1 >>A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? ?
- (A) Immobilize the neck before the client is moved onto a stretcher.
- (B) Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
- (C) Place a cap over the client’s head.
- (D) Administer a sedative as ordered.
2 >>During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to: ?
- (A) use the pointed end of the reflex hammer when striking the Achilles tendon.
- (B) support the joint where the tendon is being tested.
- (C) tap the tendon slowly and softly
- (D) hold the reflex hammer tightly.
3 >>A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client’s plan of care? ?
- (A) Disturbed sensory perception (visual)
- (B) Self-care deficient: Dressing/grooming
- (C) Impaired verbal communication
- (D) Risk for injury
4 >>A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrateD. I can’t do anything without help!” This comment best supports which nursing diagnosis? ?
- (A) Anxiety
- (B) Powerlessness
- (C) Ineffective denial
- (D) Risk for disuse syndrome
5 >>For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: ?
- (A) prevent respiratory alkalosis.
- (B) lower arterial pH.
- (C) promote carbon dioxide elimination.
- (D) maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
6 >>Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? ?
- (A) Flexed position
- (B) Head tilt-chin lift
- (C) Jaw thrust maneuver
- (D) Modified head tilt-chin lift
7 >>The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client’s peripheral response to pain? ?
- (A) Sternal rub
- (B) Nail bed pressure
- (C) Pressure on the orbital rim
- (D) Squeezing of the sternocleidomastoid muscle
8 >>A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of: ?
- (A) Hypertension
- (B) Heart failure
- (C) Prosthetic valve replacement
- (D) Chronic obstructive pulmonary disorder
9 >>A male client is having a lumbar puncture performeD. The nurse would plan to place the client in which position? ?
- (A) Side-lying, with a pillow under the hip
- (B) Prone, with a pillow under the abdomen
- (C) Prone, in slight-Trendelenburg’s position
- (D) Side-lying, with the legs pulled up and head bent down onto chest.
10 >>The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? ?
- (A) Head mildline
- (B) Head turned to the side
- (C) Neck in neutral position
- (D) Head of bed elevated 30 to 45 degrees
11 >>A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: ?
- (A) Is clear and tests negative for glucose
- (B) Is grossly bloody in appearance and has a pH of 6
- (C) Clumps together on the dressing and has a pH of 7
- (D) Separates into concentric rings and test positive of glucose
12 >>A male client with a spinal cord injury is prone to experiencing automatic dysreflexiA. The nurse would avoid which of the following measures to minimize the risk of recurrence? ?
- (A) Strict adherence to a bowel retraining program
- (B) Keeping the linen wrinkle-free under the client
- (C) Preventing unnecessary pressure on the lower limbs
- (D) Limiting bladder catheterization to once every 12 hours
13 >>The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated? ?
- (A) Loosening restrictive clothing
- (B) Restraining the client’s limbs
- (C) Removing the pillow and raising padded side rails
- (D) Positioning the client to side, if possible, with the head flexed forward
14 >>The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: ?
- (A) The client has complete bilateral paralysis of the arms and legs.
- (B) The client has weakness on the right side of the body, including the face and tongue.
- (C) The client has lost the ability to move the right arm but is able to walk independently.
- (D) The client has lost the ability to move the right arm but is able to walk independently.
15 >>The client with a brain attack (stroke) has residual dysphagiA. When a diet order is initiated, the nurse avoids doing which of the following? ?
- (A) Giving the client thin liquids
- (B) Thickening liquids to the consistency of oatmeal
- (C) Placing food on the unaffected side of the mouth
- (D) Allowing plenty of time for chewing and swallowing
16 >>The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: ?
- (A) Gets angry with family if they interrupt a task
- (B) Experiences bouts of depression and irritability
- (C) Has difficulty with using modified feeding utensils
- (D) Consistently uses adaptive equipment in dressing self
17 >>Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasiA. Which of the following actions by the nurse would be least helpful to the client? ?
- (A) Speaking to the client at a slower rate
- (B) Allowing plenty of time for the client to respond
- (C) Completing the sentences that the client cannot finish
- (D) Looking directly at the client during attempts at speech
18 >>A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: ?
- (A) Getting too little exercise
- (B) Taking excess medication
- (C) Omitting doses of medication
- (D) Increasing intake of fatty foods
19 >>The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: ?
- (A) Eating large, well-balanced meals
- (B) Doing muscle-strengthening exercises
- (C) Doing all chores early in the day while less fatigued
- (D) Taking medications on time to maintain therapeutic blood levels
20 >>A male client with Bell’s palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is: ?
- (A) Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
- (B) Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia
- (C) Primary genetic in origin, triggered by exposure to meningitis
- (D) Primarily genetic in origin, triggered by exposure to neurotoxins