The nurse has taught the client about an upcoming endoscopic retrograde

cholangiopancreatography procedure. The nurse determines that the client needs further
information if the client makes which statement?
The correct answer is: "I'm glad I don't have to lie still for this procedure."
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen.
Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:
The correct answer is: 5 minutes.
What is a classic diagnostic finding in a patient with appendicitis?
blood cell (WBC) count
The correct answer is: Elevated white blood cell (WBC) count
The nurse is caring for a client who is preparing for discharge after having had an upper GI series.
Which client statement demonstrates a need for further discharge instruction?
The correct answer is: "I will not be able to drink fluids that contain any caffeine."
A nurse notes that a patient has ascites, which indicates that which of the following is present?
The correct answer is: Fluid
Nina was diagnosed with peptic ulcer. The physician says that she has developed the most
common type of Peptic Ulcer Disease. When obtaining a history from this client, the nurse should
expect the reported pain to:
The correct answer is: Occur one to three hours after meals
The nurse reinforces post-op liver biopsy procedure to a client. Which should the nurse tell the
client?
The correct answer is: Lie on right side for 2 hours
When caring for a patient who has just had an upper GI endoscopy, the nurse assesses that the
client has developed a temperature of 101.8F. What is the appropriate nursing intervention?
The correct answer is: Promptly assess the patient for potential perforation.
Melena, the passage of black, tarry stools, suggests bleeding from:
The correct answer is: Upper gastrointestinal (GI) tract.
The nurse is performing a physical assessment on a client’s abdomen. The nurse inspects the
abdomen and finds the abdomen asymmetrical, with a non-pulsating mass in the RUQ. What is the
appropriate priority nursing intervention?
The correct answer is: Auscultate for bowel sounds and bruits.
Which of the following factors would most likely contribute to the development of a client’s hiatal
hernia?
The correct answer is: Being 4 feet, 10 inches tall and weighing 190 pounds.
The nurse is caring for a patient who has achalasia. The patient has just had esophageal dilation
performed to help alleviate the symptoms associated with achalasia. Which nursing intervention is
appropriate after this procedure is performed?
The correct answer is: Assess vital signs every 2 hours post-op after they are stable.
A client has been taking naproxen (Naprosyn) for several months. Which of the following
assessment question is important for the nurse to ask?
The correct answer is: "Have you had any stomach pain or indigestion?"
Nurse Lera is taking care of patient lien who was recently diagnosed with PUD. It is apparent that
the drug therapy for patient lien is focused on, except:
The correct answer is: Eliminating L. Pylori
"The health care team is assessing a patient for acute pancreatitis after he presented to the
emergency department with severe abdominal pain. Which laboratory value is the best diagnostic
indicator of acute pancreatitis?
The correct answer is: Serum amylase
Nurse Lily is attending to patient rem who is admitted for GERD. Which statement requires nursing
intervention?
The correct answer is: “Sometimes I wake up gasping for air in the middle of the night.”
While palpating a female client's right upper quadrant (RUQ), the nurse would expect to find which
of the following strictures?
The correct answer is: Liver
A client is taking an antacid for treatment of peptic ulcer disease. Which of the following statements
best indicates that the client understands how to correctly take the antacid?
The correct answer is: “I should take my antacid before I take my other medications.” “I need to
decrease my intake of fluids so that I don’t dilute the effects of my antacid.” “My antacid will be most
effective if I take it whenever I experience stomach pains.” “It is best for me to take my antacid 1 to
3 hours after meals.”
Sarah complains of an annoying sensation, cramping pain in the top part of her abdomen that
becomes worse in the afternoon and sometimes awakes her at night. She reports that when she
eats, it helps the pain go away but that pain is now becoming more intense. Which of the following
is the best condition for the nurse to draw:
The correct answer is: These symptoms are consistent with an ulcer
Percussion notes heard during the abdominal assessment may include:
The correct answer is: Dullness and tympany.
Upon assessment of a client with GERD, which statement requires nursing intervention?
The correct answer is: “Sometimes I wake up gasping for air in the middle of the night.”
The nurse is caring for a client with a bleeding duodenal ulcer who was admitted to the hospital after
vomiting bright, red blood. Which condition does the nurse anticipate when the client develops a
sudden, sharp pain in the mid-epigastric region and a rigid, board-like abdomen?
The correct answer is: Ulcer perforation
The nurse instructs the client on health maintenance activities to control symptoms from her hiatal
hernia. Which of the following statements would indicate that the client has understood the
instruction?
The correct answer is: “I’ll avoid lying down after meal.”
Student Nurse Lay is excited when she saw her duty schedule starting next week. She will be
assigned in the medical ward for 14 days for her clinical rotation. She is glad that her supervising
instructor is Sir Gwafitow. She was assigned with a patient from room 12L with a diagnosis of
Gastritis. Sir Gwafitow asked SN Lay on why does the injury of gastritis worsened aside from the
auto digestion. SN Lay is confident when she states:
The correct answer is: The injury is worsened due to the histamine release and the vagus
stimulation.
The following statements are true in regards with GERD, except:
The correct answer is: The constant connection of the digestive enzymes in the lamina proprietor
and antrum may cause severe infection.
The client had been diagnosed to have complete Intestinal Obstruction. Which of the following
assessment findings will the nurse expect?
The correct answer is: Absence of bowel sounds
The nurse notes that a patient has had a black, tarry stool and recalls that a possible cause would
be:
The correct answer is: Gastrointestinal bleeding.
The client being seen in a physician's office has just been scheduled for a barium swallow the next
day. The nurse writes down which of the following instructions for the client to follow before the test?
The correct answer is: Fast for 8 hours before the test
Which is the best method for evaluation and treatment of large intestine polyps?
The correct answer is: Colonoscopy
The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse
should include in the instructions that the client will be placed in which position for the procedure?
The correct answer is: Left Sims Position
A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb and has
cramps and occasional diarrhea. The nurse should include which of the following when doing a
nutritional assessment?
The correct answer is: Ask the client to list what she eats during a typical day.
Which potential problem will be emphasized in the plan of care for a patient who has
gastroesophageal reflux disease (GERD)?
The correct answer is: Risk for aspiration
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-
tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is
most appropriate?
The correct answer is: Document the findings.
A client is admitted to the health care facility with a diagnosis of Gastric Ulcer. The nurse expects
this client's stools to be:
The correct answer is: Black and tarry
The nurse is preparing to preform an abdominal examination. The initial step should be which?
The correct answer is: Inspection
Which should be included in education for a patient recently diagnosed with peptic ulcer disease?
The correct answer is: Small, frequent meals throughout the day can be beneficial.
Epigastric pain, beginning 30 minutes to 2 hours after eating when the stomach is empty or in the
middle of the night, is consistent with which diagnosis?
The correct answer is: Duodenal Ulcer.
A client is to collect a specimen for a stool guaiac test. Which direction should the client be given?
The correct answer is: "Do not eat red meat for at least 3 days before collecting the specimen."
Which sound is normal to elicit when percussing in the seventh right intercostal space at the
midclavicular line over the liver?
The correct answer is: Dullness
Which of the following tests should be administered to a client suspected of having diverticulosis?
The correct answer is: Barium enema
Red has just returned from the postanesthesia care unit (PACU) from a hemorrhidectomy. His
postoperative orders include sitz baths every morning. The nurse understands that sitz bath is use
for:
The correct answer is: promote healing
What is a common gastrointestinal problem that older adults experience more frequently as they
age?
The correct answer is: Decreased hydrochloric acid levels
If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if
the diagnosis is Crohn's disease or ulcerative colitis?
The correct answer is: Colonoscopy with biopsy
Which of the following laboratory results would be expected in a client with peritonitis?
The correct answer is: White blood cell count above 15,000
The main reason auscultation precedes percussion and palpation of the abdomen is to:
The correct answer is: Prevent distortion of bowel sounds that might occur after percussion and
palpation.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on
which item as part of the client's care plan?
The correct answer is: Assessing for the return of the gag reflex
The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The
nurse performs which of the following assessment technique next?
The correct answer is: Listens to bowel sounds in all four quadrants
The nurse is listening to bowel sounds. Which of the following is true of bowel sounds?
The correct answer is: They are usually high-pitched, gurgling, irregular sounds.
The nurse is preparing to teach a client with peptic ulcer disease about the diet that should be
followed after discharge. The nurse should explain that the diet will most likely consist of the
following:
The correct answer is: Any foods that are tolerated
The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is:
The correct answer is: Decreased gastric acid secretion.
Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. The nurse reviews the
client's medical record and should question the prescription if which data is noted in the client's
history?
The correct answer is: Use of nitroglycerin
As a well-equipped student nurse, you were correct when you identify below the correct concepts in
terms of hypophysectomy, except:
The correct answer is: Removal of the thyroid gland.

A client with SIADH is treated with water restriction and administration of IV fluids. The nurses
evaluates that treatment has been effective when the client experiences which of the following?
The correct answer is: increased urine output, increased serum sodium, and decreased urine
specific gravity
A nurse went to a client’s room to do routine vital signs monitoring and found out that the client’s
bedtime snack was not eaten. This should alert the nurse to check and assess for:
Feedback
The correct answer is: Signs of hypoglycemia earlier than expected
The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin
NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse
should tell the client to take which action?
The correct answer is: Refrigerate the insulin.
Early this morning, a female client had a Subtotal Thyroidectomy. During evening rounds, nurse
Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and
extreme restlessness. What is the most likely cause of these signs?
The correct answer is: Thyroid crisis
During preoperative teaching for a female client who will undergo Subtotal Thyroidectomy, the nurse
should include which of the following statement?
The correct answer is: “You must avoid hyperextending your neck after surgery.”
A client with Grave's Disease asks the nurse what caused the disorder. Which of the following is a
best response by the nurse?
The correct answer is: "In genetically susceptible persons antibodies form that attack thyroid tissue
and stimulate overproduction of thyroid hormones."
The symptoms of Diabetes Mellitus may include all the following except:
The correct answer is: Abnormal mineral absorption
A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client
regarding administration of the medication and should instruct the client that which time is best to
take this medication?
The correct answer is: Early morning
Nympha, 32-year-old presents with weight gain, round face and presence of a fatty hump between
the shoulders. In order to determine adrenocortical disorder, the attending physician orders 17-
ketosteroids test. Student Nurse Eli is correct when he remembered the test as:
The correct answer is: If it increases, it is a determinant of Cushings Syndrome if it is low, it may
only be hypofunction of the gland.
To prevent complications in the client with Cushing Syndrome, the nurse monitors the client for?
The correct answer is: cardiac arrhythmias
An 18 year old client is seen at the health center with swelling of the hands and face. The client is
diagnosed with Acromegaly. The nurse knows that this condition is typically caused by:
The correct answer is: Benign tumors on the pituitary that causes excess secretion of growth
hormone.
The nurse provides medication instructions to a client who is taking levothyroxine (Synthroid) and
should tell the client to notify the health care provider (HCP) if which problem occurs?
The correct answer is: Tremors
SN Mira is about to collect a urine for patient L for Calcium Deprivation test. SN Mira is correct when
she performs the following:
The correct answer is: Collection of 24-hour urine specimen.
The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism.
Which findings indicate the presence of a side effect associated with this medication? Select all that
apply.
1. Insomnia
2. Weight loss
3. Bradycardia
4. Constipation
5. Mild heat intolerance
The correct answer is: 1, 2, 5
Thyroidectomy is a procedure performed when persistent hyperthyroidism exists. So, with the
procedure total thyroidectomy, the patient is prone for tetany. What medication should be in the
patient’s bed side for these circumstances?
The correct answer is: Calcium Gluconate
Patient Urem is cleared for parathyroidectomy. The most common crisis that the patient may
experience after the surgery is:
The correct answer is: Hypocalcemic Crisis
SN Liu is attending to patient O, who recently had thyroid scan 26 minutes ago. It is understandable
that SN Liu will check the most important post-procedural assessment:
The correct answer is: Auscultating the chest and posterior part for a high-pitched whistling sound.
The nurse performs an admission assessment on a client who visits a health care clinic for the first
time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to
collect data from the client, suspecting that the client has a history of which condition?
The correct answer is: Graves' disease
A male client is admitted for treatment of the Syndrome of Inappropriate Antidiuretic Hormone
(SIADH). Which of the following nursing intervention is appropriate?
The correct answer is: Restricting fluids.
Which of the following is the most important nursing intervention during the medical and surgical
treatment of the client with a Pheochromocytoma?
The correct answer is: monitoring blood pressure
The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell
the client that which occurrence is a side effect of the medication?
The correct answer is: Runny nose,
Chief Nurse Edmund asks the Student Nurse in-charge of room 112 who happened to be his sister,
as to why the attending physician orders a T3 & T4 Resin Uptake Test be done immediately. Below
are the concepts in relation to the test, except:
The correct answer is: This is a blood test that evaluates the hypopituitarism and hyperthyroidism.
A client with a diagnosis of Diabetic Ketoacidosis (DKA) is being treated in the Emergency
Department. Which finding would a nurse expect to note as confirming this diagnosis?
The correct answer is: Elevated blood glucose level and a low plasma bicarbonate

During care of a client with Syndrome of Inappropriate ADH (SIADH), the nurse should:
The correct answer is: monitor neurologic status Q2H or more often if needed
An appropriate nursing intervention for the client with Hyperparathyroidism is to?
The correct answer is: increase fluid intake to 3000 to 4000ml/day
When caring for a client with primary Hyperaldosteronism, the nurse would question a physician's
order for the use of which of the following medications?
The correct answer is: Lasix
The health care provider (HCP) prescribes exenatide (Byetta) for a client with type 1 diabetes
mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?
The correct answer is: Withhold the medication and call the HCP, questioning the prescription for
the client.
A client with Diabetes Melitus demonstrates acute anxiety when first admitted for the treatment of
hyperglycemia. Which of the following is the most appropriate intervention to decrease the client’s
anxiety?
The correct answer is: Convey empathy, trust, and respect toward the client
Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to
avoid consuming which food while taking this medication?
The correct answer is: Alcohol
Mrs. Write, 32-year-old presented symptoms with fatigue, hoarseness of voice, dry skin,
constipation and weight gain. Mr. Write also mention that her wife experienced secondary
amenorrhea for about 1 episode. It also alarmed herself when there are prominent physical changes
such as puffy face, prevalent to the disorder. They immediately went to an Endocrinologist to ask for
medical advice. Mrs. Write then subject for Iodine thyroid scan by Dr. Wa-il who immediately advise
Mrs. Write for admission for series of diagnostic exams. SN Michelle was one of the gifted student
nurses who assisted Nurse Elie in the Radiologic Department. SN Michelle is right when she asks
the patient to what primary questions prior to the surgery?
The correct answer is: "How are you doing today Mrs. Write? Hope all is well with you. I just would
like to ask ma’am if you're pregnant?"
A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing
considerations are associated with this medication? Select all that apply.
1. Administer methimazole with food.
2. Place the client on a low-calorie, low-protein diet.
3. Assess the client for unexplained bruising or bleeding
4. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches.
5. Use special radioactive precautions when handling the client's urine for the first 24 hours
following initial administration
The correct answer is: 1, 3, 4
To prevent complications in the client with Cushing syndrome, the nurse monitors the client for
which of the following?
The correct answer is: cardiac arrhythmias
The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe.
Which action, if performed by the client, indicates the need for further teaching?
The correct answer is: Withdraws the NPH insulin first
A clinical feature that distinguishes a Hypoglycemic reaction from a Ketoacidosis Reaction is:
The correct answer is: Diaphoresis
A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide
which instructions to the client? Select all that apply.
1. Hypoglycemia may be experienced before dinnertime.
2. The insulin dose should be decreased if illness occurs.
3. The insulin should be administered at room temperature.
4. The insulin vial needs to be shaken vigorously to break up the precipitates.
5. The NPH insulin should be drawn into the syringe first, then the regular insulin
The correct answer is: 1, 3
Patient Ed was recently diagnosed with endocrine disease. With its laboratory indicator of Serum
Calcium 11.7mg/dL, SN Jan is correct when she mentions:
The correct answer is: Patient Ed has hyperparathyroidism
SN Liow is preparing for an OR procedure as a surgical scrub with Adrenalectomy. SN Liow
reviewed on the procedure and equipment needed to hand-over to the attending surgeon. SN liow,
then asked by the Resident Physician if they are going to remove all adrenal glands, to what
hormones is your adrenal gland secretes? With confidence, SN Liow answers:
The correct answer is: Sex hormones, adrenaline and cortisol.
Sierra, 31-year-old triathlete submit herself for a serum-glucose test. The result indicates 201mg/dL.
With the result of Sierras serum sugar level, it means:
The correct answer is: There are more glucagons in the blood than insulin.
When caring for a client with Nephrogenic DI, the nurse would expect treatment to include?
The correct answer is: thiazide diuretics
Patient Ren was admitted in the hospital 9 months ago for symptoms of hyperglycemia. With 12
days stay in the hospital and with right medication and management the serum level of patient ren
moves to normal. But then, he was advise to have a follow-up check to Dr. Us his attending
physician after 5 months of continued therapy. With the knowledge you knew during the class of
Medical Surgical Nursing, it is ideal to use this laboratory testing to check the serum glucose level
months after patient is discharged:
The correct answer is: HBA1C
The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes
mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the
nurse to explain these medications. The nurse should provide which instructions to the client?
Select all that apply.
1. Diarrhea may occur secondary to the metformin.
2. The repaglinide is not taken if a meal is skipped.
3. The repaglinide is taken 30 minutes before eating.
4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes.
5. Metformin increases hepatic glucose production to prevent hypoglycaemia associated with
repaglinide.
6. Muscle pain is an expected effect of metformin and may be treated with acetaminophen (Tylenol).
The correct answer is: 1, 2, 3, 4
Patient was admitted for a series of endocrine diagnostic exams for the next 2 days. Mr. Leri, 42-
year-old widowed who constantly feel tired and has a low energy even if he is well rested. Student
Nurse Pad was assigned to the patient, SN Pad was tasked to give client teaching prior to the
procedure – thyroid scan, to which client teaching is most vital, except:
The correct answer is: Reassure Mr. Leri on the proper use of breathing exercises during the scan.
An incoherent female client with a history of Hypothyroidism is brought to the emergency
department by the rescue squad. Physical and laboratory findings reveal hypothermia,
hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face
and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby
prepares to take emergency action to prevent the potential complication of:
The correct answer is: Myxedema coma.
SN Lara was assigned in the medical ward, she is with her patient who has hypothyroidism and
subject for a thyroid scan at 9am tomorrow. Mr. Joy, husband of the patient asked SN Lara about
the Oral I-123 radionuclide. SN Lara is correct when she says:
The correct answer is: "The I-123 or the radionuclide agent is to be administered today at 9:00 in
the morning."
Nurse Oliver should expect a client with Hypothyroidism to report which of the following health
concerns?
The correct answer is: Puffiness of the face and hands
The community health nurse visits a client at home. Prednisone, 10 mg orally daily, has been
prescribed for the client and the nurse teaches the client about the medication. Which statement, if
made by the client, indicates that further teaching is necessary?
The correct answer is: "I can take aspirin or my antihistamine if I need it."
The nurse provides instructions to a client who is taking levothyroxine (Synthroid). The nurse should
tell the client to take the medication at which time?
The correct answer is: On an empty stomach
Below are the concept relating to Sulkowitch test, except:
The correct answer is: Blood is the Specimen
Methylprednisolone was given to Patient Um, to which of the following negative effects patient may
experience?
The correct answer is: Euphoria
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would
alert the nurse that cerebrospinal fluid is present?
The correct answer is: Fluid separates into concentric rings and tests positive for glucose.
A 50 year old man with multiple sclerosis reports “I've been nauseated and tired since I've begun
taking my medication. I'm also having a high fever”. You notice in the patient's chart that she is
taking Interferon beta 1b, which is an anti-inflammatory drug (Betaseron). What is the best response
from the nurses?
The correct answer is: "Taking a Tylenol at bedtime with your medications may help you feel better
and reduce symptoms."
The nurse has given instructions to a client with Parkinson’s disease about maintaining mobility.
Which action demonstrates that the client understands the directions?
The correct answer is: Rocks back and forth to start movement with bradykinesia.
The nurse is assessing the motor and sensory function of an unconscious client who sustained a
Head Injury. The nurse should use which of the following technique to test the client’s peripheral
response to pain?
The correct answer is: Nailbed pressure

A client’s vision is tested with a Snellen chart. The results of the tests are documented as 20/60.
What action should the nurse implement based on this finding?
The correct answer is: Instruct the client that he or she may need glasses when driving.
The nurse is assessing patients with PD. Which patient with Parkinson's disease should the nurse
be concerned about administering benztropine to?
The correct answer is: Diagnosed with glaucoma
Tonometry is performed on a client with a suspected diagnosis of Glaucoma. The nurse looks at the
documented test results and notes an intraocular pressure (IOP) value of 23. What should be the
nurse’s initial action?
The correct answer is: Note the time of day the test was done.
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. What is
the chief clinical manifestation that the nurse expects to note in the early stages of cataract
formation?
The correct answer is: Blurred vision
The nurse is performing an admission assessment on a client with a diagnosis of Detached Retina.
Which of the following sign or symptom is associated with this eye problem?
The correct answer is: A sense of a curtain falling across the field of vision
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain
attack). Which observation indicates to the nurse that the client is adapting most successfully?
The correct answer is: Consistently uses adaptive equipment in dressing self
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous
hemianopsia about measures to help the client overcome the deficit. Which statement suggests that
the family understands the measures to use when caring for the client?
The correct answer is: “We need to remind him to turn his head to scan the lost visual field.”
The nurse is performing an admission assessment on a client with a diagnosis of detached retina.
Which sign/symptom is associated with this eye disorder?
The correct answer is: A sense of a curtain falling across the field of vision
Nurse Jingle is taking care of a patient with Multiple Sclerosis, what should be the medications
prescribed for MS include those for disease modification and those for symptom management. The
disease-modifying therapies available to treat MS include:
The correct answer is: Interferon beta-1a (Rebif)
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury.
Which observation indicates that spinal shock persists?
The correct answer is: Flaccid paralysis
The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and
cholinergic crises. Which client activity suggests that teaching is most effective?
The correct answer is: Taking medications on time to maintain therapeutic blood levels
The client is having a Lumbar Puncture performed. The nurse would plan to place the client in which
of the following position for the procedure?
The correct answer is: Side-lying, with legs pulled up and head bent down onto the chest.
Patient Liu who had a cervical spine injury 21 hours ago is being cared for by Nurse Michael. Which
of the following drugs should Nurse Michael discuss with the physician?
The correct answer is: Muscle relaxants
The nurse is performing an assessment on a client with a suspected diagnosis of Cataract. Which
clinical manifestation should the nurse expect to note in the early stages of cataract formation?
The correct answer is: Blurred vision
Which assessment data would indicate to the nurse that the client would be at risk for a
Hemorrhagic Stroke?
The correct answer is: A blood pressure of 220/120 mmHg.
You're instructing a group of myasthenia gravis patients. Which of the following is not an option for
treating this condition?
The correct answer is: Cholinesterase medications
"I feel queasy and weary since I began taking my medicine," a multiple sclerosis sufferer says. I'm
also sick with a fever." You notice that the patient is taking Interferon beta 1b after glancing at her
file (Betaseron). What is the best reaction from the nurses?
The correct answer is: "Taking your prescription with a Tylenol at night may help lessen these
symptoms."
The nurse is caring for the client with increased Intracranial Pressure as a result of a Head Injury?
The nurse would note which trend in vital signs if the intracranial pressure is rising?
The correct answer is: Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure
If a male client experienced a Cerebrovascular Accident (CVA) that damaged the hypothalamus, the
nurse would anticipate that the client has problems with:
The correct answer is: Body temperature control
The nurse is assigned to care for a client with complete right-sided hemiparesis. Which
characteristics are associated with this condition? Select all that apply.
1. The client is aphasic.
2. The client has weakness in the face and tongue.
3. The client has weakness on the right side of the body.
4. The client has complete bilateral paralysis of the arms and legs.
5. The client has lost the ability to move the right arm but is able to walk independently.
6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or
herself without assistance.
The correct answer is: 1, 2, 3
When caring for a patient suffering from Multiple Sclerosis (MS), the nurse makes the following
arrangements:
The correct answer is: Teach the patient how to inject drugs, since all MS treatments are given via
injection (SQ or IM).
A Carotid Endarterectomy is considered a treatment for a patient who has had several TIAs. What
should the nurse explain to the patient about this surgery?
The correct answer is: It involves removing an atherosclerotic plaque in the carotid artery to prevent
an impending stroke.
An older adult client has multiple tibia and fibula fractures of the left extremity after a motor vehicle
crash. Which pain medication does the nurse anticipate will be requested for this client?
The correct answer is: PCA with Morphine
The nurse is caring for the client with increased intracranial pressure. The nurse would note which
trend in vital signs if the intracranial pressure is rising?
The correct answer is: Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure
A client is admitted to the hospital with a left hemiplegia. To determine the size and location and to
ascertain whether a Stroke is ischemic or hemorrhagic, the nurse anticipates that the health care
provider will request which of the following diagnostic test?
The correct answer is: CT scan
The nurse is caring for a client who begins to experience seizure activity while in
bed. Which action by the nurse is contraindicated?
The correct answer is: Restraining the client’s limbs
Nurse Jojo is caring a 72-year-old male patient with Parkinson’s. The Wife of the patient is asking
the nurse about how dopamine therapy works. Nurse Jojo best response would be:
The correct answer is: Dopamine is the drug of choice of patient with Parkinson’s but totally not a
cure.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should
avoid which measure to minimize the risk of occurrence?
The correct answer is: Limiting bladder catheterization to once every 12 hours
A client who had a Stroke is seen bumping into things on the side and is having difficulty picking up
the beginning of the next line of what he is reading. The client is experiencing which of the following
conditions?
The correct answer is: Homonymous Hemianopsia
Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the
test results documented in the client’s chart, knowing that which is the range for normal intraocular
pressure?
The correct answer is: 10 to 21 mm Hg
The nurse is planning to institute seizure precautions for a client who is being
admitted from the emergency department. Which measures should the nurse
include in planning for the client’s safety? Select all that apply.
1. Padding the side rails of the bed
2. Placing an airway at the bedside
3. Placing the bed in the high position
4. Putting a padded tongue blade at the head of the bed
5. Placing oxygen and suction equipment at the bedside
6. Having intravenous equipment ready for insertion of an intravenous catheter
The correct answer is: 1, 2, 5, 6
The nurse has instructed the family of a client with Stroke (brain attack) who has homonymous
hemianopsia about measures to help the client overcome the deficit. Which of the following
statement suggests that the family understands the measures to use when caring for the client?
The correct answer is: “We need to remind him to turn his head to scan the lost visual field.”

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with
intraocular implantation. Which home care measures should the nurse include in the plan? Select all
that apply.
1. Avoid activities that require bending over.
2. Contact the surgeon if eye scratchiness occurs.
3. Place an eye shield on the surgical eye at bedtime.
4. Episodes of sudden severe pain in the eye are expected.
5. Contact the surgeon if a decrease in visual acuity occurs.
6. Take acetaminophen (Tylenol) for minor eye discomfort.
The correct answer is: 1, 3, 5, 6
A client recovering from a head injury is participating in care. The nurse determines that the client
understands measures to prevent elevations in intracranial pressure if the nurse observes the client
doing which activity?
The correct answer is: Exhaling during repositioning
A client is diagnosed with a disorder involving the inner ear. Which is the most common client
complaint associated with a disorder involving this part of the ear?
The correct answer is: Tinnitus
The MS client's nurse is educating him about corticosteroids. S/he has correctly understood which
of the following propositions.
The correct answer is: I should watch for side effects such as euphoria and insomnia while taking
this medication.
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the
nurse include in the plan of care?
The correct answer is: Eye medications will need to be administered for life.
Patient appears to the ER with diplopia and ptosis. Upon interview, he has maintenance medication
of Mestinon 1 tab of 35mg. As a nurse you know that with the medication, patient may have:
The correct answer is: Myasthenia Gravis
A patient with multiple sclerosis and a fresh baclofen prescription is being taught by the nurse. In
teaching the patient, which of the following statements should the nurse include?
The correct answer is: “Your skin may turn yellow as a result of this drug”.
During the early postoperative period, a client who has undergone a cataract extraction complains
of nausea and severe eye pain over the operative site. What should be the initial nursing action?
The correct answer is: Call the health care provider (HCP).
During the early postoperative period, a client who has undergone a Cataract Extraction complains
of nausea and severe eye pain over the operative site. What should be the nurse's initial nursing
action?
The correct answer is: Call the surgeon.
A client with Ménière’s disease is experiencing severe vertigo. Which instruction should the nurse
give to the client to assist in controlling the vertigo?
The correct answer is: Avoid sudden head movements.
The nurse is assessing the adaptation of a client to changes in functional status after a Stroke (brain
attack). Which of the following observation indicates to the nurse that the client is adapting most
successfully?
The correct answer is: Consistently uses adaptive equipment in dressing self
Patient Alexa is suffering from myasthenia gravis, she will be served lunch at 1200. Now that it is
1000, the patient is set to get Pyridostigmine. When should you provide this medicine to ensure that
the patient receives the most benefit?
The correct answer is: 1 hour before the patient eats (at 1100)
You're getting ready to assist the neurologist with the Tensilon test. Which antidote do you intend to
have on hand in the event of an emergency?
The correct answer is: Atropine