation gradually returns. The increased level
likely represents greater awareness of the discomfort and is not severe enough to notify the
provider.

C. Systolic blood pressure changed from 140 mm Hg to 120 mm Hg

Rationale: Spinal anesthesia causes vasodilation and if the blood pressure remains more than 10 mm Hg
below the client's baseline, there is a potential for shock. The nurse should notify the provider.

D. Temperature changed from 37.2° C (99.0° F) to 37.5° C (99.5° F)

Rationale: This temperature change is not significant, but a temperature elevation of 38.3° C (101° F) or
above is suggestive of infection and should be reported.

208.A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating.
Which of the following actions should the nurse take?

A. Provide a nonskid mat to alleviate plate movement.

Rationale: The nurse should provide a nonskid mat to alleviate plate movement, but this action does not
resolve the problem of homonymous hemianopsia.

B. Encourage the client to use his right hand when feeding himself.

Rationale: The nurse should encourage the client to use his right hand when feeding himself, but this
action does not resolve the problem of homonymous hemianopsia.

C. Remind the client to look for food on the left side of the tray.

Rationale: The nurse's action to remind the client to look for food on the left side of the tray will train the
client to scan the tray by moving his head and eyes, which will help to resolve the problem of
homonymous hemianopsia.

D. Encourage the use of the wide grip utensils.

Rationale:

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The nurse should encourage the client to use wide grip utensils, but this action does not
resolve the problem of homonymous hemianopsia.

209.A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the
following questions should the nurse ask the client?

A. "Do have a history of chronic alcohol abuse?"

Rationale: Chronic alcohol abuse has not been associated with GBS.

B. "Have you had a recent influenza infection?"

Rationale: The nurse should ask the client about a recent Haemophilus influenzae infection. The cause of
GBS is unknown, but it usually follows a viral infection.

C. "Have traveled overseas recently?"

Rationale: Traveling overseas is not associated with GBS.

D. "Are you taking a multivitamin?"

Rationale: Taking a multivitamin is not associated with GBS.

[Link] the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client's progress.

Answers cannot be displayed for this alternate item format.

211.A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the
nurse plan to take?

A. Elevate the head of bed to 45&deg.

Rationale: The nurse should elevate the head of the client's bed no higher than 30&deg to support
venous return and lower intracranial pressure. In some cases, the bed should remain flat to
increase cerebral perfusion.

B. Maintain the client on absolute bed rest.

Rationale: The nurse should place the client on absolute bed rest in a quiet environment. Activity can
elevate blood pressure and increase the risk for bleeding.

C. Administer a cleansing enema.

Rationale: The nurse should not administer an enema because straining or discomfort can elevate the
client's blood pressure and increase intracranial pressure.

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D. Place the client in a room near the nurses' station.

Rationale: The nurse should maintain the client on bed rest in a quiet, non-stressful environment.

[Link] the following sentence by using the list of options.

Answers cannot be displayed for this alternate item format.

Rationale: Drop Down Box 1: Drowsiness is correct. Loss of consciousness is the most important
variable to assess with head injuries. A decrease or a change in loss of consciousness is often
the first sign of deterioration and can indicate increased intracranial pressure. This should be
reported to the provider immediately. Limited range of motion is incorrect. When a client has
pain in an area, they will often limit movement in that area or guard that area. This will need to be
addressed by the nurse later; however, it is not a [Link] pressure is incorrect. The
client's blood pressure is within the expected reference range for an adult, which is a systolic
pressure less than 120 mm Hg and a diastolic pressure less than 80 mm Hg. Drop Down Box 2:
Capillary refill time is incorrect. A capillary refill time of less than 3 seconds is an expected
[Link] shoulder pain is correct. The nurse should address the client's right shoulder pain
after addressing the client's drowsiness. A client's recovery can be affected by pain by inhibiting
their ability to become active and involved in self-care. The goal is to provide pain relief so that
the client is able to participate in their recovery and to improve the client's functional status.
Assessment of pain should include intensity, quality, duration, and location. Temperature is
incorrect. The client's temperature is within the expected reference range of 36º C to 38º C
(96.8º F to 100.4º F) for an adult.

213.A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following
findings indicated that the client is ready for discharge?

A. The client is restless.

Rationale: A client who is restless will have a Ramsay Sedation score of 1, which is not adequate for
discharge.

B. The client is cooperative and oriented.

Rationale: A client who is cooperative, oriented, and calm will have a Ramsay Sedation score of 2, which
indicates the client has recovered adequately to go home with a responsible adult.

C. The client shows a brisk response to stimulus.

Rationale: A client who only shows a brisk response to stimuli will have a Ramsay Sedation score of 4,
which is not adequate for discharge.

D. The client shows a sluggish response to stimulus.

Rationale: A client who shows a sluggish response to stimuli will have a Ramsay Sedation score of 5,
which is not adequate for discharge.

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[Link] nurse is assisting with planning care for a client who has a subarachnoid hemorrhage (SAH). Which of the
following relates to a high mortality rate for a client who has an SAH?

A. Rebleeding of the injury

B. Decreased cerebrosp fluid

C. Use of nimodipine

D. Poor functional ability

215.A nurse is reviewing discharge medications with a client who has Parkinson's disease. The nurse should include
teaching about the client's anticholinergic agent. Which of the following side effects should the nurse advise the
client to report?

A. Anhidrosis

B. Drooling

C. Rigidity

D. Tremors

216.A nurse working with clients in the critical care unit has been feeling overwhelmed and losing focus while working.
Which of the following is the most important strategy in minimizing stress and preventing burnout?

A. Focusing on self-care

B. Incorporating diaphragmatic breathing

C. Decreasing use of social media

D. Ignoring fake news

217.A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While
assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the
following should be the nurse’s initial action?

A. Document the amount of drainage.

Rationale: The nurse should document the amount of drainage along with the clarity to determine the
extent of the cerebral spinal fluid (CSF) leakage and the presence of blood or pus; however
there is another action that is priority.

B. Obtain a culture of the drainage.

Rationale: Although infection is a potential complication of the procedure, there is another action that is
priority.

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C. Check the drainage for glucose.

Rationale: A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid
leakage from the nose is a sign that this complication has occurred. The first action the nurse
should take using the nursing process is to assess the drainage for the presence of glucose,
which would indicate that the drainage is CSF.

D. Notify the client's provider.

Rationale: Although the provider should be notified of the findings, there is another action that is priority.

218.A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol
therapy. The nurse should understand that which of the following should be monitored?

A. Visual acuity

Rationale: A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color
discrimination, especially red and green. Baseline vision testing should be performed before
use, and visual acuity monitored at regular intervals.

B. Skin color

Rationale: Ethambutol does not affect skin color.

C. Urine output

Rationale: Although ethambutol increases uric acid formation, it is not toxic to the kidneys. The client
should be encouraged to increase fluid intake.

D. Cardiac rhythm

Rationale: Ethambutol is not associated with cardiovascular adverse effects.

[Link] of the following interventions should the nurse expect to perform? Select all that apply.

Answers cannot be displayed for this alternate item format.

Rationale: When analyzing cues, the nurse should identify the client might be experiencing neurogenic
shock secondary to the spinal cord injury as evidenced by their decreased blood pressure and
oxygen levels. A large bore IV should be inserted in preparation of administration of dopamine to
treat their hypotension. Oxygen should be administered based on the lowering of the oxygen
saturation. These are indications that the client might be experiencing neurogenic shock which
can result in further damage to the spinal cord. Atropine would be given if the client was
experiencing bradycardia. A nasogastric tube is not indicated based upon the assessment
findings.

[Link] each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, or
multiple sclerosis. Each finding can support more than 1 disease process.

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Answers cannot be displayed for this alternate item format.

Rationale: Orientation status is consistent with Parkinson's disease, stroke, and multiple sclerosis.
Cognitive impairment can occur in Parkinson's disease and multiple sclerosis due to
degeneration of neural pathways. Cognitive impairment is consistent with a stroke due to an
interruption in cerebral [Link] pattern is consistent with Parkinson's disease.
The client is experiencing slowed movement and shuffling gait which are consistent with
Parkinson’s disease due to the progressive loss of the neurotransmitter, [Link]
movements are consistent with Parkinson's disease. The client is experiencing resting
tremors which are consistent with Parkinson’s disease due to the progressive loss of the
neurotransmitter, [Link] is consistent with Parkinson's disease, stroke, and
multiple sclerosis. The client is experiencing slurred speech which can occur in Parkinson's
disease and multiple sclerosis due to degeneration of neural pathways. Slurred speech is also
consistent with a stroke due to an interruption in cerebral [Link] rigidity is consistent
with Parkinson's [Link] rigidity can occur in Parkinson’s disease due to the progressive
loss of the neurotransmitter, dopamine.

221.A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the
nurse include in the plan of care?

A. Monitor the client for an elevated temperature.

Rationale: A halo fixation device is used to stabilize a cervical fracture on a client. The device is secured
with four screws inserted directly into the client's skull to promote cervical alignment.
Complications include loose pins, local infection, and scarring. More serious complications
include osteomyelitis, subdural abscess, and instability. The nurse should monitor and report
manifestations of infection, such as fever and purulent drainage from pin sites.

B. Provide range of motion to the client's neck.

Rationale: A halo fixation device is used to stabilize the head and neck following a cervical fracture or
dislocation. Performing range of motion to the client's neck increases the risk for injury to the
client's spinal cord.

C. Remove the vest daily to inspect the client's skin integrity.

Rationale: The nurse should monitor skin integrity under the halo fixation device without removing it. The
nurse should be able to insert one finger between the vest and the client's skin. The vest is
not removed, except for emergencies, because removal would disrupt the traction and
possibly cause cervical cord damage.

D. Check that the halo jacket is snug against the client's skin.

Rationale: The nurse should be able to insert one finger easily between the halo jacket and the client's
skin to reduce the risk for a pressure sore.

222.A nurse is reinforcing teaching to a group of nursing students about possible psychosocial changes a client might
have after sustaining a neurologic injury such as increased intracranial pressure. Which of the following
psychosocial changes should the nurse include in the teaching?

A. Changes to social cognition and challenges to inhibitory control

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B. Improved rehabilitation outcomes and temporary behavior changes

C. Improved mood stability and improved temper control

D. Sense of purpose, improved motivation, and stable relationships

223.A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

A. Severe headache

Rationale: The nurse should expect a client who has meningitis to manifest a severe headache due to
meningeal inflammation.

B. Bradycardia

Rationale: The nurse should expect a client who has meningitis to manifest tachycardia.

C. Blurred vision

Rationale: The nurse should expect a client who has meningitis to manifest photosensitivity.

D. Oriented to person, place, and year

Rationale: The nurse should expect a client who has meningitis to manifest disorientation to person,
place and year.

224.A client is beginning inpatient rehabilitation after experiencing a stroke. A nurse is working with the client during
this transition and helping to set realistic goals. Which of the following is the most appropriate goal for this client?

A. Achieve pre-stroke function

B. Determine if the client can return to their home

C. Maintain full independence

D. Optimize functional status

225.A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular
lens. Which of the following instructions should the nurse include?

A. "Take aspirin for discomfort."

Rationale: The nurse should instruct the client to take acetaminophen for discomfort. Aspirin inhibits
platelet aggregation and can increase the risk for bleeding.

B. "Restrict lifting objects greater than 10 pounds."

Rationale: The nurse should instruct the client to restrict lifting objects greater than 10 lb to reduce the

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risk for increased intraocular pressure.

C. "Expect reduced vision for 48 hours after procedure."

Rationale: The nurse should instruct the client to report a reduction of vision following the procedure.

D. "Apply warm compresses for discomfort."

Rationale: The nurse should instruct the client to apply a cool compress for discomfort.

226.A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the
following client responses to painful stimulus is expected?

A. Pushes the painful stimulus away

Rationale: Pushing away a painful stimulus is an expected response.

B. Extends her body toward the painful stimulus

Rationale: A client who extends her body toward the stimulus is manifesting increased intracranial
pressure and is not displaying an expected response.

C. Shows no reaction to the painful stimulus

Rationale: A client who shows no reaction to the painful stimulus is not displaying an expected response
and might have a neurologic impairment.

D. Flexes the upper and extends the lower extremities in response to the painful stimulus

Rationale: A client who flexes the upper and extends the lower extremities in response to the painful
stimulus is displaying decorticate or decerebrate posturing, which is not an expected
response.

227.A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client
expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses
should the nurse make?

A. "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible."

Rationale: The client is seeking information. This open-ended therapeutic response gives the client the
information that the client needs to cope, reassures the client of the nurse's presence, and
encourages further communication.

B. "Relax, you'll be asleep for most of the procedure and you won't remember a thing."

Rationale: The client is seeking information. This nontherapeutic response devalues the client's feelings
and makes two promises that the nurse cannot possibly keep.

C. "I will call your doctor and tell him you still have questions about the procedure."

Rationale: This closed-ended, nontherapeutic response puts the client's concerns on hold and focuses

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on an inappropriate person (the doctor). The client is seeking information that the nurse is
able to give independently.

D. "I can understand because you must be very worried about what the biopsy will show."

Rationale: While this is an example of a therapeutic response that focuses on the client's feelings, this
response does not reassure the client on the procedure.

228.A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs).
Which of the following should the nurse include in the teaching?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale A, B, CSports-related injuries, violence, and falls are common causes of TBIs.
Rationale DWorking as a firefighter is not a cause of [Link] EWorking in a factory is not
a cause of TBIs.

[Link] each manifestation, click to specify if the assessment finding is consistent with brain herniation, subarachnoid
hemorrhage, or chronic traumatic encephalopathy. Each finding may support more than 1 disease process.

Answers cannot be displayed for this alternate item format.

Rationale: When analyzing cues, the nurse should recognize that manifestations of brain herniation include
pupil asymmetry, lower limb weakness, low brainstem reflexes, and decorticate or decerebrate
posturing. Pupil asymmetry is a sign when one pupil might be dilated while the other is not and is
a result of high pressure within the skull, squeezing the brain and vital areas of the brain across
structures within the skull leading to brain herniation. Brain herniation might lead to lower limb
weakness as motor control is affected. If too much pressure is put on the brainstem, loss of
brainstem reflexes will occur. A disrupted brainstem can also lead to [Link] analyzing
cues, the nurse should recognize that manifestations of traumatic brain injury (TBI) include
hemiparesis, memory difficulties, and aggressive behavior. TBIs occur from a disruption in the
cellular function of the brain from an outside mechanical force. The types of mechanical forces
can be direct, rotational, or shear, and can result in mild, moderate, or severe [Link]
analyzing cues, the nurse should recognize that manifestations of chronic traumatic
encephalopathy (CTE) include broad and nonspecific cognitive changes, such as increased
aggression and memory difficulties. CTE is a type of brain degeneration that typically occurs due
to repeated head trauma. Symptoms develop over years after repeated brain injuries. These are
nonspecific and might include increased aggression and memory issues.

230.A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing
interventions should be added to the plan of care?

Answers cannot be displayed for this alternate item format.

Rationale: The head of the bed should be elevated to 30° to 45°.The nurse should include the following
nursing interventions in the plan of care: elevation of the head of the bed to 30° to 45°,
maintenance of the neck in the midline position, maintenance of the ventriculostomy at the
correction position, maintenance of enteral feedings, and administration of pain medication as

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[Link] nurse should include the following nursing interventions in the plan of care: elevation
of the head of the bed to 30° to 45°, maintenance of the neck in the midline position, maintenance
of the ventriculostomy at the correction position, maintenance of enteral feedings, and
administration of pain medication as [Link] nurse should include the following nursing
interventions in the plan of care: elevation of the head of the bed to 30° to 45°, maintenance of the
neck in the midline position, maintenance of the ventriculostomy at the correction position,
maintenance of enteral feedings, and administration of pain medication as [Link] nurse
should include the following nursing interventions in the plan of care: elevation of the head of the
bed to 30° to 45°, maintenance of the neck in the midline position, maintenance of the
ventriculostomy at the correction position, maintenance of enteral feedings, and administration of
pain medication as needed.

231.A nurse is teaching a client who is newly diagnosed with Alzheimer's disease and their family about newly
prescribed medications for Alzheimer's disease. Which statement by the client indicates the teaching was
effective?

A. "Medications for Alzheimer's disease will cure the disease."

B. "Medications for Alzheimer's disease will help slow the progression of my disease."

C. "Medications for Alzheimer's disease will help to increase my energy levels."

D. "Medications for Alzheimer's disease will help me remember what I forgot."

232.A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she
should communicate with the client. Which of the following responses by the nurse is appropriate?

A. "Incorporate nonverbal cues in the conversation."

Rationale: Nonverbal cues enhance the client's ability to comprehend and use language.

B. "Ask multiple choice questions as part of the conversation."

Rationale: Simple questions requiring yes and no responses are better understood by the client.

C. "Use a higher-pitched tone of voice when speaking."

Rationale: Tone of voice is understood by clients who have aphasia, unless they have a hearing
impairment.

D. "Use simple, child-like statements when speaking."

Rationale: It is important to respect the client and use age-appropriate communication.

233.A nurse is preparing to administer clonazepam 1.5 mg PO in 3 equally divided doses every 8 hr for a client who
has seizures. The amount available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer
per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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1 tablet(s)

Correct Rationale: <b>Follow these steps for the Ratio and Proportion method of calculation:</b>Step 1:
What is the unit of measurement the nurse should calculate? tablet(s) Step 2: What is
the dose the nurse should administer? Dose to administer = Desired 1.5 mg/day Step 3:
What is the dose available? Dose available = Have 0.5 mg Step 4: Should the nurse
convert the units of measurement? No Step 5: What is the quantity of the dose
available? 1 tablet Step 6: Set up an equation and solve for X.
<i>Have</i><i>Desired<i/><hr>&#160 =
&#160<hr><i>Quantity<i/><i>X</i></br></br>0.5 mg1.5 mg<hr>&#160 = &#160<hr>1
tablet<i>X</i> tablet(s)</br></br><i>X</i> tablet(s) = 3 tabletsThe dose is divided into 3
equal doses; therefore, divide X by 3.3 tablets<hr>&#160 = &#160<hr>1
tablet/dose3</br></br>Step 7: Round if necessary. Step 8: Reassess to determine
whether the amount to administer makes sense. If there are 0.5 mg/tablet and the
prescription reads 1.5 mg/day divided into 3 equal doses, it makes sense to administer 3
tablets daily or 1 tablet every 8 hr. The nurse should administer clonazepam 1 tablet PO
per dose.<b>Follow these steps for the Desired Over Have method of
calculation:</b>Step 1: What is the unit of measurement the nurse should calculate?
tablet(s) Step 2: What is the dose the nurse should administer? Dose to administer =
Desired 1.5 mg/day Step 3: What is the dose available? Dose available = Have 0.5 mg
Step 4: Should the nurse convert the units of measurement? No Step 5: What is the
quantity of the dose available? 1 tablet Step 6: Set up an equation and solve for X.
<i>Desired<i/> &#215 <i>Quantity</i><i>X</i>&#160 =
&#160<hr><i>Have<i/></br></br>1.5 <s>mg &#215 1 tablet<i>X</i> tablet(s)&#160 =
&#160<hr>0.5 <s>mg</br></br><i>X</i> tablet(s) = 3 tabletsThe dose is divided into 3
doses; therefore, divide X by 3.3 tablets<hr>&#160 = &#160<hr>1
tablet/dose3</br></br>Step 7: Round if necessary. Step 8: Reassess to determine
whether the amount to administer makes sense. If there are 0.5 mg/tablet and the
prescription reads 1.5 mg divided into 3 equal doses, it makes sense to administer 3
tablets daily or 1 tablet every 8 hr. The nurse should administer clonazepam 1 tablet PO
per dose. <b>Follow these steps for the Dimensional Analysis method of
calculation:</b>Step 1: What is the unit of measurement the nurse should calculate?
(Place the unit of measure being calculated on the left side of the equation.) <i>X</i>
tablet(s) = Step 2: Determine the ratio that contains the same unit as the unit being
calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the
numerator matches the unit being calculated.) 1 tablet<i>X</i> tablet(s)&#160 =
&#160<hr>0.5 mg</br></br>Step 3: Place any remaining ratios that are relevant to the
item on the right side of the equation, along with any needed conversion factors, to
cancel out unwanted units of measurement. 1 tablet1.5 <s>mg1 <s>day<i>X</i>
tablet(s)&#160 = &#160<hr>&#160 &#215 &#160<hr>&#160 &#215 &#160<hr>0.5
<s>mg1 <s>day3 doses</br></br>Step 4: Solve for X. <i>X</i> tablet(s) = 1 tabletsStep
5: Round if necessary. Step 6: Reassess to determine whether the amount to administer
makes sense. If there are 0.5 mg/tablet and the prescription reads 1.5 mg/day divided
into 3 equal doses, it makes sense to administer 3 tablets daily or 1 tablet every 8 hr.
The nurse should administer clonazepam 1 tablet PO per dose.

InCorrect Rationale: <b>Follow these steps for the Ratio and Proportion method of calculation:</b>Step 1:
What is the unit of measurement the nurse should calculate? tablet(s) Step 2: What is
the dose the nurse should administer? Dose to administer = Desired 1.5 mg/day Step
3: What is the dose available? Dose available = Have 0.5 mg Step 4: Should the
nurse convert the units of measurement? No Step 5: What is the quantity of the dose
available? 1 tablet Step 6: Set up an equation and solve for X.
<i>Have</i><i>Desired<i/><hr>&#160 =
&#160<hr><i>Quantity<i/><i>X</i></br></br>0.5 mg1.5 mg<hr>&#160 = &#160<hr>1
tablet<i>X</i> tablet(s)</br></br><i>X</i> tablet(s) = 3 tabletsThe dose is divided into
3 equal doses; therefore, divide X by 3.3 tablets<hr>&#160 = &#160<hr>1
tablet/dose3</br></br>Step 7: Round if necessary. Step 8: Reassess to determine

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o determine whether the amount to administer makes sense. If there are 0.5 mg/tablet
and the prescription reads 1.5 mg/day divided into 3 equal doses, it makes sense to
administer 3 tablets daily or 1 tablet every 8 hr. The nurse should administer
clonazepam 1 tablet PO per dose.<b>Follow these steps for the Desired Over Have
method of calculation:</b>Step 1: What is the unit of measurement the nurse should
calculate? tablet(s) Step 2: What is the dose the nurse should administer? Dose to
administer = Desired 1.5 mg/day Step 3: What is the dose available? Dose available =
Have 0.5 mg Step 4: Should the nurse convert the units of measurement? No Step 5:
What is the quantity of the dose available? 1 tablet Step 6: Set up an equation and
solve for X. <i>Desired<i/> &#215 <i>Quantity</i><i>X</i>&#160 =
&#160<hr><i>Have<i/></br></br>1.5 <s>mg &#215 1 tablet<i>X</i> tablet(s)&#160 =
&#160<hr>0.5 <s>mg</br></br><i>X</i> tablet(s) = 3 tabletsThe dose is divided into
3 doses; therefore, divide X by 3.3 tablets<hr>&#160 = &#160<hr>1
tablet/dose3</br></br>Step 7: Round if necessary. Step 8: Reassess to determine
whether the amount to administer makes sense. If there are 0.5 mg/tablet and the
prescription reads 1.5 mg divided into 3 equal doses, it makes sense to administer 3
tablets daily or 1 tablet every 8 hr. The nurse should administer clonazepam 1 tablet
PO per dose. <b>Follow these steps for the Dimensional Analysis method of
calculation:</b>Step 1: What is the unit of measurement the nurse should calculate?
(Place the unit of measure being calculated on the left side of the equation.) <i>X</i>
tablet(s) = Step 2: Determine the ratio that contains the same unit as the unit being
calculated. (Place the ratio on the right side of the equation, ensuring that the unit in
the numerator matches the unit being calculated.) 1 tablet<i>X</i> tablet(s)&#160 =
&#160<hr>0.5 mg</br></br>Step 3: Place any remaining ratios that are relevant to the
item on the right side of the equation, along with any needed conversion factors, to
cancel out unwanted units of measurement. 1 tablet1.5 <s>mg1 <s>day<i>X</i>
tablet(s)&#160 = &#160<hr>&#160 &#215 &#160<hr>&#160 &#215 &#160<hr>0.5
<s>mg1 <s>day3 doses</br></br>Step 4: Solve for X. <i>X</i> tablet(s) = 1
tabletsStep 5: Round if necessary. Step 6: Reassess to determine whether the
amount to administer makes sense. If there are 0.5 mg/tablet and the prescription
reads 1.5 mg/day divided into 3 equal doses, it makes sense to administer 3 tablets
daily or 1 tablet every 8 hr. The nurse should administer clonazepam 1 tablet PO per
dose.

234.A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The
nurse should monitor the client for which of the following complications? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

Rationale: Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The
nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal
cord.
Polyuria is incorrect. The nurse should check the client for bladder distention and inability to
urinate due to ineffective function of the bladder muscles.
Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a
lack of lack of sympathetic input.
Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could
cause the client to develop a paralytic ileus.
Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or
coughing and drooling noted with oral intake.

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235.A nurse is assessing a client who was involved in a motor-vehicle crash. Which of the following techniques
should the nurse use to test corneal reflexes?

A. Examine the eyes with a penlight.

Rationale: The nurse should examine the eyes with a penlight to determine pupil reaction.

B. Instill drops of dye into the eyes.

Rationale: The nurse should instill drops of dye into the eyes to determine if there are foreign bodies
present.

C. Visualize the red reflex of the eyes.

Rationale: The nurse should examine the red reflex of the eyes to inspect the retina.

D. Lightly touch the eyes with a wisp of cotton.

Rationale: The nurse should lightly touch a cornea with a wisp of cotton. Absent corneal reflexes, or the
loss of the ability to blink, can be caused by a head injury or stroke.

236.A nurse is preparing to administer desipramine 150 mg PO daily to a client to treat diabetic neuropathy. The
amount available is desipramine 100 mg/tablet. How many tablets should the nurse administer per dose?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1.5 tablet(s)

Correct Rationale: <b>Follow these steps for the Ratio and Proportion method of calculation:</b>Step 1:
What is the unit of measurement the nurse should calculate? tablet(s) Step 2: What is
the dose the nurse should administer? Dose to administer = Desired 150 mg Step 3:
What is the dose available? Dose available = Have 100 mg Step 4: Should the nurse
convert the units of measurement? No Step 5: What is the quantity of the dose
available? 1 tablet Step 6: Set up an equation and solve for X.
<i>Have</i><i>Desired<i/><hr>&#160 =
&#160<hr><i>Quantity<i/><i>X</i></br></br>100 mg150 mg<hr>&#160 = &#160<hr>1
tablet<i>X</i> tablet(s)</br></br><i>X</i> tablet(s) = 1.5 tabletsStep 7: Round if
necessary. Step 8: Reassess to determine whether the amount to administer makes
sense. If there are 100 mg/tablet and the prescription reads 150 mg, it makes sense to
administer 1.5 tablets. The nurse should administer desipramine 1.5 tablets PO
daily.<b>Follow these steps for the Desired Over Have method of calculation:</b>Step
1: What is the unit of measurement the nurse should calculate? tablet(s) Step 2: What is
the dose the nurse should administer? Dose to administer = Desired 150 mg Step 3:
What is the dose available? Dose available = Have 100 mg Step 4: Should the nurse
convert the units of measurement? No Step 5: What is the quantity of the dose
available? 1 tablet Step 6: Set up an equation and solve for X. <i>Desired<i/> &#215
<i>Quantity</i><i>X</i>&#160 = &#160<hr><i>Have<i/></br></br>150 <s>mg &#215 1
tablet<i>X</i> tablet(s)&#160 = &#160<hr>100 <s>mg</br></br><i>X</i> tablet(s) = 1.5
tabletsStep 7: Round if necessary. Step 8: Reassess to determine whether the amount
to administer makes sense. If there are 100 mg/tablet and the prescription reads 150
mg, it makes sense to administer 1.5 tablets. The nurse should administer desipramine
1.5 tablets PO daily. <b>Follow these steps for the Dimensional Analysis method of
calculation:</b>Step 1: What is the unit of measurement the nurse should calculate?
(Place the unit of measure being calculated on the left side of the equation.) <i>X</i>
tablet(s) = Step 2: Determine the ratio that contains the same unit as the unit being

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calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the
numerator matches the unit being calculated.) 1 tablet<i>X</i> tablet(s)&#160 =
&#160<hr>100 mg</br></br>Step 3: Place any remaining ratios that are relevant to the
item on the right side of the equation, along with any needed conversion factors, to
cancel out unwanted units of measurement. 1 tablet150 <s>mg<i>X</i> tablet(s)&#160
= &#160<hr>&#160 &#215 &#160<hr>100 <s>mg1 dose</br></br>Step 4: Solve for X.
<i>X</i> tablet(s) = 1.5 tabletsStep 5: Round if necessary. Step 6: Reassess to
determine whether the amount to administer makes sense. If there are 100 mg/tablet
and the prescription reads 150 mg, it makes sense to administer 1.5 tablets. The nurse
should administer desipramine 1.5 tablets PO daily.

InCorrect Rationale: <b>Follow these steps for the Ratio and Proportion method of calculation:</b>Step 1:
What is the unit of measurement the nurse should calculate? tablet(s) Step 2: What is
the dose the nurse should administer? Dose to administer = Desired 150 mg Step 3:
What is the dose available? Dose available = Have 100 mg Step 4: Should the nurse
convert the units of measurement? No Step 5: What is the quantity of the dose
available? 1 tablet Step 6: Set up an equation and solve for X.
<i>Have</i><i>Desired<i/><hr>&#160 =
&#160<hr><i>Quantity<i/><i>X</i></br></br>100 mg150 mg<hr>&#160 =
&#160<hr>1 tablet<i>X</i> tablet(s)</br></br><i>X</i> tablet(s) = 1.5 tabletsStep 7:
Round if necessary. Step 8: Reassess to determine whether the amount to administer
makes sense. If there are 100 mg/tablet and the prescription reads 150 mg, it makes
sense to administer 1.5 tablets. The nurse should administer desipramine 1.5 tablets
PO daily.<b>Follow these steps for the Desired Over Have method of
calculation:</b>Step 1: What is the unit of measurement the nurse should calculate?
tablet(s) Step 2: What is the dose the nurse should administer? Dose to administer =
Desired 150 mg Step 3: What is the dose available? Dose available = Have 100 mg
Step 4: Should the nurse convert the units of measurement? No Step 5: What is the
quantity of the dose available? 1 tablet Step 6: Set up an equation and solve for X.
<i>Desired<i/> &#215 <i>Quantity</i><i>X</i>&#160 =
&#160<hr><i>Have<i/></br></br>150 <s>mg &#215 1 tablet<i>X</i> tablet(s)&#160 =
&#160<hr>100 <s>mg</br></br><i>X</i> tablet(s) = 1.5 tabletsStep 7: Round if
necessary. Step 8: Reassess to determine whether the amount to administer makes
sense. If there are 100 mg/tablet and the prescription reads 150 mg, it makes sense to
administer 1.5 tablets. The nurse should administer desipramine 1.5 tablets PO daily.
<b>Follow these steps for the Dimensional Analysis method of calculation:</b>Step 1:
What is the unit of measurement the nurse should calculate? (Place the unit of
measure being calculated on the left side of the equation.) <i>X</i> tablet(s) = Step 2:
Determine the ratio that contains the same unit as the unit being calculated. (Place the
ratio on the right side of the equation, ensuring that the unit in the numerator matches
the unit being calculated.) 1 tablet<i>X</i> tablet(s)&#160 = &#160<hr>100
mg</br></br>Step 3: Place any remaining ratios that are relevant to the item on the
right side of the equation, along with any needed conversion factors, to cancel out
unwanted units of measurement. 1 tablet150 <s>mg<i>X</i> tablet(s)&#160 =
&#160<hr>&#160 &#215 &#160<hr>100 <s>mg1 dose</br></br>Step 4: Solve for X.
<i>X</i> tablet(s) = 1.5 tabletsStep 5: Round if necessary. Step 6: Reassess to
determine whether the amount to administer makes sense. If there are 100 mg/tablet
and the prescription reads 150 mg, it makes sense to administer 1.5 tablets. The
nurse should administer desipramine 1.5 tablets PO daily.

237.A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological
changes should the nurse educate the client and family to monitor?

Answers cannot be displayed for this alternate item format.

Rationale:

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Rationale A:Weight loss is correct. The client may experience weight loss due to forgetting to eat
or difficulty eating and [Link] B:Decreased mobility is correct. The client may
experience decreased mobility due to cognitive decline and limited physical [Link] C:
Increased physical activity is incorrect. The client is likely to experience decreased mobility due to
cognitive decline and therefore limited physical activity, not increased physical [Link]
D:Unkempt appearance is correct. The client may have an unkempt appearance due to poor
hygiene practices related to [Link] E:Constipation is correct. The client may
experience constipation due to decreased mobility and limited physical activity.

238.A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following
preoperative instructions should the nurse include?

A. Keep both eyes patched.

Rationale: With retinal detachment, the client should wear an eye patch over the affected eye to limit its
movement.

B. Restrict head movement.

Rationale: The client should restrict head and eye movement to prevent further detachment prior to
surgery.

C. Eye drops to constrict the pupils will be prescribed.

Rationale: Topical medications are administered preoperatively to prevent pupil constriction and
accommodation.

D. Apply cool compresses.

Rationale: Retinal detachment is painless, so there is no need for comfort measures like cool
compresses.

239.A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following
instructions should the nurse include?

A. "Rest in bed for at least 2 days."

Rationale: Remaining in bed after cataract surgery puts the client at risk for the hazards of immobility.
The client may resume previous mobility as soon as 1 hr after surgery but should avoid
activities involving rapid or jerking head motions, such as running and dancing, for several
weeks.

B. "Keep your head up and straight."

Rationale: Keeping the head straight and avoiding looking down prevents increasing intraocular
pressure.

C. "Deep breathe and cough four times a day."

Rationale: Deep breathing is helpful for any client, but coughing increases intraocular pressure. Thus, the
client should avoid coughing after cataract surgery.

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D. "Lie on the side of the surgery when in bed."

Rationale: Most clients have mild discomfort in the eye after cataract surgery, so it is more comfortable
for clients to lie on the other side or on their back when resting. Also it avoids raising
intraocular pressure in the operative eye.

240.A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following
actions is most likely to facilitate resolution of the headache?

A. Administer pain medication.

Rationale: A spinal headache following a lumbar puncture develops due to a leaking of the cerebrospinal
fluid (CSF) which depletes the amount of circulating CSF and results in insufficient fluid to
maintain the mechanical stability of the brain. While a medication for pain may help control the
symptoms, it doesn't facilitate resolution of the headache.

B. Darken the client's room and close the door.

Rationale: The client who has a spinal headache experiences a throbbing headache that worsens with
sitting or standing and is the result of a decreased amount of circulating CSF. Darkening the
room and closing the door may assist in controlling the pain for the client who has a migraine,
but it is not useful in the client who has a spinal headache.

C. Increase fluid intake.

Rationale: The client who has had a lumbar puncture is at risk for continued leaking of CSF from the
puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is
helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and
increasing fluids will facilitate resolution of the headache. The client should also be instructed
to remain in a prone position for 6 hours to prevent leaking of CSF fluid.

D. Elevate the head of the bed to 30º.

Rationale: The client who has a spinal headache experiences a throbbing headache that worsens with
sitting or standing and is the result of a decreased amount of circulating CSF. Resolution of
the discomfort will occur by placing the client in a prone position. A client who has increased
intracranial pressure would be placed in a position with the head of the bed at 30º.

241.A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale
(GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the
following is an appropriate conclusion based on this data?

A. The client can follow simple motor commands.

Rationale: The client's ability to follow commands would require a score of 6 for best motor response.

B. The client is unable to make vocal sound.

Rationale: The inability of the client to make vocal sounds would result in a score of 1 for best verbal
response.

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C. The client is unconscious.

Rationale: The unconscious client would have a score of 1 for eye opening and a 1 for best verbal
response.

D. The client opens his eyes when spoken to.

Rationale: A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and
is able to localize pain.

242.A nurse is caring for a group of clients with dementia. The nurse recognizes which of the following factors as
reasons for the growing numbers of clients diagnosed with dementia in the United States?

Answers cannot be displayed for this alternate item format.

Rationale: Rationale A:The use of technology in and outside of the home is not linked to the development of
dementia and does not contribute to the growing number of individuals diagnosed with dementia.
Rationale B:Longer average life expectancy could contribute to more clients being diagnosed
with dementia, since living longer means more years of exposure to toxins, like air pollution, that
create changes in the [Link] C:A reason for the increase in the number of clients with
dementia could be related to the growing number of Americans within the United States
65-years-old and older, known as the baby boomer generation, since this age group is more likely
to be diagnosed with [Link] D:Traveling abroad is not linked to the development of
[Link] E:Studies have indicated that there is a link between a decreased
educational status and the development of Alzheimer's disease and dementia.

243.A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the
following interventions should the nurse take?

A. Place the client in protective isolation.

Rationale: Protective isolation is for clients who are at high risk for infection. This client is at risk for
rupture of the aneurysm.

B. Minimize environmental stimuli.

Rationale: A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation
that could cause anxiety, such as noise or bright lights.

C. Elevate the head of the client's bed 45°.

Rationale: The nurse should elevate the head of the client's bed 15° to 30° to promote venous return and
to reduce intracranial pressure.

D. Limit the client's ambulation to once a day.

Rationale: A client who has a cerebral aneurysm should remain on bed rest.

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244.A nurse is instructing a client who is experiencing episodes of tinnitus on lifestyle modifications to make. Which of
the following statements should the nurse include in the teaching?

A. "You should practice deep breathing exercises."

B. "You should avoid exercising."

C. "You can use at least 2,300 mg of sodium daily."

D. "You can have 2 to 3 cups of coffee throughout the day."

[Link] each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple
sclerosis. Each finding can support more than one disease process.

Answers cannot be displayed for this alternate item format.

Rationale: Facial symmetry is consistent with stroke. Unilateral facial droop can occur in a stroke due to a
decrease in cerebral perfusion to one hemisphere of the brain. Rigid facial muscles is consistent
with Parkinson's disease. Hypertension is consistent with stroke. Hypertension is a risk factor
for the development of a stroke. Orthostatic hypotension can occur in Parkinson’s disease due to
a decrease in sympathetic nervous system response. Cognitive function is consistent with
Parkinson's disease, stroke, and multiple sclerosis. Cognitive impairment can occur in
Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Cognitive
impairment is consistent with a stroke due to an interruption in cerebral [Link] is
consistent with Parkinson's disease, stroke, and multiple sclerosis. Slurred speech can
occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways.
Aphasia is consistent with a stroke due to an interruption in cerebral [Link] status is
consistent with Parkinson's disease, stroke, and multiple sclerosis. Impaired mobility can
occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways.
Impaired mobility is consistent with a stroke due to an interruption in cerebral perfusion.

246.A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the
nurse anticipate?

A. Initiate a low-residue diet.

Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate
the provider will prescribe withholding of foods and fluids. This serves to manage the client's
pain by limiting gastrointestinal activity and stimulation of the pancreas.

B. Pantoprazole 80 mg IV bolus twice daily

Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease
gastric acid production, which ultimately decrease pancreatic secretions.

C. Ambulate twice daily.

Rationale: The nurse should anticipate a provider prescription for bed rest during the acute stage of
pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes.

D. Pancrelipase 500 units/kg PO three times daily with meals

Rationale:

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The nurse should identify that pancrelipase, an enzyme replacement medication, is used in
the treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute
pancreatitis.

247.A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the
nurse anticipate with this client?

A. Bruising over the mastoid process

B. Pooling of blood and edema around the eyes

C. Ability to recall how the injury occurred

D. Chvostek's sign

248.A nurse is completing an admission assessment on a client who has hearing loss. Which of the following client
statements should indicate to the nurse that the client is experiencing manifestations of Mèniére’s disease?

A. "I can't get out of bed because the room is spinning."

B. "I often feel like I have cotton balls in my ears."

C. "Sometimes I feel slightly dizzy when I am in a loud restaurant."

D. "I did feel some fluid dripping from my ear when I laid down."

249.A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain
management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense
another dose. Which of the following responses should the nurse make?

A. "Next time you think he needs more medication, call me and I’ll push the button."

Rationale: The nurse should administer a PRN or around-the-clock dosing if the client is having
breakthrough pain, but should not push the client’s PCA button.

B. "It’s a good idea to help make sure your husband can sleep comfortably."

Rationale: The nurse should determine with the client’s awareness if there is breakthrough pain that may
require more pain medication.

C. "Why do you think your husband needs more medication when he is asleep?"

Rationale: The nurse’s goal is to educate the client’s partner. Asking “why” questions can make the
partner defensive.

D. "Your husband should decide when more medication is needed."

Rationale: The nurse should explain to the client’s partner that the client is the only one who should

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operate the PCA pump. In situations where the client is not able to do so, the provider may
authorize a nurse or a family member to operate the pump.

250.A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following
assessments is the nurse's priority?

A. Intracranial pressure

Rationale: Assessing intracranial pressure is important to determine if the client's intracranial pressure is
increased as a result of cerebral edema or bleeding following intracranial surgery; however,
another assessment is the priority.

B. Serum electrolytes

Rationale: Assessing the client's serum electrolytes is important to determine if the client is retaining
sodium. This can be a risk following intracranial surgery; however, another assessment is the
priority.

C. Temperature

Rationale: Assessing the client's temperature is important to determine if the client is experiencing
hyperthermia. This can occur due to infection and also from damage to the hypothalamus
following intracranial surgery. However, another assessment is the priority.

D. Respiratory status

Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place
the priority on assessing the client's respirations, noting the rate and pattern, and evaluating
arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral
ischemia.

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