Archive for October 2020

Parents of a preschool child ask the nurse, "Should we set rules for our child as part of a discipline plan?" Which is an accurate response by the nurse?

Parents of a preschool child ask the nurse, "Should we set rules for our child as part of a discipline plan?" Which is an accurate response by the nurse?



a. "It is best to delay the punishment if a rule is broken."

b. "The child is too young for rules. At this age, unrestricted freedom is best."

c. "It is best to set the rules and reason with the child when the rules are broken."

d. "Set clear and reasonable rules and expect the same behavior regardless of the circumstances."



Asnwer: D. "Set clear and reasonable rules and expect the same behavior regardless of the circumstance."

A foster parent is talking to the nurse about the health care needs for the child who has been placed in the parent's care. Which statement best describes the health care needs of foster children?

A foster parent is talking to the nurse about the health care needs for the child who has been placed in the parent's care. Which statement best describes the health care needs of foster children?



a. Foster children always come from abusive households and are emotionally fragile.

b. Foster children tend to have a higher than normal incidence of acute and chronic health problems.

c. Foster children are usually born prematurely and require technologically advanced health care.

d. Foster children will not stay in the home for an extended period, so health care needs are not as important as emotional fulfillment.



Asnwer: B. Foster children tend to have a higher than normal incidence of acute and chronic health problems.

A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?



a. It is best to wait until the child asks about it.

b. The best time to tell the child is between the ages of 7 and 10 years.

c. It is not necessary to tell a child who was adopted so young.

d. Telling the child is an important aspect of their parental responsibilities.



Asnwer: D. Telling the child is an important aspect of their parental responsibilities.

A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as what?

A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as what?



a. Indicative of maladjustment

b. A common reaction to divorce

c. Suggestive of a lack of adequate parenting

d. An unusual response that indicates a need for referral



Asnwer: B. A common reaction to divorce.

A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, "I want to go back to work, but I don't want Eric to suffer because I'll have less time with him." Which is the nurse's most appropriate answer?

A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, "I want to go back to work, but I don't want Eric to suffer because I'll have less time with him." Which is the nurse's most appropriate answer?



a. "I'm sure he'll be fine if you get a good babysitter."

b. "You will need to stay home until Eric starts school."

c. "Let's talk about the child care options that will be best for Eric."

d. "You should go back to work so Eric will get used to being with others."



Asnwer: C. "Let's talk about the child care options that will be best for Eric."

When discussing discipline with the mother of a 4-year-old child, which should the nurse include?

When discussing discipline with the mother of a 4-year-old child, which should the nurse include?



a. Parental control should be consistent.

b. Withdrawal of love and approval is effective at this age.

c. Children as young as 4 years rarely need to be disciplined.

d. One should expect rules to be followed rigidly and unquestioningly.



Asnwer: A. Parental control should be consistent.

Which is a consequence of the physical punishment of children, such as spanking?

Which is a consequence of the physical punishment of children, such as spanking?



a. The psychologic impact is usually minimal.

b. The child's development of reasoning increases.

c. Children rarely become accustomed to spanking.

d. Misbehavior is likely to occur when parents are not present.



Asnwer: D. Misbehavior is likely to occur when parents are not present.

The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?

 The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?



a. Send the child to his or her room if the child has one.

b. A general rule for length of time is 1 hour per year of age.

c. Select an area that is safe and nonstimulating, such as a hallway.

d. If the child cries, refuses, or is more disruptive, try another approach.



Asnwer: C. Select an area that is safe and nonstimulating, such as a hallway.

Which is an accurate description of homosexual (or gay-lesbian) families?

Which is an accurate description of homosexual (or gay-lesbian) families?



a. A nurturing environment is lacking.

b. The children become homosexual like their parents.

c. The stability needed to raise healthy children is lacking.

d. The quality of parenting is equivalent to that of nongay parents.



Asnwer: D. The quality of parenting is equivalent to that of nongay parents.

The nurse is teaching a group of new nursing graduates about identifiable qualities of strong families that help them function effectively. Which quality should be included in the teaching?

The nurse is teaching a group of new nursing graduates about identifiable qualities of strong families that help them function effectively. Which quality should be included in the teaching?



a. Lack of congruence among family members

b. Clear set of family values, rules, and beliefs

c. Adoption of one coping strategy that always promotes positive functioning in dealing with life events

d. Sense of commitment toward growth of individual family members as opposed to that of the family unit



Asnwer: B. Clear set of family values, rules, and beliefs.

A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?

A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?



a. The parent is trying to feed the child only what the child likes most.

b. Hispanics believe the "evil eye" enters when a person gets cold.

c. The parent is trying to restore normal balance through appropriate "hot" remedies.

d. Hispanics believe an innate energy called chi is strengthened by eating soup.



Asnwer: C. The parent is trying to restore normal balance through appropriate "hot" remedies.

How is family systems theory best described?

How is family systems theory best described?



a. The family is viewed as the sum of individual members.

b. A change in one family member cannot create a change in other members.

c. Individual family members are readily identified as the source of a problem.

d. When the family system is disrupted, change can occur at any point in the system.



Asnwer: D. When the family system is disrupted, change can occur at any point in the system.

The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal?

The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal?



a. Adapt, as necessary, ethnic practices to health needs.

b. Attempt, in a nonjudgmental way, to change ethnic beliefs.

c. Encourage continuation of ethnic practices in the hospital setting.

d. Strive to keep ethnic background from influencing health needs.



Asnwer: A. Adapt, as necessary, ethnic practices to health needs.

The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child's mother says she has rubbed the edge of a coin on her child's oiled skin. The nurse should recognize this as what?

The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child's mother says she has rubbed the edge of a coin on her child's oiled skin. The nurse should recognize this as what?



a. Child abuse

b. Cultural practice to rid the body of disease

c. Cultural practice to treat enuresis or temper tantrums

d. Child discipline measure common in the Vietnamese culture



Asnwer: B. Cultural practice to ride the body of disease.

Children are taught the values of their culture through observation and feedback relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that which factor may be culturally determined?

Children are taught the values of their culture through observation and feedback relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that which factor may be culturally determined?


a. Ethnicity

b. Racial variation

c. Status

d. Geographic boundaries


Asnwer: C. Status

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?


a) Refusal to lie flat

b) Forceful coughing

c) High-pitched noise on inhalation

d) Wheezing between coughs



Asnwer: High-pitched noise on inhalation

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next?

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next?


a) Encourage the patient to cough forcefully.

b) Prepare the patient for a bronchoscopy.

c) Insert a nasopharyngeal airway.

d) Insert an oropharyngeal airway.


Asnwer: Encourage the patient to cough forcefully.

A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed?

A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed?


a) "I need to avoid using perfumes and scented soaps when I'm going outside."

b) "If a bee comes near me, I should stay still."

c) "I should always wear something on my feet when I'm outside."

d) "Brightly colored clothes help to ward off bees."



Asnwer: "Brightly colored clothes help to ward off bees."

A 40-year-old female patient is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which of the following is the nurse's best course of action?

A 40-year-old female patient is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which of the following is the nurse's best course of action?


a) Asking the patient how she obtained the various bruises

b) Providing the patient with information about local shelters

c) Contacting the local police and report the suspected abuse

d) Asking the patient if someone is abusing her



Asnwer: Asking the patient if someone is abusing her

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?


a) Ask the ambulance team for information about the client's family to ensure informed consent.

b) Document the client's condition and absence of friends or family for obtaining consent to treatment.

c) Explain to the client that care is going to be provided because he is seriously ill.

d) Check the client's record for the name of a family member to call to allow care to be provided.



Asnwer: Document the client's condition and absence of friends or family for obtaining consent to treatment.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?


a) Dilution with water or milk

b) Administration of activated charcoal

c) Induced vomiting

d) Gastric lavage



Asnwer: Induced vomiting

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?


a) Stage IV

b) Stage II

c) Stage I

d) Stage III



Asnwer: Stage III

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?


a) Administer an analgesic as ordered.

b) Apply a heat lamp.

c) Elevate the legs.

d) Massage the extremities.



Asnwer: Administer an analgesic as ordered.

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?


a) Head tilt-chin lift

b) Abdominal thrust

c) Seldinger

d) Jaw-thrust


Asnwer: Jaw-thrust

Which of the following guidelines is appropriate to helping family members cope with sudden death?

Which of the following guidelines is appropriate to helping family members cope with sudden death?


a) Provide details of the factors attendant to the sudden death

b) Inform the family that the patient has passed on

c) Obtain orders for sedation for family members

d) Show acceptance of the body by touching it, giving the family permission to touch



Asnwer: Show acceptance of the body by touching it, giving the family permission to touch

The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following?

The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following?


a) "Do you want to discuss antipregnancy measures?"

b) "Do you want the phone number for the National Sexual Assault Hotline?"

c) "Would you like us to complete HIV testing?"

d) "Let's talk about this; do you want me to call a support person?"



Asnwer: "Let's talk about this; do you want me to call a support person?"

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following?

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? 


a) Decreasing blood pressure

b) Increasing urine volume

c) Increasing heart rate

d) Delayed capillary refill

e) Cool, moist skin



Asnwer: 


• Decreasing blood pressure

• Cool, moist skin

• Increasing heart rate

• Delayed capillary refill

An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse?

An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse?



a) Ask them to sit in the waiting room until she can spend time alone with them.

b) Speak to one parent at a time in a private setting so that each can ventilate feelings of loss without upsetting the other.

c) Speak to both parents together and encourage them to support each other and express their emotions freely.

d) Ask the emergency physician to medicate the parents so that they can handle their child's unexpected death quietly and without hysteria.



Asnwer: Speak to both parents together and encourage them to support each other and express their emotions freely.

Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is:

Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is:


a) orthostatic hypotension.

b) a prolonged partial thromboplastin time (PTT).

c) diminished breath sounds.

d) a recent history of warfarin (Coumadin) usage.


Asnwer: orthostatic hypotension.

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following?

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following?


a) Head injury

b) Hyponatremia

c) Hypothermia

d) Pulmonary edema



Asnwer: Pulmonary edema

A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion?

A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion?


a) Denuded skin

b) Tearing away of tissue from supporting structures

c) Incision of the skin with well-defined edges, usually longer than deep

d) Skin tear with irregular edges and vein bridging



Asnwer: Tearing away of tissue from supporting structures

A client is brought to the emergency department with suspected genitourinary injury. The nurse prepares the client for insertion of an indwelling urinary catheter for bladder decompression and urine output monitoring. The nurse reviews the client's medical record to ensure that which of the following has been completed?

A client is brought to the emergency department with suspected genitourinary injury. The nurse prepares the client for insertion of an indwelling urinary catheter for bladder decompression and urine output monitoring. The nurse reviews the client's medical record to ensure that which of the following has been completed?


a) Rectal examination

b) Computed tomography scan

c) Diagnostic peritoneal lavage

d) Bladder ultrasound



Asnwer: Rectal examination

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings?

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings?



a) Hand that is firm to palpation

b) Hand that is insensitive to touch

c) Hand that is cool with pale nailbeds

d) Hand that appears pink with some white spotting



Asnwer: Hand that is insensitive to touch

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?


a) Immobilize the area to control blood loss.

b) Elevate the injured part.

c) Apply firm pressure over the involved area or artery.

d) Apply a tourniquet.



Asnwer: Apply firm pressure over the involved area or artery.

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure?

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? 


a) Facilitate removal of an upper airway obstruction

b) Allow connection to a manual resuscitation bag

c) Decrease tracheobronchial secretions

d) Establish an airway for ventilation

e) Prevent aspiration into the lungs



Asnwer: 


• Establish an airway for ventilation

• Allow connection to a manual resuscitation bag

• Prevent aspiration into the lungs

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure?

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? 



a) Decrease tracheobronchial secretions

b) Prevent aspiration into the lungs

c) Facilitate removal of an upper airway obstruction

d) Establish an airway for ventilation

e) Allow connection to a manual resuscitation bag


Asnwer: 


• Allow connection to a manual resuscitation bag

• Prevent aspiration into the lungs

• Establish an airway for ventilation

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess?

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? 


a) Visual hallucinations

b) Hypoactive reflexes

c) Clonus

d) Hypothermia

e) Tachycardia



Asnwer: 


• Tachycardia

• Visual hallucinations

• Clonus

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level?

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level?



a) 24 hours from the last dose

b) 8 p.m.

c) 11:00 p.m.

d) Stat



Asnwer: 11:00 p.m.

The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after?

The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after?


a) Assess peripheral pulses.

b) Administer cimetidine (Tagamet).

c) Administer diphenhydramine (Benadryl).

d) Measure the circumference of the arm.



Asnwer: Measure the circumference of the arm.

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed?

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed?


a) Notify the rape crisis team.

b) Notify the client's family.

c) Notify the physician of her findings immediately.

d) Attend to the client's physiological needs.



Asnwer: Attend to the client's physiological needs.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided?

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided?



a) Record a history of the event, using the patient's own words.

b) Ensure that the police are present when the examination is performed.

c) Assess and document any bruises and lacerations.

d) Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

e) Have the patient shower or wash the perineal area before the examination.


Asnwer: 

• Record a history of the event, using the patient's own words.

• Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

• Assess and document any bruises and lacerations.

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?


a) Make an incision and suck the venom out.

b) Have the patient lie down and place the arm below the level of the heart.

c) Apply ice to the area.

d) Apply a tourniquet to the arm above the bite.



Asnwer: Have the patient lie down and place the arm below the level of the heart.

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate?

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? 



a) Patient with laryngeal edema secondary to anaphylaxis

b) Patient with a lumbar spine injury

c) Patient with extensive facial trauma

d) Patient with an obstructed larynx

e) Patient who is bleeding from the chest



• Patient with laryngeal edema secondary to anaphylaxis

• Patient with an obstructed larynx

• Patient with extensive facial trauma

Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following?

Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following?


a) Large intestines

b) Spleen

c) Gallbladder

d) Liver



Asnwer: Spleen

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?


a) Just below the tip of the patient's nose

b) At the level of the patient's epiglottis

c) Directly in front of the patient's teeth

d) Approximately at the patient's lips



Asnwer: Approximately at the patient's lips

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?


a) Establishing a patent airway

b) Assessing neurologic function

c) Applying electrocardiogram electrodes

d) Providing adequate ventilation



Asnwer: Applying electrocardiogram electrodes

A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury?

A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury?


a) Urinalysis

b) Serum amylase

c) White blood cell count

d) Hemoglobin and hematocrit



Asnwer: Serum amylase


A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?


a) Administration of activated charcoal

b) Dilution with water or milk

c) Induced vomiting

d) Gastric lavage



Asnwer: Induced vomiting

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?


a) Lethargy

b) Lack of perspiration

c) Seizures

d) Hypotension



Asnwer: Seizures

A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation?

A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation?


a) Do nothing because the nurse has no proof of wrongdoing.

b) Report the suspicion to the local agency on aging within 24 hours of the visit.

c) Try to convince the client to report the problem.

d) Monitor the situation during subsequent visits.



Asnwer: Report the suspicion to the local agency on aging within 24 hours of the visit.

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma?

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma?


a) Gunshot wound

b) Fall from a roof

c) Knife-stab wound

d) Motor-vehicle crash

e) Being struck with a baseball bat



Asnwer: 


• Gunshot wound

• Knife-stab wound

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?


a) Diving in an ocean

b) Working in a chemical plant

c) Running a race in hot humid weather

d) Swimming in a lake



Asnwer: Diving in an ocean

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?


a) Huntington disease

b) Parkinson's disease

c) Creutzfeldt-Jakob disease

d) Multiple sclerosis (MS)



Asnwer: Multiple sclerosis (MS)

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?


a) 1 hour after the antibiotic has infused and daily for 7 days

b) 2 hours prior to the administration of antibiotics for 7 days

c) It can be administered every 6 hours for 10 days.

d) 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days



Asnwer: 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?



a) Hyporeflexia and weakness of the lower extremities

b) Ptosis and diplopia

c) Facial distortion and pain

d) Fatigue and depression



Asnwer: Facial distortion and pain

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?


a) Encourage the client to close his eyes.

b) Alternatively patch one eye every 2 hours.

c) Instill artificial tears.

d) Turn out the lights in the room.


Asnwer: Alternatively patch one eye every 2 hours.

A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?

A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?


a) Red blood cells present in the CSF

b) Glucose in the CSF

c) White blood cells in the CSF

d) Elevated protein levels in the CSF



Asnwer: Elevated protein levels in the CSF

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?


a) Place the patient in the supine position.

b) Administer atropine to control the side effects of edrophonium.

c) Call the rapid response team because the patient is preparing to arrest.

d) Administer diphenhydramine (Benadryl) for the allergic reaction.



Asnwer: Administer atropine to control the side effects of edrophonium.

The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education?

The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education?


a) "The exercises should be completed quickly to reduce fatigue."

b) "I should participate in non-weight-bearing exercises."

c) "I will take hot tub baths to decrease spasms."

d) "I will stretch daily as directed by the physical therapist."



Asnwer: "I will stretch daily as directed by the physical therapist."

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?


a) Acts as chemical messenger

b) Carries message to the next nerve cell

c) Speeds nerve impulse transmission

d) Represents building block of nervous system



Asnwer: Speeds nerve impulse transmission

A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?

A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?


a) Placement of a feeding tube

b) Placement of a urinary catheter

c) Placement of a tracheostomy tube

d) Placement of a colostomy tube



Asnwer: Placement of a feeding tube

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?


a) Wernicke's abscess

b) Frontal lobe abscess

c) Temporal lobe abscess

d) Cerebellar abscess



Asnwer: Cerebellar abscess

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?


a) Acts as chemical messenger

b) Represents building block of nervous system

c) Speeds nerve impulse transmission

d) Carries message to the next nerve cell



Asnwer: Speeds nerve impulse transmission

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?


a) The client will take the seizure medication at the same time daily.

b) The client will post emergency numbers on the refrigerator for ease of obtaining.

c) The client will remain free of injury if a seizure does occur.

d) The client will verbalize an understanding of feelings that preempt seizure activity.



Asnwer: The client will remain free of injury if a seizure does occur.

A patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for

A patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for


a) hypoxia.

b) renal insufficiency.

c) mood changes and fluid and electrolyte alterations.

d) leukopenia and cardiac toxicity.



Asnwer: leukopenia and cardiac toxicity.

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?


a) Assess the respiratory rate and oxygen saturation.

b) Listen to the bowel sounds.

c) Assess the blood pressure and heart rate.

d) Assess the peripheral pulses.



Asnwer: Assess the blood pressure and heart rate.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?


a) Trigeminal neuralgia

b) Migraine headache

c) Bell's palsy

d) Angina pectoris



Answer: Trigeminal neuralgia

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at


a) controlling seizures and increased intracranial pressure.

b) preventing renal insufficiency.

c) preventing muscular atrophy.

d) maintaining hemodynamic stability and adequate cardiac output.



Answer: controlling seizures and increased intracranial pressure.

A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has?

A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has?


a) Benign

b) Primary progressive

c) Relapsing-remitting (RR)

d) Disabling



Answer: Relapsing-remitting (RR)

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?


a) "Have you experienced any ptosis in the last few weeks?"

b) "Have you had difficulty with urination in the last 6 weeks?"

c) "Have you experienced any viral infections in the last month?"

d) "Have you developed any new allergies in the last year?"



Answer: "Have you experienced any viral infections in the last month?"

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?


a) There should not be a problem, since the medication was only delayed by about 2 hours.

b) The patient will require a double dose prior to lunch.

c) The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

d) The patient will go into cardiac arrest.



Answer: The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?


a) "I was taking a bath."

b) "I was brushing my teeth."

c) "I was sitting at home watching television."

d) "I was putting my shoes on."



Answer: "I was brushing my teeth."

Within the acute care facility where you practice nursing, you have cared for hundreds of clients who have suffered neurologic deficits from various causes, including cerebrovascular accident and closed head injury. While caring for these clients, what was an important nursing goal that motivated you to offer the best care possible?

Within the acute care facility where you practice nursing, you have cared for hundreds of clients who have suffered neurologic deficits from various causes, including cerebrovascular accident and closed head injury. While caring for these clients, what was an important nursing goal that motivated you to offer the best care possible?


a) Prevent complications, which may interfere with recovering function.

b) Prevent infection.

c) Prevent falls.

d) Prevent choking.



Answer: Prevent complications, which may interfere with recovering function.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?


a) Lung auscultation and measurement of vital capacity and tidal volume

b) Evaluation of pain and discomfort

c) Evaluation of nutritional status and metabolic state

d) Evaluation for signs and symptoms of increased intracranial pressure (ICP)



Answer: Lung auscultation and measurement of vital capacity and tidal volume

Stephen Oswald, a 68-year-old retired salesman, was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how Stephen reported a severe headache and then was unable to talk or move his right arm and leg. After diagnostics are completed and Mr. Oswald is admitted to the hospital, when would you expect basic rehabilitation to begin?

Stephen Oswald, a 68-year-old retired salesman, was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how Stephen reported a severe headache and then was unable to talk or move his right arm and leg. After diagnostics are completed and Mr. Oswald is admitted to the hospital, when would you expect basic rehabilitation to begin?


a) Two to 3 days

b) Immediately

c) Upon transfer to a rehabilitation unit

d) After 1 week



Answer: Immediately

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?


a) Represents building block of nervous system

b) Speeds nerve impulse transmission

c) Carries message to the next nerve cell

d) Acts as chemical messenger



Answer: Speeds nerve impulse transmission

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?


a) The client arranges a community service to deliver meals.

b) The client uses a mechanical lift to climb steps.

c) The client ambulates with the assistance of one.

d) The client grasps the affected arm at the wrist and raises it.



Answer: The client grasps the affected arm at the wrist and raises it.

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?


a) Muscle weakness and hyporeflexia of the lower extremities

b) Ptosis and muscle weakness of upper extremities

c) Hyporeflexia and skin rash

d) Fever and cough



Answer: Muscle weakness and hyporeflexia of the lower extremities

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?


a) Neurovascular system

b) Endocrine system

c) Cardiovascular system

d) Respiratory system



Answer: Neurovascular system

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms?

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms?



a) Allow the patient adequate time to perform exercises

b) Apply warm compresses to the affected areas.

c) Demonstrate daily muscle stretching exercises.

d) Have the patient take a hot tub bath to allow muscle relaxation.

e) Assist with a rigorous exercise program to prevent contractures.



• Demonstrate daily muscle stretching exercises.

• Apply warm compresses to the affected areas.

• Allow the patient adequate time to perform exercises

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?


a) Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

b) After administration of the medication, there will be no change in the status of the ptosis or facial weakness.

c) Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms.

d) The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon.



Answer: Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A patient has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the patient was complaining of neck stiffness earlier in the day. What action should the nurse do first?

A patient has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the patient was complaining of neck stiffness earlier in the day. What action should the nurse do first?


a) Administer prescribed antibiotics.

b) Ensure the family receives prophylaxis antibiotic treatment.

c) Initiate isolation precautions.

d) Apply a cooling blanket.



Answer: Initiate isolation precautions.

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?


a) Suggest applying cool compresses on the face several times a day to tighten the muscles.

b) Inform the patient that the muscle function will return as soon as the virus dissipates.

c) Tell the patient to smile every 4 hours.

d) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.



Answer: Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms?

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms?



a) Have the patient take a hot tub bath to allow muscle relaxation.

b) Assist with a rigorous exercise program to prevent contractures.

c) Demonstrate daily muscle stretching exercises.

d) Allow the patient adequate time to perform exercises

e) Apply warm compresses to the affected areas.



• Allow the patient adequate time to perform exercises

• Demonstrate daily muscle stretching exercises.

• Apply warm compresses to the affected areas.

The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse?

The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse?


a) "Don't worry; your child will be fine."

b) "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

c) "Once Guillain-Barré syndrome progresses to the diaphragm there is a significant decrease in surviving."

d) "It's too early to give a prognosis."



Answer: "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?


a) Within 72 hours after exposure

b) Within 24 hours after exposure

c) Within 48 hours after exposure

d) Therapy is not necessary prophylactically and should only be used if the person develops symptoms.



Answer: Within 24 hours after exposure

The patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for

The patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for




a) signs and symptoms of cardiac insufficiency.

b) renal complications related to acyclovir therapy.

c) signs of improvement in the patient's condition.

d) signs of relapse.



Answer: renal complications related to acyclovir therapy.

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?


a) Equipment to maintain infection control precautions

b) Extra lighting

c) Nasogastric tubing

d) IV tensilon



Answer: Equipment to maintain infection control precautions

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?



a) Elevated blood pressure


b) Decreased level of consciousness (LOC)


c) Increased urine output


d) Decreased heart rate



Answer: Increased urine output

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?



a) Provide a high-fat diet.


b) Include dry or crisp foods and chewy meats.


c) Always serve hot or tepid foods.


d) Provide thickened commercial beverages and fortified cooked cereals.



Answer: Provide thickened commercial beverages and fortified cooked cereals.

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?



a) 5:30 p.m.


b) 3:00 p.m.


c) 4:00 p.m.


d) 2:30 p.m.



Answer: 4:00 p.m.

A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?

A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?



a) Form words that are understandable


b) Speak at all


c) Form words that are understandable or comprehend the spoken word


d) Comprehend the spoken word



Answer: Form words that are understandable or comprehend the spoken word

Which of the following statements reflect nursing management of the patient with expressive aphasia?

Which of the following statements reflect nursing management of the patient with expressive aphasia?



a) Frequently reorient the patient to time, place, and situation


b) Speak clearly to the patient in simple sentences, use gestures or pictures when able


c) Speak slowly and clearly to assist the patient in forming the sounds


d) Encourage the patient to repeat sounds of the alphabet



Answer: Encourage the patient to repeat sounds of the alphabet

A 73-year-old client is visiting the neurologist. The client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?

A 73-year-old client is visiting the neurologist. The client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?



a) Atherosclerotic plaque


b) TIA


c) Diplopia


d) Bruit



Answer: Bruit

Which of the following is accurate regarding a hemorrhagic stroke?

Which of the following is accurate regarding a hemorrhagic stroke?



a) It is caused by a large-artery thrombosis.


b) One of the main presenting symptoms is numbness or weakness of the face.


c) Main presenting symptom is an "exploding headache."


d) Functional recovery usually plateaus at 6 months.



Answer: Main presenting symptom is an "exploding headache."

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?



a) Cerebral aneurysm


b) Cardiogenic emboli


c) Large artery thrombosis


d) Small artery thrombosis


Answer: Cerebral aneurysm

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?



a) Left-sided cerebrovascular accident (CVA)


b) Completed Stroke


c) Transient ischemic attack (TIA)


d) Right-sided cerebrovascular accident (CVA)



Answer: Left-sided cerebrovascular accident (CVA)

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:



a) Footdrop and external hip rotation


b) Severe headache and early change in level of consciousness


c) Confusion or change in mental status


d) Weakness on one side of the body and difficulty with speech



Answer: Severe headache and early change in level of consciousness

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:



a) Dyslipidemia


b) Obesity


c) Hypertension


d) Smoking



Answer: Hypertension

A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following?

A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following?



a) Ticlodipine (Ticlid)


b) Dipyridamole (Persantine)


c) Clopidogrel (Plavix)


d) Aspirin



Answer: Aspirin

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?



a) Pregabalin (Lyrica)


b) Diphenhydramine (Benadryl)


c) Heparin


d) Lioresal (Baclofen)



Answer: Lioresal (Baclofen)

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?



a) Limited attention span and forgetfulness


b) Visual agnosia


c) Auditory agnosia


d) Lack of deep tendon reflexes



Answer: Lack of deep tendon reflexes

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?



a) Maintaining the client in a quiet environment


b) Positioning the client to prevent airway obstruction


c) Keeping the client in one position to decrease bleeding


d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess



Answer: Keeping the client in one position to decrease bleeding

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes?

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes?



a) Oropharyngeal suctioning as needed.


b) Kepprais ordered for treatment of focal seizures.


c) A unit of fresh frozen plasma is infusing.


d) Neurological checks are ordered every 2 hours.



Answer: A unit of fresh frozen plasma is infusing.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms?

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms?



a) Hypertension


b) Cardiac disease


c) Diabetes insipidus


d) Impaired cerebral circulation



Answer: Impaired cerebral circulation

The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient?

The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient?



a) Allowing ample time to eat


b) Assisting the patient with meals


c) Testing the gag reflex prior to offering food or fluids


d) Placing food on the affected side of mouth



Answer: Placing food on the affected side of mouth

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?



a) Take the client's blood pressure.


b) Ask the client if he has a headache.


c) Ask the client if he has trouble breathing.


d) Place antiembolism stockings on the client.



Answer: Ask the client if he has trouble breathing.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?



a) Left-sided cerebrovascular accident (CVA)


b) Right-sided cerebrovascular accident (CVA)


c) Transient ischemic attack (TIA)


d) Completed Stroke



Answer: Left-sided cerebrovascular accident (CVA)

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:



a) Footdrop and external hip rotation


b) Severe headache and early change in level of consciousness


c) Weakness on one side of the body and difficulty with speech


d) Confusion or change in mental status



Answer: Severe headache and early change in level of consciousness

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?



a) Maintaining the client in a quiet environment


b) Keeping the client in one position to decrease bleeding


c) Positioning the client to prevent airway obstruction


d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess



Answer: Keeping the client in one position to decrease bleeding

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?



a) Footdrop and external hip rotation


b) Vomiting and seizures


c) Severe headache and early change in level of consciousness


d) Weakness on one side of the body and difficulty with speech



Answer: Weakness on one side of the body and difficulty with speech

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?



a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."


b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing."


c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."


d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."



Answer: "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."


A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?



a) Cerebral aneurysm


b) Transient ischemic attack


c) Left-sided stroke


d) Right-sided stroke



Answer: Transient ischemic attack

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken?

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken?



a) Reposition the tray and plate.


b) Perform a vision field assessment.


c) Know this is a normal finding for CVA.


d) Assist the client with feeding.



Answer: Perform a vision field assessment.

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?



a) She is not within the treatment time window.


b) She had surgery 6 weeks ago.


c) She is taking digoxin.


d) She is taking coumadin.



Answer: She is taking coumadin.

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?



a) Blood pressure (BP): 128/86 mm Hg


b) Neck pain: 3/10 (0 to 10 pain scale)


c) Mild neck edema


d) Difficulty swallowing



Answer: Difficulty swallowing

Which blood test confirms the presence of antibodies to HIV?

Which blood test confirms the presence of antibodies to HIV?


a) Enzyme-linked immunosorbent assay (ELISA)

b) Erythrocyte sedimentation rate (ESR)

c) p24 antigen

d) Reverse transcriptase



Answer: Enzyme-linked immunosorbent assay (ELISA)

The client comes to the clinic to obtain the results from the test to determine if he is infected with HIV. The physician informs the client that he has a CD4 cell count of 300 cells/mm3 and a high viral load. What does the nurse anticipate the physician will discuss with the client?

The client comes to the clinic to obtain the results from the test to determine if he is infected with HIV. The physician informs the client that he has a CD4 cell count of 300 cells/mm3 and a high viral load. What does the nurse anticipate the physician will discuss with the client?


a) The initiation of antiretroviral therapy

b) The initiation of antibiotic therapy to prevent the development of an opportunistic infection

c) The administration of an antifungal medication to prevent the development of an opportunistic fungal infection

d) Retroviral therapy is not warranted at this time.



Answer: The initiation of antiretroviral therapy

Which of the following indicates that a client with HIV has developed AIDS?

Which of the following indicates that a client with HIV has developed AIDS?


a) Weight loss of 10 lb over 3 months

b) Pain on standing and walking

c) Severe fatigue at night

d) Herpes simplex ulcer persisting for 2 months



Answer: Herpes simplex ulcer persisting for 2 months

A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order:

A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order:


a) enzyme-linked immunosorbent assay (ELISA).

b) quantification of T-lymphocytes.

c) E-rosette immunofluorescence.

d) ELISA with Western blot test.



Answer: quantification of T-lymphocytes.

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?


a) Sputum specimen for acid fast bacillus

b) Urine specimen for culture and sensitivity

c) Stool specimen for ova and parasites

d) Blood specimen for electrolyte studies



Answer: Stool specimen for ova and parasites

The nurse is administering an injection to a client with AIDS and, when finished, attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse?

The nurse is administering an injection to a client with AIDS and, when finished, attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse?


a) Obtain counseling.

b) Fill out a risk management report.

c) Report the incident to the supervisor

d) Call the lab to draw the nurse's blood.



Answer: Report the incident to the supervisor

A patient with HIV develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this patient?

A patient with HIV develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this patient?


a) Tuberculosis

b) Pneumocystis pneumonia

c) Community-acquired pneumonia

d) Mycobacterium avium complex (MAC)



Answer: Pneumocystis pneumonia

A client visits the nurse complaining of diarrhea every time he eats. The client has AIDS and wants to know what he can do to stop having diarrhea. What should the nurse advise?

A client visits the nurse complaining of diarrhea every time he eats. The client has AIDS and wants to know what he can do to stop having diarrhea. What should the nurse advise?


a) Encourage large, high-fat meals.

b) Increase the intake of iron and zinc.

c) Avoid fibrous foods, lactose, fat, and caffeine.

d) Reduce food intake.


Answer: Avoid fibrous foods, lactose, fat, and caffeine.

A patient with AIDS informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the patient has developed?

A patient with AIDS informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the patient has developed?


a) Kaposi's sarcoma

b) Candidiasis

c) MAC

d) Wasting syndrome



Answer: Candidiasis

A client with HIV will be started on a medication regimen of three medications. Which medication will be given that will interfere with the virus's ability to make a genetic blueprint. What drug will the nurse instruct the client about?

A client with HIV will be started on a medication regimen of three medications. Which medication will be given that will interfere with the virus's ability to make a genetic blueprint. What drug will the nurse instruct the client about?


a) Protease inhibitor

b) Reverse transcriptase inhibitors

c) Integrase inhibitors

d) Hydroxyurea (Hydrea)



Answer: Reverse transcriptase inhibitors

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse demonstrates a need for a review of transmission routes by identifying which body fluid as a means of transmission?

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse demonstrates a need for a review of transmission routes by identifying which body fluid as a means of transmission?


a) Breast milk

b) Blood

c) Semen

d) Urine



Answer: Urine

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