Adult Nursing II

I. Circle the most correct answer :

1. The client is placed on seizure precautions. Which of the following measures would be contraindicated?a) Encourage him to perform his own personal hygiene.b) Allow him to wear his own clothing.c) Assess oral temperature with a glass thermometer.d) Encourage him to be out of bed.

2. The nurse plans to teach the client about the computed tomography(CT) scan that will be done at noon the next day. Which of the following statements by the nurse would be most accurate?a) “You must shampoo your hair tonight to remove all oil and dirt”.

b) “You may drink fluids until about 8 AM. Then we will give you a cleansing enema”.

c) We will partially shave your head tonight so that electrodes can be securely attached to your scalp”.

d) “There is no special preparation necessary. You will need to hold your head very still during the examination”.

3. An electroencephalogram (EEG) is ordered for the client. What action should the nurse take when the client is served a breakfast consisting of a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee on the morning of the EEG?a) Remove all the food.b) Remove the coffee.c) Remove the toast, butter, and marmalade only.d) Substitute vegetable juice for the orange juice.

4. The nurse enters the client’s room as the client, who is sitting in a chair, begins to have a seizure. Which of the following actions should the nurse take first?a) Lift the client onto his bed.b) Ease the client to the floor.c) Restrain the client’s body movements.d) Insert any airway into the client’s mouth.

5. A priority goal for the client after the seizure has subsided is to:a) Monitor for an aura.b) Determine what the client was doing when the seizure began.c) Maintain a patent airway.d) Place the client in a position of comfort.

6. Which of the following observations would the nurse expect in the client after

a tonic-clonic (grand mal) seizure? The clienta) May be drowsy after the seizure.b) May be unable to move after the seizure.c) Will remember what triggered the seizure.d) Will be hypotensive.

7. The nurse plans to teach the client about prescribed phenytoin sodium therapy. It is important that the client understand that the medication must not be stopped suddenly because:a) A physical dependency on the drug develops over time.b) This can precipitate the development of status epilepticus.c) This would lead to a hypoglycemic reaction.d) Phenytoin is the only effective drug for tonic-clonic seizures.

8. The client tells the nurse that he is unclear about what an aura is. The nurse would correctly define an aura as:a) A postseizure state of amnesia.b) Hallucinations occurring during a seizure.c) A symptom that occurs just before a seizure.d) A feeling of relaxation as the seizure begins to subside.

9. Which of the following findings should suggest to the nurse that a client is having a typical reaction to long-term phenytoin sodium therapy? The clienta) Has gained considerable weight.b) Reports insomnia.c) Exhibits an excessive growth of his gum tissue.d) Says that he now needs to wear eyeglasses.

A 72 year old retired man experiences a thrombotic cerebrovascular accident (CVA) and is admitted to the hospital the diagnosis is a left CVA with flaccid hemiplegia of his right side.

10. Regular oral hygiene is an essential intervention for the client. Which of the following nursing measures would be inappropriate when providing oral hygiene?a) Placing the client on his back with a small pillow under his head.b) Keeping portable suctioning equipment at the bedside.c) Opening the client’s mouth with a padded tongue blade.d) Cleansing the client’s mouth and teeth with a toothbrush.

11. A priority assessment in the first 24 hours of admission for this client is assessment of:a) Risk factors for vascular disease.b) Pupil size and papillary response.c) Urinary elimination patterns.d) Health behaviors before the CVA.

12. The nurse is concerned about the possible development of plantar flexion. Which of the following measures has been found to be the most effective means of preventing plantar flexion in a stroke client?a) Placing the client’s feet against a firm footboard.b) Repositioning the client every 2 hours.c) Having the client wear ankle-high tennis shoes at intervals throughout the day.d) Massaging the client’s feet and ankles regularly.

13. For the client experiencing expressive aphasia, which of the following nursing actions would be most helpful in promoting communication?a) Speaking loudly.b) Using short sentences.c) Writing all directions so the client can read them.d) Correcting all of the client’s speech errors.

14. For the client with dysphasia, which of the following measures would be ineffective in decreasing the risk f aspiration while eating?a) maintaining an upright position.b) Restricting the diet to liquids until swallowing improves.c) Introducing foods on the unaffected side of the mouth.d) Keeping distractions to a minimum.

15. the CVA has caused homonymous hemianopia (blind in half of the visual field). Homonymous hemianopia would probably manifest itself in which of the following food-related behaviors?a) Increased preference for foods high in salt.b) Eating food on only half of the plate.c) Forgetting the names of foods.d) Inability to swallow liquids.

16. The nurse is preparing the client for discharge to home. Which of the following factors would most likely influence the client’s continuing progress in rehabilitation at home?a) The family’s ability to provide support to the client.b) The client’s ability to ambulate.c) The availability of a home health aide to care for the client.d) The frequency of follow-up visits with the physician.

A 67-year-old man is admitted to the hospital for a diagnostic workup for probable Parkinson’s disease.

17. When assessing the client, the nurse would anticipate which of the following signs and symptoms?a) Dry mouth.

b) Aphasia.c) An exaggerated sense of euphoria.d) A stiff, mask-like facial expression.

18. A priority nursing diagnosis category for this client is:a) Alteration in Nutrition.b) Lack of knowledge.c) Ineffective breathing pattern.d) Potential for injury.

19. The nurse observes that the client’s upper arm tremors disappear as he unbuttons his shirt. Which of the following statements would best guide the nurse when analyzing these observations about the client’s tremors?a) The tremors are probably psychological and can be controlled at will.b) The tremors sometimes disappear with purposeful and voluntary movements.c) The tremors often increase in severity when the client’s attention is diverted by some activity.d) There is no explanation for the observation, which is probably a chance occurrence.

20. To minimize the effects of hypokinesia, the client should be taught to schedule his most demanding physical activities.a) Early in the morning, when his energy level is high.b) To coincide with the peak action of drug therapy.c) Immediately after a rest period.d) When family members will be available.

21. The client is started on levodopa (L-dopa) therapy. The nurse would evaluate that the drug is exerting its desired effect when the client experiences an improvement in:a) Mood.b) Muscle rigidity.c) Appetite.d) *****ness.

A 38-year-old man is admitted to the emergency room after being found unconscious at the wheel of his car in the hospital parking lot.

22. The client has been positioned on his side. The nurse would anticipate that which of the following areas would be a pressure point in this position?a) Sacrum.b) Occiput.c) Ankles.d) Heels.

23. The nurse is assessing the client’s respiratory status. Which of the following

symptoms may be an early indicator of hypoxia in the unconscious client?a) Gyanosis.b) Decreased respirations.c) Restlessness.d) Hypotension.

24. The client is to receive 200 mL of tube feeding every 4 hours. The nurse checks the client’s gastric residual before administering the feeding and obtains 40 mL of gastric residual. What should the nurse do next?a) Withhold the tube feeding and notify the physician.b) Dispose of the residual and continue with the feeding.c) Delay feeding the client for 1 hour and then recheck the residual.d) Readminister the residual to the client and continue with the feeding.

25. Of the following actions the nurse could take when providing catheter care, which should have the highest priority?a) Cleansing the area around the urethral meatus.b) Clamping the catheter periodically to maintain muscle tone.c) Irrigating the catheter with several ounces of normal saline solution.d) Changing the location where the catheter is taped to the client’s leg.

A client is admitted to outpatient surgery for a cataract extraction on the right eye.

26. The client asks, “what does the lens of my eye do?” The nurse should explain that the lens of the eye.a) Produces aqueous humor.b) Holds the roods and cones.c) Focuses light rays onto the retina.d) Regulates the amount of light entering the eye.

27. A client with a cataract would most likely complain of which symptoms?a) Halos and rainbows around lights.b) Eye pain and irritation that worsens at night.c) Blurred and hazy vision.d) Eye strain and headache when doing close work.

28. Which of the following statements indicates the client has understood the instructions to follow at home after cataract surgery?a) “I may not watch television for 3 weeks”.b) “I should keep my protective eye shield in place at all times”.c) “I should not bend over to pick up objects from the floor”.d) “I can lift what I want”.

29. An essential aspect of the plan of care for the client after cataract removal

surgery would be to:a) Increase cardiac output.b) Prevent fluid volume excess.c) Maintain a darkened environment.d) Promote safety at home.

30. Which of the following activities would be appropriate for achieving the goal of decreasing intraocular pressure after eye surgery? The client will avoid:a) Lying supine.b) Coughing.c) Deep breathing.d) Ambulation.

31. After cataract removal surgery, the nurse teaches the client about activities that she can do at home. Which of the following activities would be contraindicated?a) Walking down the hall unassisted.b) Lying in bed on the nonoperative side.c) Performing isometric exercises.d) Bending over the sink to wash her hair.

A client is admitted through the emergency department with a diagnosis of detached retina in the right eye.

32. The client does not understand what happened to his eye. Which of the following explanations by the nurse would most accurately describe the pathology of retinal detachment?a) “A tear in the retina permits the escape of vitreous humor from the eye”.b) “The optic nerve is damaged when it is exposed to vitreous humor”.c) “The two layers of the retina separate, allowing fluid to enter between them”.

d) “Retinal injury produces inflammation and edema, which increase intraocular pressure”.

33. The client asks the nurse why his eyes have to be patched. The nurse’s reply should be based on the knowledge that eye patches serve to:a) Reduce rapid eye movements.b) Decrease the irritation of light entering the damaged eye.c) Protect the injured eye from infection.d) Rest the eyes to promote healing.

34. Which of the following clinical manifestations commonly occur in retinal detachment?a) Sudden, severe eye pain and colored halos around lights.b) Inability to move the eye and loss of light accommodation.c) A tearing sensation and increased lacrimation.d) Flashing lights and visual field loss.

35. Scleral buckling, a procedure used to treat retinal detachment, involves:a) Removing the torn segment of the retina and stitching down the remaining segment.b) Replacing the torn segment of the retina with a strip of retina from a donor.c) Stitching the retina firmly to the optic nerve to give it support.d) Creating a splint to hold the retina together until a scar can form and seal off the tear.

A client has been treated for chronic open-angle glaucoma for 5 years

36. The client asks the clinic nurse, “How does glaucoma damage my eyesight?” the nurse’s reply should be based on the knowledge that chronic open-angle glaucoma:a) Results from chronic eye inflammation.b) Causes increased intraocular pressure.c) Leads to detachment of the retina.d) Is caused by decreased blood flow to the retina.

37. If the client experienced any symptom of glaucoma, it would most likely be:a) Eye pain.b) Excessive lacrimation.c) Colored light flashes.d) Decreasing peripheral vision.

38. The nurse reevaluates the client’s ability to instill eye drops correctly. The client correctly demonstrates the procedure when he:a) Blows his nose immediately after administering the eye drops.b) Positions himself on his right side to instill the eye drops.c) Instills the eye drops into the conjunctival sac.d) Wipes the tip of the eye drop applicator with a disposable tissue.

39. Miotics are frequently used in the basic treatment of glaucoma. The nurse should understand that miotics work by:a) Paralyzing ciliary muscles.b) Constricting intraocular vessels.c) Constricting the pupil.d) Relaxing ciliary muscles.

40. The most effective health-promotion measure related to glaucoma that the nurse can teach clients is:a) Promote treatment of all eye infections.b) Avoidance of extended-wear contact lenses by older people.c) Annual intraocular pressure measurements for people older than 40 years.d) Appropriate blood pressure control.

41. Which of the following information should the nurse give the client when preparing him for tonometry?a) Oral pain medication will be given before the procedure.b) It is a painless procedure with no side effects.c) Blurred or double vision may occur after the procedure.d) Medication will be given to dilate the pupils before the procedure.

42. The nurse learns that the client uses timololmaleate (Timoptic) eye drops. The nurse would understand that this B-adrenergic blocker helps control glaucoma by:a) Constricting the pupils.b) Dilating the canals of Schlemm.c) Reducing aqueous humor formation.d) Improving the ability of the ciliary muscle to contract.

43. The client with glaucoma is scheduled for a minor surgical procedure. Which of the following orders would require clarification or correction before the nurse would carry it out:a) Administer morphine sulfate.b) Administer atropine sulfate.c) Teach deep breathing exercises.d) Teach leg exercises.

44. The client asks when he can stop taking the eye medication for his chronic open-angle glaucoma. The nurse should tell the client that he:a) Can stop using the eye drops only when his vision improves.b) Needs to use the eye drops only when he has symptoms.c) Can discontinue the eye drops after 2 months of normal eye examinations.d) Must use the eye medication for the rest of his life.

45. A client has been diagnosed with an acute episode of narrow-angle glaucoma. The nurse plans the client’s nursing care with the understanding that acute narrow-angle glaucoma:a) Frequently resolves without treatment.b) Is typically treated with sustained bed rest.c) Is a medical emergency that can rapidly led to blindness.d) Is most commonly treated with steroid therapy.

M.T. Health AssessmentI. Circle the most correct answer:

1. You obtain subjective information by:a. Observing the patient.

b. Performing a physical.c. Checking laboratory reports.

d. Listening to the patient’s de******ions of his symptoms.

2. Your patient is experiencing abdominal pain in the right upper quadrant. Which area of the abdomen should you palpate last?

a. Left upper quadrant.b. Right upper quadrant.

c. Left lower quadrant.d. Right lower quadrant.

3. The mnemonic device RQRST stands for:a. Practices, quantity, region source, and tone.

b. Provoking or palliative factors, quality or quantity, region or radiation, severity, and timing.

c. Provoking factors, quality or quantity, region or radiation, source and tone.d. Practices, quantity, region, severity, and time.

4. Which of the following should not be considered when assessing an elderly patient?

a. An elderly patient may have one or more chronic disease.b. Any new illness or physical problem is likely to cause a change in mental

status.c. Most elderly patients have trouble hearing, so you’ll need to speak loudly

obtaining the health history.d. The elderly patient may have slowed intestinal motility and weakened bones

and joints.

5. Resonant percussion sounds are typically heard over which area?a. Over a solid area, as in pleural effusion.

b. Over a consolidation, as in a telectasis.c. Over normal lung tissue.

d. Over an area of air collection, as in a gastric air bubble.

6. The normal adults normally breathe at a rate of:a. 12 – 20 breaths / minute.b. 15 – 25 breaths / minute.c. 22 – 30 breaths / minute.d. 25 – 32 breaths / minute.

7. Which assessment technique allows you to assess structures as does as 3" (7.6 cm)?

a. Inspection.b. Palpation.

c. Percussion.

d. Auscultation.

8. Wheezes:a. Are high-pitched, musical, creaking breath sounds.

b. Can be cleared by coughing.c. Can only be heard with a stethoscope.

d. Occur on inspiration only.

9. A barking cough in children is characteristic of:a. Asthma.

b. Bronchitis.c. Cystic fibrosis.

d. Croup