Exam Questions for Week 1 Med Surg

Based on PowerPoint:
Neurological Function and Assessment
What is the primary role of the neuron?
 Answer: To control motor, sensory, autonomic, cognitive, and behavioral activities.
What are the two main divisions of the nervous system?
 Answer: Central Nervous System (CNS) and Peripheral Nervous System (PNS).
What neurotransmitter is primarily involved in the sympathetic "fight or flight" response?
 Answer: Norepinephrine.
What assessment finding may indicate increased intracranial pressure (ICP)?
 Answer: Sluggish or fixed pupillary response.
What is the Glasgow Coma Scale (GCS) used for?
 Answer: To assess a patient's level of consciousness.
What does a score of 3 on the GCS indicate?
 Answer: Deep coma or brain death.

Diagnostic Testing and Imaging

What imaging test requires the patient to lie still and may include the use of contrast dye?
 Answer: Computed Tomography (CT) scan.
Why are fluids encouraged after a CT scan with contrast dye?
 Answer: To help flush out the contrast material from the body.
Which imaging test is contraindicated in patients with metal implants?
 Answer: Magnetic Resonance Imaging (MRI).
What is the purpose of Electroencephalography (EEG)?
 Answer: To measure electrical activity of the brain.
Neurological Disorders and Interventions
What are the two types of strokes?
 Answer: Ischemic and hemorrhagic.
Which type of stroke is most common?
 Answer: Ischemic stroke.
What is the treatment window for thrombolytic therapy in an ischemic stroke?
 Answer: 3 hours from symptom onset.
Name one early sign of increased ICP.
 Answer: Restlessness or confusion.
What are the three components of Cushing’s Triad?
 Answer: Increased systolic blood pressure, bradycardia, and irregular respirations.
What does SIADH stand for, and how does it relate to ADH levels?
 Answer: Syndrome of Inappropriate Antidiuretic Hormone; it involves increased ADH
levels.
Which nursing intervention is key in preventing aspiration in patients with altered
consciousness?
 Answer: Elevating the head of the bed 30 degrees.
What type of seizure is characterized by sudden, excessive firing of cerebral neurons?
 Answer: Generalized seizure.
Which medication is commonly used to manage chronic seizure activity?
 Answer: Phenytoin.
What does the term "locked-in syndrome" refer to?
 Answer: A condition where the patient is aware but cannot move or communicate, except
with eye movements.
Neurological Surgery and Post-Op Care
What is the main risk after a craniotomy?
 Answer: Infection.
Why is the head positioned at 0-60 degrees following intracranial surgery?
 Answer: To promote venous drainage and reduce ICP.
What is the role of mannitol in managing increased ICP?
 Answer: It reduces cerebral edema.
What is the purpose of a burr hole procedure?
 Answer: To relieve intracranial pressure by draining blood or fluid.

Spinal Cord Injury and Trauma

What is autonomic dysreflexia?
 Answer: A life-threatening condition with exaggerated autonomic responses in patients
with spinal cord injuries above T6.
What is spinal shock?
 Answer: Temporary loss of reflexes below the level of a spinal injury.
Which intervention is immediate for a patient showing signs of autonomic dysreflexia?
 Answer: Elevate the patient to a sitting position.
What is the primary cause of traumatic brain injuries (TBIs) in young adults?
 Answer: Motor vehicle accidents.
Which population is at higher risk for developing subdural hematomas?
 Answer: Elderly individuals, often due to minor, forgotten injuries.
Infections and Autoimmune Disorders
What is Kernig’s sign used to assess?
 Answer: Meningeal irritation or meningitis.
What is a common cause of Guillain-Barré Syndrome?
 Answer: Viral infection or immunization.
Which condition results from inflammation of the pia matter and arachnoid space?
 Answer: Meningitis.
What type of medication is commonly used to manage exacerbations of multiple sclerosis?
 Answer: Corticosteroids.

Neurological Conditions and Disorders

What is the primary symptom of trigeminal neuralgia?
 Answer: Severe, episodic facial pain.
Which autoimmune disorder affects the acetylcholine receptors at the neuromuscular junction?
 Answer: Myasthenia gravis.
Which neurological disorder is characterized by demyelination of CNS neurons?
 Answer: Multiple sclerosis.
What progressive genetic disorder leads to motor and cognitive decline, known for chorea
movements?
 Answer: Huntington’s Disease.
Seizures, Epilepsy, and Headaches
What is status epilepticus?
 Answer: A prolonged seizure lasting over 30 minutes or repeated seizures without
recovery.
Name a non-pharmacologic measure to relieve a migraine headache.
 Answer: Rest in a dark, quiet room.
Which phase of a migraine involves sensory disturbances such as aura?
 Answer: Aura phase.
What medication is used for abortive therapy in migraine management?
 Answer: Sumatriptan (Imitrex).

Degenerative and Oncologic Neurological Disorders

What are the primary symptoms of Parkinson’s disease?
 Answer: Tremor, rigidity, bradykinesia, and postural instability.
What degenerative disorder is also known as "Lou Gehrig's disease"?
 Answer: Amyotrophic Lateral Sclerosis (ALS).
What are the common symptoms in brain tumors that affect vision and balance?
 Answer: Visual disturbances and gait difficulties.
Which type of brain tumor is often benign and slow growing, originating from the meninges?
 Answer: Meningioma.
What are the three cardinal signs of brain death?
 Answer: Coma, absence of brain-stem reflexes, and apnea.
Interventions and Patient Education
What is essential teaching for a patient taking levodopa-carbidopa for Parkinson's?
 Answer: Monitor for toxicity, including muscle twitching and facial grimacing.
How often should a patient with impaired mobility be repositioned to prevent skin breakdown?
 Answer: Every 2 hours.
Why is it important to maintain the day/night cycle for patients with altered consciousness?
 Answer: To prevent confusion and help with orientation.
What intervention helps prevent respiratory complications in bedridden patients?
 Answer: Elevating the head of the bed and encouraging coughing and deep breathing
exercises.
Extra Questions:

A patient is brought to the ER following a motor vehicle accident in which he sustained head
trauma. Preliminary assessment reveals a vision deficit in the patient's left eye. The nurse should
associate this abnormal finding with trauma to which of the following cerebral lobes?
A) Temporal
B) Occipital
C) Parietal
D) Frontal
B

A patient scheduled for magnetic resonance imaging (MRI) at the radiology department. The
nurse who prepares the patient for the MRI should prioritize which of the following actions?
A) Withholding stimulants 24 to 48 hours prior to exam
B) Removing all metal-containing objects
C) Instructing the patient to void prior to the MRI
D) Initiating an IV line for administration of contrast
B

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal,
age-related changes. What phenomenon should the nurse be aware of?
A) Hyperactive deep tendon reflexes
B) Reduction in cerebral blood flow
C) Increased cerebral metabolism
D) Hypersensitivity to painful stimuli
B

The nurse has admitted a new patient to the unit. One of the patient's admitting orders is for an
adrenergic medication. The nurse knows that this medication will have what effect on the
circulatory system?
A) Thin, watery saliva
B) Increased heart rate
C) Decreased BP
D) Constricted bronchioles
B

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot
is abruptly dorsiflexed, it continues to "beat" two times before settling into a resting
position. How would the nurse document this finding?
A) Rigidity
B) Flaccidity
C) Clonus
D) Ataxia
C

The nurse is doing an initial assessment on a patient newly admitted to the unit with a
diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure
that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain
region is primarily involved in this deficit?
A) Temporal lobe
B) Parietal-occipital area
C) Inferior posterior frontal areas
D) Posterior frontal area
B

The nurse is admitting a patient to the unit who is diagnosed with lower motor neuron lesion.
What entry in the patient's electronic record is most consistent with this diagnosis?
A) "Patient exhibits increased muscle tone."
B) "Patient demonstrates normal muscle structure with no evidence of atrophy."
C) "Patient demonstrates hyperactive deep tendon reflexes."
D) "Patient demonstrates an absence of deep tendon reflexes."
D

An elderly patient is being discharged home. The patient lives alone and has atrophy of his
olfactory organs. The nurse tells the patient's family its essential that the patient have what
installed in the home?
A) Grab bars
B) Nonslip mats
C) Baseboard heaters
D) A smoke detector
D

A nurse is caring for a patient diagnosed with Ménière's disease. While completing a neurologic
examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in
identifying the function of this nerve as what?
A) Movement of the tongue
B) Visual acuity
C) Sense of smell
D) Hearing and equilibrium
D

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the
following is the most plausible cause of this patient's health problems?
A) Cerebellar dysfunction
B) A lesion in the pons
C) Dysfunction of the medulla
D) A hemorrhage in the midbrain
A
The nursing students are learning how to assess function of cranial nerve VIII. To assess the
function of cranial nerve VIII the students would be correct in completing which of the following
assessment techniques?
A) Have the patient identify familiar odors with the eyes closed
B) Assess papillary reflex.
C) Utilize the Snellen chart.
D) Test for air and bone conduction (Rinne test).
D

A patient is being given a medication that stimulates her parasympathetic system. Following
administration of this medication, the nurse should anticipate what effect?
A) Constricted pupils
B) Dilated bronchioles
C) Decreased peristaltic movement
D) Relaxed muscular walls of the urinary bladder
A

A patient is having a "fight or flight response" after receiving news about his prognosis.
What effect will this have on the patient's sympathetic nervous system?
A) Constriction of blood vessels in the heart muscle
B) Constriction of bronchioles
C) Increase in the secretion of sweat
D) Constriction of pupils
C

The nurse is planning the care of a patient with Parkinson's Disease The nurse should be aware
that treatment will focus on what pathophysiological phenomenon?
A) Premature degradation of acetylcholine
B) Decreased availability of dopamine
C) Insufficient synthesis of epinephrine
D) Delayed reuptake of serotonin
B

A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the
anesthetic. The nurse knows the brain area that regulates body temperature is which of the
following?
A) Cerebellum
B) Thalamus
C) Hypothalamus
D) Midbrain
C

A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When
assessing this patient, the nurse has the patient stick out her tongue and move it back and forth.
What is the nurse assessing?
A) Function of the hypoglossal nerve
B) Function of the vagus nerve
C) Function of the spinal nerve
D) Function of the trochlear nerve
A

When caring for a patient with an altered level of consciousness, the nurse is preparing to test
cranial nerve VII. What assessment technique would the nurse use to elicit a response from
cranial nerve VII?
A) Palpate trapezius muscle while patient shrugs should against resistance.
B) Administer the whisper or watch-tick test.
C) Observe for facial movement symmetry, such as a smile.
D) Note any hoarseness in the patient's voice
C)
The nurse caring for an 80 year-old patient knows that she has a pre-existing history of
dulled tactile sensation. The nurse should first consider what possible cause for this
patient's diminished tactile sensation?
A) Damage to cranial nerve VIII
B) Adverse medication effects
C) Age-related neurologic changes
D) An undiagnosed cerebrovascular accident in early adulthood
C

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers.

Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with
caution?
A) Hot or cold packs
B) Analgesics
C) Anti-inflammatory medications
D) Whirlpool baths
A

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making
the determination of brain death?
A) Magnetic resonance imaging (MRI)
B) Electroencephalography (EEG)
C) Electro myelography (EMG)
D) Computed tomography (CT)
B

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic
deficits. What should the nurse tell the patient in preparation for this test?
A) "No metal objects can enter the procedure room."
B) "You need to fast for 8 hours prior to the test."
C) "You will need to lie still throughout the procedure."
D) "There will be a lot of noise during the test."
C

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an
invasive procedure, which assesses for any lesions in the spinal cord. The nurse should
explain that the preparation is similar to which of the following neurologic tests?
A) Lumbar puncture
B) MRI
C) Cerebral angiography
D) EEG
A

A patient had a lumbar puncture performed at the outpatient center the nurse has phoned the
patient and family that evening. What does this phone call enable the nurse to determine?
A) What are the patient's and family's expectations of the test
B) Whether the patient's family had any questions about why the test was necessary
C) Whether the patient has had any complications of the test
D) Whether the patient understood accurately why the test was done
C

The nurse is performing a neurologic assessment of a patient whose injuries have rendered her
unable to follow verbal commands. How should the nurse proceed with assessing the patient's
level of consciousness (LOC)?
A) Assess the patient's vital signs and correlate these with the patient's baselines.
B) Assess the patient's eye opening and response to stimuli.
C) Document that the patient currently lacks a level of a consciousness
D) Facilitate diagnostic testing in an effort to obtain objective data.
B
The nurse is testing the neurological function of a patient's cerebellum and basal ganglia.
What action will most accurately test these structures?
A) Have the patient identify the location of a cotton swab on his or her skin with the eyes closed.
B) Elicit the patient's response to a hypothetical problem.
C) Ask the patient to close his or her eyes and discern between hot and cold stimuli.
D) Guide the patient through the performance of rapid extraocular movements.
D

A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to
an oncology unit. What symptoms is the nurse likely to find during the initial assessment?
A) Loss of hearing, tinnitus, and vertigo
B) Loss of vision, change in mental status, and hyperthermia
C) Loss of hearing, increased sodium retention, and hypertension
D) Loss of vision, headache, and tachycardia
A

A 25-year-old female patient with brain metastases is considering her life expectancy after her
most recent meeting with her oncologist. Based on the fact that the patient is not receiving
treatment for her brain metastases, what is the nurse's most appropriate action?
A) Promoting the patient's functional status and ADLs
B) Ensuring that the patient receives adequate palliative care
C) Ensuring that the family does not tell the patient that her condition is terminal
D) Promoting adherence to the prescribed medication regimen
B

The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an
appropriate nursing diagnosis is "anxiety related to loss of control over the health
circumstances." In establishing this plan of care for the patient, the nurse should include what
intervention?
A) The patient will receive antianxiety medications every 4 hours.
B) The patient's family will be instructed on planning the patient's care.
C) The patient will be encouraged to verbalize concerns related to the disease and its treatment.
D) The patient will begin intensive therapy with the goal action
C

A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of
motor function and sensation. The physician suspects the patient has a spinal cord tumor
and hospitalizes him for diagnostic testing. In light of the need to diagnose spinal cord
compression from a tumor, the nurse will most likely prepare the patient for what test?
A) Anterior-posterior x-ray
B) Ultrasound
C) Lumbar puncture
D) MRI
D

While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing
covering the operative site after the patients' cervical diskectomy. The nurse notes that the
drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate
action?
A) Page the physician and report this sign of infection.
B) Reinforce the dressing and reassess in 1 to 2 hours.
C) Reposition the patient to prevent further hemorrhage
D) Inform the surgeon of the possibility of a dural leak.
D

A patient, diagnosed with cancer of the lung, has just been tested for metastases to the brain.
What change in health status would the nurse attribute to the patient's metastatic brain disease?
A) Chronic pain
B) Respiratory distress
C) Fixed pupils
D) Personality changes
D
A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain
tumor. The patient has just exhibited seizure activity for the first time. What is the nurse's priority
response to this event?
A) Identify the triggers that precipitated the seizure.
B) Implement precautions to ensure the patient's safety.
C) Teach the patient's family about the relationship between tumors and seizure activity.
D) Ensure that the patient is housed in a private room
B

A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When
planning the patient's care, the nurse should be aware that the effects of the tumor will
primarily depend on what variable?
A) Whether the tumor utilizes aerobic or anaerobic respiration
B) The specific hormones secreted by the tumor
C) The patient's pre-existing health status
D) Whether the tumor is primary or the result of metastasis
B

A male patient with a metastatic brain tumor is having a seizure and begins vomiting. What
should the nurse do first?
A) Perform oral suctioning.
B) Page the physician.
C) Insert a tongue depressor into the patient's mouth.
D) Turn the patient on his side.
D

The nurse educator is discussing neoplasms with a group of recent graduates. The educator
explains that the effects of neoplasms are caused by the compression and infiltration of
normal tissue. The physiologic changes that result can cause what pathophysiologic events?
Select all that apply.
A) Intracranial hemorrhage
B) Infection of cerebrospinal fluid
C) Increased ICP
D) Focal neurologic signs
E) Altered pituitary function
C, D, E

The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks
the nurse where his tumor came from. What would be the nurse's best response?
A) "Your tumor originated from somewhere outside the CNS."
B) "Your tumor likely started out in one of your glands."
C) "Your tumor originated from cells within your brain itself."
D) "Your tumor is from nerve tissue somewhere in your body
C

A patient experiencing many episodes of headaches and vomiting has been referred for testing to
rule out a brain tumor. What characteristic of the patient's vomiting is most consistent with a
brain tumor?
A) The patient's vomiting is accompanied by epistaxis.
B) The patient's vomiting does not relieve his nausea.
C) The patient's vomiting is unrelated to food intake.
D) The patient's emesis is blood-tinged.
C

A male patient presents at the free clinic with complaints of impotency. Upon physical
examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis
should the nurse suspect?
A) Prolactinoma
B) Angioma
C) Glioma
D) Adrenocorticotropic hormone (ACTH)-producing adenoma
A

The nurse is planning the care of a patient diagnosed with a cerebellar tumor. Due to the
location of this patient's tumor, the nurse should implement measures to prevent what
complication?
A) Falls
B) Audio hallucinations
C) Respiratory depression
D) Labile BP
A

A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient
is scheduled to have a tumor resection/removal in the morning. Which of the following
assessment parameters should the nurse include in the initial assessment?
A) Gag reflex
B) Deep tendon reflexes
C) Abdominal girth
D) Hearing acuity
A

A patient with an inoperable brain tumor has been told that he has a short life expectancy.
On what aspects of assessment and care should the home health nurse focus? Select all that
apply.
A) Pain control
B) Management of treatment complications
C) Interpretation of diagnostic tests
D) Assistance with self-care
E) Administration of treatments
A, B, D
A client is diagnosed with an acoustic neuroma. When assessing the client, which
manifestation would the nurse expect to find? Select all that apply.
A) tinnitus
B) vertigo
C) staggering gait
D) seizures
E) headache
C, D, E

A female client is admitted to the medical unit for evaluation of cerebral metastasis from a
primary site. When reviewing the client's history, the nurse would most likely find which
site as being the primary site?
A) lung
B) prostate
C) renal
D) uterus
A

A nurse is conducting an assessment of a client who is suspected of having a brain tumor.

Assessment reveals reports of a headache, for which the nurse gathers additional information.
The nurse determines that these reports support the suspicion of a brain tumor when the client
reports that the headache occurs:
A) early in the morning.
B) around lunchtime.
C) in the middle of the afternoon.
D) at bedtime.
A

A client is exhibiting late signs of increased intracranial pressure. Which finding would the nurse
most likely assess? Select all that apply.
A) hypertension
B) bradycardia
C) respiratory depression
D) headache
E) papilledema
A, B, C

A client is diagnosed with a brain tumor of the parietal lobe. Based on the tumor's location,
which assessment finding would the nurse most likely note? Select all that apply.
A) difficulty with reading
B) problems with mathematical calculations
C) impaired reasoning
D) memory changes
E) changing moods
A, B

A nurse is conducting a presentation about brain cancer for a community group. During the
presentation, one of the group members asks, "What causes brain tumors?" Which response by
the nurse would be most appropriate?
A) "There is scientific evidence that cigarette smoking the list of causes."
B) "The cause of most brain tumors is still really not known."
C) "It's a known fact that using cell phones increases your risk for a tumor."
D) "Exposure to residential power lines is a definite cause of brain tumors."
B

The ED nurse is caring for a patient brought in by ambulance after a fall at home. What
physical assessment finding is suggestive of a basilar skull fracture?
A) Epistaxis
B) Periorbital edema
C) Bruising over the mastoid
D) Unilateral facial numbness
C

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical
manifestations would the nurse expect in this patient?
A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia
B

A patient is brought to the ED by her family after falling. A family member tells the nurse that
when the patient fell she was "knocked out," but came to and "seemed okay." Now she is
complaining of a severe headache and not feeling well. The care team suspects an epidural
hematoma, prompting the nurse to prepare for which priority intervention?
A) Insertion of an intracranial monitoring device
B) Treatment with antihypertensives
C) Emergency craniotomy
D) Administration of anticoagulant therapy
C

The staff educator is precepting a nurse new to the critical care unit when a patient with a
T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of
neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's
most appropriate action?
A) Prepare to transfuse packed red blood cells.
B) Prepare for interventions to increase the patient's BP.
C) Place the patient in the Trendelenburg position.
D) Prepare an ice bath to lower core body temperature.
B
ED nurse has just received a call from EMS that a 17-yearold man who has just sustained a
spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury
is what?
A) Sports-related injuries
B) Acts of violence
C) Injuries due to a fall
D) Motor vehicle accidents
D

A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse
recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would
be included as an appropriate nursing intervention to prevent DVT from occurring?
A) Placing the patient on a fluid restriction as ordered to prevent a DVT
B) Applying thigh-high elastic stockings
C) Administering an antifibrinolytic agent
D) Assisting the patient with passive range of motion (PROM) exercises
B

A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit.
Nursing care should include which of the following?
A) Preparation for emergency craniotomy
B) Watchful waiting and close monitoring
C) Administration of inotropic drugs
D) Fluid resuscitation
B

A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care
plan, the nurse specifies that contractures can be prevented by what action?
A) Repositioning the patient every 2 hours
B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates
C) Initiating (ROM) exercises as soon as possible after the accident
D) Performing ROM exercises once a day
C

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient
the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of
injury. What should the nurse suspect?
A) Epidural hemorrhage
B) Hypertensive emergency
C) Spinal shock
D) Hypovolemia
C

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what
assessment finding?
A) Absence of reflexes along with flaccid extremities
B) Positive Babinski's reflex along with spastic extremities
C) Hyperreflexia along with spastic extremities
D) Spasticity of all four extremities
A

A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This
allows the nurse to gauge what aspect of the patient's status?
A) Reflex activity
B) Level of consciousness
C) Cognitive ability
D) Sensory involvement
B
The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse
should be aware of what cardinal signs of brain death? Select all that apply.
A) Absence of pain response
B) Apnea
C) Coma
D) Absence of brain stem reflexes
E) Absence of deep tendon reflexes
B, C, D

Following a spinal cord injury a patient is placed in halo traction. While performing pin site care,
the nurse notes that one of the traction pins has become detached. The nurse would be correct in
implementing what priority nursing action?
A) Complete the pin site care to decrease risk of infection
B) Notify the neurosurgeon of the occurrence.
C) Stabilize the head in a lateral position.
D) Reattach the pin to prevent further head trauma.
B

A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What
would be the primary neuroimaging diagnostic tool used on this patient to evaluate the
brain structure?
A) MRI
B) PET scan
C) X-ray
D) Ultrasound
A

A neurologic flow chart is often used to document the care of a patient with a traumatic brain
injury. At what point in the patient's care should the nurse begin to use a neurologic flow chart?
A) When the patient's condition begins to deteriorate
B) As soon as the initial assessment is made
C) At the beginning of each shift
D) When there is a clinically meaningful change in the patients condition
B

The nurse has implemented interventions aimed at facilitating family coping in the care of a
patient with a traumatic brain injury. How can the nurse best facilitate family coping?
A) Help the family understand that the patient could have died
B) Emphasize the importance of accepting the patient's new limitations.
C) Have the members of the family plan the patient's inpatient care.
D) Assist the family in setting appropriate short-term goals
D

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should
the nurse identify as prominent risk factors for SCI? select that apply.
A) Young age
B) Frequent travel
C) African American race
D) Male gender
E) Alcohol or drug use
A, D, E

The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has
identified the diagnosis of "risk for impaired skin integrity." How can the nurse best
address this risk?
A) Change the patient's position frequently.
B) Provide a high-protein diet.
C) Provide light massage at least daily.
D) Teach the patient deep breathing and coughing exercise
A
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient
asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best
answer?
A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."
B) "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its
normal state."
C) "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing."
D) "The sudden, severe headache increases muscle tone and can cause further nerve damage."
A

A patient with a spinal cord injury has experienced several hypotensive episodes. How can the
nurse best address the patient's risk for orthostatic hypotension?
A) Administer an IV bolus of normal saline prior to repositioning.
B) Maintain bed rest until normal BP regulation returns.
C) Monitor the patient's BP before and during position changes
D) Allow the patient to initiate repositioning.
C

The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early
signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing
action?
A) Limit the amount of assistance provided with ADLs.
B) Collaborate with the physical therapist and immobilize the patient's extremities temporarily.
C) Increase the frequency of ROM exercises.
D) Educate the patient about the importance of frequent position changes.
C

Splints have been ordered for a patient who is at risk of developing footdrop following a
spinal cord injury. The nurse caring for this patient knows that the splints are removed and
reapplied when?
A) At the patient's request
B) Each morning and evening
C) Every 2 hours
D) One hour prior to mobility exercises
C

A patient who is being treated in the hospital for a spinal cord injury is advocating for the
removal of his urinary catheter, stating that he wants to try to resume normal elimination.
What principle should guide the care team's decision regarding this intervention?
A) Urinary retention can have serious consequences in patients with SCIs.
B) Urinary function is permanently lost following an SCI.
C) Urinary catheters should not remain in place for more than 7 days.
D ) Overuse of urinary catheters can exacerbate nerve damage
A

A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan
of care for this patient, which of the following nursing diagnosis would the nurse prioritize in the
immediate care of this patient?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal muscles
D) Urinary retention related to inability to void spontaneously
C

A patient with a documented history of seizure disorder experiences a generalized seizure. What
nursing action is most appropriate?
A) Restrain the patient to prevent injury.
B) Open the patient's jaws to insert an oral airway.
C) Place patient in high Fowler's position.
D) Loosen the patient's restrictive clothing.
D

While completing a health history on a patient who has recently experienced a seizure, the nurse
would assess for what characteristic associated with the postictal state?
A) Epileptic cry
B) Confusion
C) Urinary incontinence
D) Body rigidity
B

The nurse is caring for a patient who is in status epilepticus. What medication does the
nurse know may be given to halt the seizure immediately?
A) Intravenous phenobarbital (Luminal)
B) Intravenous diazepam (Valium)
C) Oral lorazepam (Ativan)
D) Oral phenytoin (Dilantin)
B

The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse
and other members of the care team are present at the bedside when the patient has a seizure. In
preparation for documenting this clinical event, the nurse should note which of the following?
A) The ability of the patient to follow instructions during the seizure.
B) The success or failure of the care team to physically restrain the patient.
C) The patient's ability to explain his seizure during the postictal period.
D) The patient's activities immediately prior to the seizure
D

A patient has experienced a seizure in which she became rigid and then experienced alternating
muscle relaxation and contraction. What type of seizure does the nurse recognize?
A) Unclassified seizure
B) Absence seizure
C) Generalized seizure
D) Focal seizure
C

A hospital patient has experienced a seizure. In the immediate recovery period, what action best
protects the patient's safety?
A) Place the patient in a side-lying position.
B) Pad the patient's bed rails.
C) Administer antianxiety medications as ordered.
D) Reassure the patient and family members.
A

A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding
would the nurse expect for a patient with this diagnosis?
A) Pain upon ankle dorsiflexion of the foot
B) Neck flexion produces flexion of knees and hips
C) Inability to stand with eyes closed and arms extended without swaying
D) Numbness and tingling in the lower extremities
B

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the
hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what
action should the nurse suggest?
A) Taking a hot bath at least once daily
B) Resting in an air-conditioned room whenever possible
C) Increasing the dose of muscle relaxants
D) Avoiding naps during the day
B
A patient with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is
the nurse's most appropriate action?
A) Administer bronchodilators as ordered.
B) Remind the patient of the importance of deep breathing and coughing exercises.
C) Prepare to assist with intubation.
D) Administer supplementary oxygen by nasal cannula.
C

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health
education, the nurse should promote which of the following actions?
A) Applying a protective eye shield at night
B) Chewing on the affected side to prevent unilateral neglect
C) Avoiding the use of analgesics whenever possible
D) Avoiding brushing the teeth
A

The nurse is working with a patient who is newly diagnosed with MS. What basic information
should the nurse provide to the patient?
A) MS is a progressive demyelinating disease of the nervous system.
B) MS usually occurs more frequently in men.
C) MS typically has an acute onset.
D) MS is sometimes caused by a bacterial infection.
A

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the
following should the nurse include in the patient's care plan?
A) Encourage patient to void every hour.
B) Order a low-residue diet.
C) Provide total assistance with all ADLs.
D) Instruct the patient on daily muscle stretching.
D

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient
is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects
the patient may have meningitis. What is another well-recognized sign of this infection?
A) Negative Brudzinski's sign
B) Positive Kernig's sign
C) Hyper patellar reflex
D) Sluggish pupil reaction
B

The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The
nurse's plan of care should address what characteristics manifestations of this disease?
A) Tinnitus
B) Facial paralysis
C) Pain at the base of the tongue
D) Diplopia
B

A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What
medication would the nurse expect the physician to order for the treatment of this disease
process?
A) Cyclosporine (Neoral)
B) Acyclovir (Zovirax)
C) Cyclobenzaprine (Flexeril)
D) Ampicillin (Prinicpen)
B

A middle-aged woman has sought care from her primary care provider and undergone diagnostic
testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have
prompted the woman to seek care?
A) Cognitive declines
B) Personality changes
C) Contractures
D) Difficulty in coordination
D

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia
gravis. What approach would be most appropriate for the care and scheduling of diagnostic
procedures for this patient?
A) All at one time, to provide a longer rest period
B) Before meals, to stimulate her appetite
C) In the morning, with frequent rest periods
D) Before bedtime, to promote rest
C

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess.
What is a priority nursing responsibility in the care of this patient?
A) Maintaining the patient's functional independence
B) Providing health education
C) Monitoring neurologic status closely
D) Promoting mobility
C

A patient is being admitted to the neurologic ICU with suspected herpes simplex virus
encephalitis. What nursing action best addresses the patient's complaints of headache?
A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate
B) Administering hydromorphone (Dilaudid) IV as needed
C) Dimming the lights and reducing stimulation
D) Distracting the patient with activity
C
A patient is admitted through the ED with suspected St. Louis encephalitis. The unique
clinical feature of St. Louis encephalitis will make what nursing action a priority?
A) Serial assessments of hemoglobin levels
B) Blood glucose monitoring
C) Close monitoring of fluid balance
D) Assessment of pain along dermatome
C

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis.
The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in
status would most clearly suggest a therapeutic benefit of this medication?
A) Increased muscle strength
B) Decreased pain
C) Improved GI function
D) Improved cognition
A

The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse
should prioritize what nursing action in the immediate care of this patient?
A) Suctioning secretions
B) Facilitating ABG analysis
C) Providing ventilatory assistance
D) Administering tube feedings
C

A patient diagnosed with MS has been admitted to the medical unit for treatment of MS
exacerbation. Included in the admission orders is baclofen (Lioresal). What should the
nurse identify as an expected outcome of this treatment?
A) Reduction in the appearance of new lesions on the MRI
B) Decreased muscle spasms in the lower extremities
C) Increased muscle strength in the upper extremities
D) Decreased severity and duration of exacerbations
B

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What
nursing action should the nurse consequently perform?
A) Arrange for the patient to receive a low residue diet.
B) Position the patient upright during feeding.
C) Suction the patient following each meal.
D) Withhold liquids until the patient has finished eating.
B

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid
endarterectomy. The nurse explains that this procedure will be done for what purpose?
A) To decrease cerebral edema
B) To prevent seizure activity that is common in TIA's
C) To remove atherosclerotic plaques blocking cerebral flow
D) To determine the cause of the TIA
C

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and
neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a
hemorrhagic stroke of which the nurse should be aware?
A) Generalized pain
B) Alteration in level of consciousness (LOC)
C) Tonic-clonic seizures
D) Shortness of breath
B
The nurse is performing stroke risk screenings at a hospital open house. The nurse has
identified four patients who might be at risk of a stroke. Which patient is likely at the
highest risk for a hemorrhagic stroke?
A) White female, age 60, with history of excessive alcohol intake
B) White male, age 60, with history of uncontrolled hypertension
C) Black male, age 60, with history of diabetes
D) Black male, age 50, with history of smoking
B

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance.
What should the nurse's primary assessment focus on?
A) Cardiac and respiratory status
B) Seizure activity
C) Pain
D) Fluid and electrolyte balance
A

A patient recovering from a stroke has severe shoulder pain from subluxation of the
shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse
caring for this patient is aware of what principle of care?
A) The patient should be fitted with a cast because use of a sling should be avoided due to
adduction of the affected shoulder.
B) Elevation of the arm and hand can lead to further complications associated with edema.
C) Passively exercising the affected extremity is avoided in order to minimize pain.
D) The patient should be taught to interlace fingers, place palms together, and slowly bring
scapulae forward to avoid excessive force to shoulder.
D

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do best
to make the patient's atmosphere more conducive to communication?
A) Provide a board of commonly used needs and phrases.
B) Have the patient speak to loved ones on the phone daily.
C) Help the patient complete his or her sentences.
D) Speak in a loud and deliberate voice to the patient.
A

The nurse is assessing a patient with a suspected stroke. What assessment finding is most
suggestive of a stroke?
A) Facial droop
B) Dysrhythmias
C) Periorbital edema
D) Projectile vomiting
A

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this
patient's plan of care, what goal should be prioritized?
A) Prevent complications of immobility.
B) Maintain and improve cerebral tissue perfusion.
C) Relieve anxiety and pain.
D) Relieve sensory deprivation.
B

The nurse is preparing health education for a patient who is being discharged after
hospitalization for a hemorrhagic stroke. What content should the nurse include in this
education?
A) Mild, intermittent seizures can be expected.
B) Take ibuprofen for complaints of a serious headache.
C) Take antihypertensive medication as ordered.
D) Drowsiness is normal for the first week after discharge.
C
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What
action is a priority for the nurse?
A) Sit with the patient for a few minutes.
B) Administer an analgesic.
C) Inform the nurse-manager.
D) Call the physician immediately.
D

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke.
The nurse caring for this patient is aware that an absolute contraindication for thrombolytic
therapy is what?
A) Evidence of hemorrhagic stroke
B) Blood pressure of 180/110 mm Hg
C) Evidence of stroke evolution
D) Previous thrombolytic therapy within the past 12 months
A

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient
position is most consistent with this goal?
A) Head turned slightly to the right side
B) Elevation of the head of the bed
C) Position changes every 15 minutes while awake
D) Extension of the neck
B

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle
should guide the nurse's care of this patient?
A) The patient should be approached on the side where visual perception is intact.
B) Attention to the affected side should be minimized in order to decrease anxiety.
C) The patient should avoid turning in the direction of the defective visual field to minimize
shoulder subluxation.
D) The patient should be approached on the opposite side of the visual perception is intact to
promote recovery
A

What should be included in the patient's care plan when establishing an exercise program for a
patient affected by a stroke?
A) Schedule passive range of motion every other day.
B) Keep activity limited, as the patient may be over stimulated
C) Have the patient perform active range-of-motion (ROM) exercises once a day.
D) Exercise the affected extremities passively four or five times a day
D

A patient has recently begun mobilizing during the recovery from an ischemic stroke. To
protect the patient's safety during mobilization, the nurse should perform what action?
A) Support the patient's full body weight with a waist belt during ambulation.
B) Have a colleague follow the patient closely with a wheelchair.
C) Avoid mobilizing the patient in the early morning or late evening.
D) Ensure that the patient's family members do not participate in mobilization.
B

A female patient is diagnosed with a right-sided stroke. The patient is now experiencing
hemianopsia. How might the nurse help the patient manage her potential sensory and
perceptional difficulties?
A) Keep the lighting in the patient's room low.
B) Place the patient's clock on the affected side.
C) Approach the patient on the side where vision is impaired.
D) Place the patient's extremities where she can see them
D
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic
stroke. The nurse performs frequent neurologic assessments and observes that the patient is
becoming progressively drowsier over the course of the day. What is the nurse's best response to
this assessment finding?
A) Report this finding to the physician as an indication of decreased metabolism.
B) Provide more stimulation to the patient and monitor closely.
C) Recognize this as the expected clinical course of a hemorrhagic stroke.
D) Report this to the physician as a possible sign of clinical deterioration.
D

The nurse is reviewing the medication administration of a female patient who possesses
numerous risk factors for stroke. Which of the woman's medications carries the greatest potential
for reducing her risk of stroke?
A) Naproxen 250 PO b.i.d.
B) Calcium carbonate 1,000 mg PO b.i.d.
C) Aspirin 81 mg PO o.d.
D) Lorazepam 1 mg SL b.i.d. PRN
C

A family member brings the patient to the clinic for a follow-up visit after a stroke. The
family member asks the nurse what he can do to decrease his chance of having another
stroke. What would be the nurse's best answer?
A) "Have your heart checked regularly."
B) "Stop smoking as soon as possible."
C) "Get medication to bring down your sodium levels."
D) "Eat a nutritious diet."
B

A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new
nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes?
A) Ventricular tachycardia
B) Atrial Fibrillation
C) Supraventricular tachycardia
D) Bundle branch block
B

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment
with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to
closely monitoring the patient's cardiac and neurologic status, the nurse monitors the
patient for signs of what complication?
A) Acute pain
B) Septicemia
C) Bleeding
D) Seizures
C

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the
following steps: Put these steps in order in which they occur.
1. Change in pH
2. Blood flow decreases
3. A switch to anaerobic respiration
4. Membrane pumps fail
5. Cells cease to function
6. Lactic acid is generated
A) 635241
B) 352416
C) 236145
D) 162534
C
A nursing student is writing a care plan for a newly admitted patient who has been diagnosed
with a stroke. What major nursing diagnosis should most likely be included in the patient's plan
of care?
A) Adult failure to thrive
B) Post-trauma syndrome
C) Hyperthermia
D) Disturbed sensory perception
D

When preparing to discharge a patient home, the nurse met with the family and warned them that
the patient may exhibit unexpected emotional responses. The nurse should teach the family that
these responses are typically a result of what cause?
A) Frustration around changes in function and communication
B) Unmet physiologic needs
C) Changes in brain activity during sleep and wakefulness
D) Temporary changes in metabolism
A

The nurse has taken shift reports on her patients and has been told that one patient has an ocular
condition that has primarily affected the rods in his eyes. Considering this information, what
should the nurse do while caring for the patient?
A) Ensure adequate lighting in the patient's room.
B) Provide a dimly lit room to aid vision by limiting contrast.
C) Carefully point out color differences for the patient.
D) Carefully point out fine details for the patient.
A

A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40.
The patient asks the nurse what these numbers specifically mean. What is the correct response by
the nurse?
A) "A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20
vision can see from 20 feet away."
B) "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20
vision can see from 40 feet away."
C) "A person whose vision is 20/40 can see an object from 40 inches away that a person with
20/20 vision can see from 20 inches away
D) "A person whose vision is 20/40 can see an object from 20 inches away that a person with
20/20 vision can see from 40 inches away."
B

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse
that he often sees floaters in his vision. How should the nurse best interpret this subjective
assessment finding?
A) This is a normal aging process of the eye.
B) Glasses will minimize this phenomenon.
C) The patient may be exhibiting signs of glaucoma.
D) This may be a result of weakened ciliary muscles.
A

The nurse's assessment of a patient with significant visual loss reveals that the patient cannot
count fingers. How should the nurse proceed with assessment of the patient's visual acuity?
A) Assess the patient's vision using a Snellen chart.
B) Determine whether the patient is able to see the nurse's hand motion.
C) Perform a detailed examination of the patient's external eye structures.
D) Palpate the patient's periocular regions.
B

A patient has informed the home health nurse that she has recently noticed distortions when she
looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most
appropriate action?
A) Reassure the patient that this is an age-related change in vision
B) Arrange for the patient to have her visual acuity assessed.
C) Arrange for the patient to be assessed for macular degeneration.
D) Facilitate tonometry testing.
C

A 56-year-old patient has come to the clinic for a routine eye examination and informed bifocals
will be prescribed. The patient asks the nurse what change in his eyes has caused a need for
bifocals. How should the nurse respond?
A) As you age, vision typically deteriorates to a point where many people require bifocals.
B) "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry."
C) "There is a gradual thickening of the lens of the eye, and it can limit the eye's ability for
accommodation."
D) "The eye gets shorter, back to front, as we age, and it changes how we see things."
C

The public health nurse is addressing eye health and vision projection during an educational
event. What statement by a participant best demonstrates an understanding of threats to vision?
A) "I'm planning to avoid exposure to direct sunlight on my vacation."
B) "I've never exercised regularly, but I'm going to start working out at the gym daily."
C) "I'm planning to talk with my pharmacist to review my current medications."
D) "I'm certainly going to keep a close eye on my blood pressure from now on."
D

An older adult patient has been diagnosed with macular degeneration and the nurse has been
assessing for changes in visual acuity since last visit. When assessing the patient for recent
changes in visual acuity, the patient states that the lines on an Amsler grid as being distorted.
What is the nurse's most appropriate response?
A) Ask if the patient has been using OTC vasoconstrictors.
B) Instruct the patient to repeat the test at various times of the day when at home.
C) Arrange for the patient to visit an ophthalmologist.
D) Encourage the patient to adhere to prescribed drug regimen.
C

Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical
assessment findings related to the ear should be reported by the nurse immediately?
A) The malleus can be visualized during otoscopic examination
B) The tympanic membrane is pearly gray.
C) Tenderness is reported by the patient when the mastoid area is palpated.
D) Clear, watery fluid is draining from the patient's ear
D

The nurse is discussing the results of a patient's diagnostic testing with the nurse practitioner.
What Weber test result would indicate the presence of a sensorineural loss?
A) The sound is heard better in the ear in which hearing is better.
B) The sound is heard equally in both ears.
C) The sound is heard better in the ear in which hearing is poorer.
D) The sound is heard longer in the ear in which hearing is better.
A

The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because
of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the
patient's ear with a solution of hydrogen peroxide water to remove the impacted cerumen. What
nursing intervention is most important to minimize nausea and vertigo during the procedure?
A) Maintain the irrigation fluid at a warm temperature.
B) Instill short, sharp bursts of fluid into the ear canal.
C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax.
D) Have the patient stand during the procedure.
A

The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary,
rhythmic eye movements. What term will the nurse use when documenting these eye
movements?
A) Vertigo
B) Tinnitus
C) Nystagmus
D) Astigmatism
C

A child goes to the school nurse and complains of not being able to hear the teacher. What test
could the school nurse perform that would preliminarily indicate hearing loss?
A) Audiometry
B) Rinne test
C) Whisper test
D) Weber test
C

A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at
his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic
membrane should be what color in a healthy ear?
A) Yellowish white
B) Pink
C) Gray
D) Bluish white
C

An advanced practice nurse has performed a Rinne test on a new patient. During the test, the
patient reports that air-conducted sound is louder than bone-conducted sound. How should the
nurse best interpret this assessment finding?
A) The patient's hearing is likely normal.
B) The patient is at risk for tinnitus.
C) The patient likely has otosclerosis.
D) The patient likely has sensorineural hearing loss.
A

A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse
notes that the client has a history of dry eyes. This information indicates a problem with which
structure?
A) lacrimal apparatus
B) sclera
C) cornea
D) pupil
A

A nurse is examining a client's inner eye. When viewing the retina, which structure would the
nurse identify as a retinal landmark? Select all that apply.
A) optic disk
B) macula
C) posterior chamber
D) vitreous humor
E) ciliary body
A, B

A nurse is interviewing a middle-aged client at the clinic. During the interview, the client states,
"I've noticed that I keep having to move the newspaper farther away to read it. Soon my arms
will be too short!" The nurse interprets this finding as indicative of which age-related change?
A) loss of accommodation
B) shrinkage of the vitreous body
C) meibomian gland dysfunction (MBG)
D) loss of skin elasticity
A
A client is scheduled for audiometry to evaluate hearing. When teaching the client about this test,
which characteristic would the nurse include as being evaluated? Select all that apply.
A) pitch
B) frequency
C) intensity
D) compliance
E) postural control capabilities
A, B, C

The registered nurse taking shift report learns that an assigned patient is blind. How should the
nurse best communicate with this patient?
A) Provide instructions in simple, clear terms.
B) Introduce herself in a firm, loud voice at the doorway.
C) Lightly touch the patient's arm and then introduce herself.
D) State her name and role immediately after entering the patient's room.
D

While inspecting the external eye of a client, the nurse notices that the client's right eyelid
droops. Which term would the nurse use to document this finding?
A) ptosis
B) entropion
C) ectropion
D) presbyopia
A

A nurse is assisting the ophthalmologist performing direct ophthalmoscopy. When conducting

this examination, which structure would the nurse expect to be examined last?
A) red reflex
B) vasculature
C) optic disc
D) macula
D

A nurse is preparing a presentation for a group of elementary school parents about ways to
promote the health of the ears and hearing in their children. When describing the structure and
function of the ears, which structure would the nurse include as part of the middle ear? Select all
that apply.
A) pinna
B) tympanic membrane
C) oval window
D) cochlea
E) organ of Corti
B, C

An older adult client comes to the clinic for an evaluation and says, "It just doesn't seem
like I hear as well as I used to hear." As part of the assessment, the nurse evaluates the
client's gross auditory acuity. Which test would the nurse most likely conduct?
A) whisper test
B) Weber test
C) Rinne test
D) audiometry
A

During discharge teaching the nurse realizes that the patient is not able to read medication bottles
accurately and has not been taking her medications consistently at home. How should the nurse
intervene most appropriately?
A) Ask the social worker to investigate alternative housing arrangements.
B) Ask the social worker to investigate community support agencies.
C) Encourage the patient to explore surgical correctional problems.
D) Arrange for referral to a rehabilitation facility for vision training.
B
The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse
teaches the patient that this disease has a familial tendency. The nurse should encourage the
patient's immediate family members to undergo clinical examinations how often?
A) At least monthly
B) At least once every 2 years
C) At least once every 5 years
D) At least once every 10 years
B

A patient is exploring treatment options after being diagnosed with age-related cataracts that
affect her vision. What treatment is most likely to be used in this patient's care?
A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium
B) Eyeglasses or magnifying lenses
C) Corticosteroid eye drops
D) Surgical intervention
D

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In
reviewing the discharge instructions with the patient, the nurse instructs the patient to
immediately call the office if the patient experiences what?
A) Slight morning discharge from the eye
B) Any appearance of redness of the eye
C) A "scratchy" feeling in the eye
D) A new floater in vision
D

A patient's ocular tumor has necessitated enucleation, and the patient will be fitted with a
prosthesis. The nurse should address what nursing diagnosis when planning the patient's
discharge education?
A) Disturbed body image
B) Chronic pain
C) Ineffective protection
D) Unilateral neglect
A

A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum
absorption. The nurse should teach the patient what action to perform?
A) Instill the medication in the conjunctival sac.
B) Maintain a supine position for 10 minutes after administration.
C) Keep the eyes closed for 1 to 2 minutes after administration.
D) Apply the medication evenly to the sclera
A

A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After
the patient administers the pilocarpine the patient states that her vision is blurred. Which nursing
action is most appropriate?
A) Holding the next dose and notifying the physician
B) Treating the patient for an allergic reaction
C) Suggesting that the patient put on her glasses
D) Explaining that this is an expected adverse effect
D

The nurse should recognize the greatest risk for the development of blindness in which of the
following patients?
A) A 58-year-old Caucasian woman with macular degeneration
B) A 28-year-old Caucasian man with astigmatism
C) A 58-year-old African American woman with hyperopia
D) A 28-year-old African American man with myopia
A
A 6-year-old is brought to the pediatric clinic for the assessment of redness and discharge from
the eye and is diagnosed with viral conjunctivitis. What is the most valuable information to
discuss with the parents and child?
A) Handwashing can prevent the spread of the disease
B) The importance of compliance with antibiotic therapy
C) Signs and symptoms of complications, such as meningitis and septicemia
D) The likely need for surgery to prevent scarring of the tissue
A

The nurse is admitting a 55-year-old patient diagnosed with a left eye retinal detachment. While
assessing this patient, what characteristic symptom would the nurse expect to find?
A) Flashing lights in the visual field
B) Sudden eye pain
C) Loss of color vision
D) Colored halos around lights
A

Several residents of a long-term care facility have developed signs and symptoms of viral
conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility?
A) Arrange for the administration of prophylactic antibiotics to unaffected residents.
B) Instill normal saline into the eyes of affected residents two to three times daily.
C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing.
D) Isolate affected residents from residents who have not been exposed to conjunctivitis.
D

The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse
emphasize during the patient's health education?
A) The need to limit exposure to bright light
B) The need to maintain a low Fowler's position when removing the prosthesis
C) The need to perform thorough hand hygiene before handling the prosthesis
D) The need to apply antiviral ointment to the prosthesis daily
C

A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The
glass had to be surgically removed, and the patient is about to be discharged home. The patient
asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond?
A) "Overuse of these drops could soften your cornea and damage your eye."
B) "You could lose the peripheral vision in your eye if you used these drops too much."
C) "I'm sorry, this medication is considered a controlled substance, and patients cannot take it
home."
D) "I know these drops will make your eye feel better, but I can't let you take them home."
A

A patient has been diagnosed with glaucoma and the nurse is preparing health education
regarding the patient's medication regimen. The patient says she is eager to "beat this disease"
and looks forward to no longer needing medication. How should the nurse best respond?
A) "You have a great attitude. This will likely shorten the amount of time that you need
medications."
B) "In fact, glaucoma usually requires lifelong treatment with medications."
C) "Most people are treated until their intraocular pressure is below 50 mm Hg."
D) "You can likely expect a minimum of 6 months of treatment."
B

A public health nurse is teaching a health promotion workshop that focuses on vision and eye
health. What should this nurse cite as the most common causes of blindness and visual
impairment among adults over 40? Select all that apply.
A) Diabetic retinopathy
B) Trauma
C) Macular degeneration
D) Cytomegalovirus
E) Glaucoma
A, C, E

The nurse is providing discharge education to an adult patient that will begin a regimen of ocular
medications for the treatment of glaucoma. How can the nurse best determine if the patient can
self-administer these medications safely and effectively?
A) Assess the patient for any previous inability to self-manage medications.
B) Ask the patient to demonstrate the installation of her medications.
C) Determine whether the patient can accurately describe the appropriate method of
administering her medications
D) Assess the patient's functional status.
B

A patient has had a sudden loss of vision after head trauma. How should the nurse best describe
the placement of items on the dinner tray?
A) Explain the location of items using clock cues.
B) Explain that each of the items on the tray is clearly separated
C) Describe the location of items from the bottom to top.
D) Ask the patient to describe the location of items before confirming their location.
A

When administering a patient's eye drops, the nurse recognizes the need to prevent absorption by
the nasolacrimal duct. How can the nurse best achieve this goal?
A) Ensure the patient is always well hydrated.
B) Encourage self-administration of eye drops.
C) Occlude the puncta after applying the medication.
D) Position the patient supine before administering eye drops.
C

A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure

on an outpatient basis. What subject should the nurse prioritize during discharge
education?
A) Risk factors for postoperative cytomegalovirus (CMV)
B) Compensating for vision loss for the next several weeks
C) Non-pharmacologic pain management strategies
D) Signs and symptoms of increased intraocular pressure
B

A patient with glaucoma has been presented for a scheduled clinic visit and tells the nurse that
she has begun taking an herbal remedy for her condition that was recommended by a work
colleague. What instruction should the nurse provide to the patient?
A) The patient should discuss this new remedy with her ophthalmologist promptly.
B) The patient should monitor her IOP closely for the next several weeks.
C) The patient should do further research on the herbal
D) The patient should report any adverse effects to her pharmacist.
A

While reviewing the health history of an older adult experiencing hearing loss the nurse
notes the patient has had no trauma or loss of balance. What aspect of this patient's health
history is most likely to be linked to the patient's hearing deficit?
A) Recent completion of radiation therapy for treatment of cancer
B) Routine use of quinine for management of leg cramps
C) Allergy to hair coloring and hair spray
D) Previous perforation of the eardrum
B

A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The
patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most
crucial to include in the patient's preoperative teaching?
A) The procedure is an effective, time-tested treatment for sensory hearing loss.
B) The patient is likely to experience resolution of conductive hearing loss after the procedure.
C) Several months of post-procedure rehabilitation will be needed to maximize benefits.
D) The procedure is experimental, but early indications of therapeutic benefits.
B

Which of the following nursing interventions would most likely facilitate effective
communication with a hearing-impaired patient?
A) Ask the patient to repeat what was said to evaluate understanding.
B) Stand directly in front of the patient to facilitate lip .test
C) Reduce environmental noise and distractions before communicating.
D) Raise the voice to project sound at a higher frequency.
C

The nurse is providing discharge education for a patient with a new diagnosis of Ménière's
disease. What food should the patient be instructed to limit or avoid?
A) Sweet pickles
B) Frozen yogurt
C) Shellfish
D) Red meat
A

A patient with otosclerosis has significant hearing loss. What should the nurse do to best
facilitate communication with the patient?
A) Sit or stand in front of the patient when speaking.
B) Use exaggerated lip and mouth movements when test
C) Stand in front of a light or window when speaking.
D) Say the patient's name loudly before starting to talk.
A

A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus
and hearing loss. What should the nurse teach this patient?
A) The hearing loss will likely resolve with time after the drug is discontinued.
B) The patient's hearing loss and tinnitus are irreversible at this point.
C) The patient's tinnitus is likely multifactorial, and not related to aspirin use.
D) The patient's tinnitus will abate as tolerance to aspirin develops.
A

A patient is postoperative on day 6 following tympanoplasty and mastoidectomy. The patient has
phoned the surgical unit and states that she is experiences occasional sharp, shooting pains in her
affected ear. How should the nurse best interpret this patient's complaint?
A) These pains are expected to be found during the first few weeks of recovery.
B) The patient's complaints are suggestive of a postoperative infection.
C) The patient may have experienced a spontaneous rupture of the tympanic membrane.
D) The patient's surgery may have been unsuccessful.
A

The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first
time. What is the most significant challenge experienced by a patient with hearing loss who is
adapting to using a hearing aid for the first time?
A) Regulating the tone and volume
B) Learning to cope with amplification of background noise
C) Constant irritation of the external auditory canal
D) Challenges in keeping the hearing aid clean while minimizing exposure to moisture
B

The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis
risk should the nurse prioritize in this patient's care?
A) Risk for disturbed sensory perception
B) Risk for unilateral neglect
C) Risk for falls
D) Risk for ineffective health maintenance
C
A patient with a sudden onset of hearing loss tells the nurse that he would like to begin
using hearing aids. The nurse understands that the health professional dispensing hearing
aids would have what responsibility?
A) Test the patient's hearing promptly.
B) Perform an otoscopy.
C) Measure the width of the patient's ear canal.
D) Refer the patient to his primary care physician.
D

The nurse is providing care for a patient who has benefited from a cochlear implant. The
nurse should understand that this patient's health history includes which of the following?
Select all that apply.
A) The patient was diagnosed with sensorineural hearing loss.
B) The patient's hearing did not improve appreciably with the use of hearing aids
C) The patient has deficits in peripheral nervous function of hearing aids.
D) The patient's hearing deficit is likely accompanied by a cognitive deficit.
E) The patient is unable to lip-read.
A, B

Which of the following nurse's actions carries the greatest potential to prevent hearing loss
due to ototoxicity?
A) Ensure that patients understand the differences between sensory hearing loss and conductive
hearing loss.
B) Educate patients about expected age-related changes in hearing perception.
C) Educate patients about the risks associated with prolonged exposure to environmental noise.
D) Be aware of patients' medication regimens and collaborate with other professionals
accordingly.
D
The nurse is caring for a patient who has undergone a mastoidectomy. To prevent postoperative
infection, what intervention should the nurse implement?
A) Teach the patient about the risks of ototoxic medications.
B) Instruct the patient to protect the ear from water for several weeks.
C) Teach the patient to remove cerumen safely at least once a week
D) Instruct the patient to protect the ear from temperature extremes until healing is complete.
B

A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse
to remember when caring for this patient?
A) Patient is likely unable to hear the nurse during test.
B) A person adept in sign language must be present during test
C) Lip reading will be the method of communication that is necessary.
D) The nurse should interact with the patient like any other patient
A

The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis
of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing
what action?
A) Placing the patient in a prone position
B) Assisting the patient into a sitting position
C) Instilling 15 mL of warm normal saline into one of the patient's ears
D) Assessing the patient's baseline hearing by performing the whisper test
B

On otoscopy, a red blemish behind the tympanic membrane is suggestive of what

diagnosis?
A) Acoustic tumor
B) Cholesteatoma
C) Facial nerve neuroma
D) Glomus tympanicum
D

The nurse is discharging a patient home after mastoid surgery. What should the nurse include in
discharge teaching?
A) "Try to induce a sneeze every 4 hours to equalize pressure."
B) "Be sure to exercise to reduce fatigue."
C) "Avoid sleeping in a side-lying position."
D) "Don't blow your nose for 2 to 3 weeks."
D

A client diagnosed with benign paroxysmal positional vertigo is experiencing an acute attack.
The client is prescribed a vestibular suppressant. Which would the nurse anticipate being used?
A) scopolamine
B) meclizine
C) dimenhydrinate
D) promethazine
B

A nurse suspects that an older adult client may be experiencing hearing loss. Which finding
would support the nurse's suspicion? Select all that apply.
A) dropping of word endings
B) disinterest in conversations
C) social withdrawal
A. B, C

A client with hearing loss is scheduled to undergo aural testing. When describing this
therapy, the nurse would include which information as the primary purpose?
A) increase hearing ability
B) maximize ability to communicate
C) facilitate use of a hearing aid
D) limit extraneous noise
B

A client develops a perforated eardrum. When teaching the client about this condition, the nurse
would identify which condition as a most probable cause?
A) infection
B) otosclerosis
C) Meniere's disease
D) cholesteatoma
A
Exam Questions for Week 2 Med Surg

Based on PowerPoint:
Integumentary Function & Dermatological Disorders
What is the largest organ in the body?
 Answer: Skin
Which function of the skin is primarily involved in temperature regulation?
 Answer: Sweat glands
Name a common symptom of dermatologic disorders that may also indicate internal disease.
 Answer: Pruritis (itching)
Which chronic, noninfectious skin disease involves rapid skin cell turnover and scaling?
 Answer: Psoriasis
Identify one nursing intervention for patients with psoriasis.
 Answer: Educate on avoiding skin injury and dryness.
What should patients avoid reducing itching associated with pruritis?
 Answer: Hot baths and vigorous towel drying
What type of infection is Tinea Pedis?
 Answer: Fungal (Athlete's foot)
List two viral infections that affect the skin.
 Answer: Herpes simplex, Herpes zoster (shingles)
Which bacterial skin infection is characterized by yellowish, crusted lesions?
 Answer: Impetigo
What should be avoided to prevent the spread of impetigo?
 Answer: Sharing towels and personal items

Skin Infections and Infestations

Name two types of lice infestations.
 Answer: Pediculosis capitis (head lice), Pediculosis corporis (body lice)
Which skin infestation is characterized by burrows in the skin and increased itching at night?
 Answer: Scabies
What is a major component of patient education for fungal skin infections?
 Answer: Keep skin folds and feet dry, avoid sharing towels.
What are two nursing interventions for patients with skin grafts?
 Answer: Monitor for drainage, promote immobilization
Which disorder may result in 100% skin loss and require burn-like treatment?
 Answer: Stevens-Johnson Syndrome

Burns and Burn Care

What is the primary nursing goal during the emergent phase of burn care?
 Answer: Establish airway, breathing, and circulation (ABCs)
What is the most commonly used method for estimating Total Body Surface Area (TBSA) in
burn patients?
 Answer: Rule of Nines
What is a common complication for patients in the emergent/resuscitative phase of burn care?
 Answer: Acute respiratory failure
What type of burn involves only the epidermis?
 Answer: First-degree burn
What are common signs of third-degree burns?
 Answer: Total destruction of skin layers, no pain at burn site
What kind of shock is commonly associated with severe burns?
 Answer: Hypovolemic shock
What formula is often used for fluid resuscitation in burn patients?
 Answer: Parkland Baxter formula
Name a nursing intervention to minimize risk of infection in burn wound care.
 Answer: Use sterile technique during dressing changes.
How should chemical burns be treated initially?
 Answer: Irrigate with large amounts of water
What is the priority nursing intervention when preparing for burn wound debridement?
 Answer: Administer pain medication before procedure

Pain Management
What is the most reliable indicator of pain?
 Answer: The patient’s self-report
Which pain scale is commonly used for children and patients with communication difficulties?
 Answer: Wong-Baker FACES Scale
What type of pain is associated with nerve damage?
 Answer: Neuropathic pain
Which non-opioid is commonly used for mild to moderate pain and has minimal GI side effects?
 Answer: Acetaminophen
Why should NSAIDs be used cautiously in older adults?
 Answer: Increased risk for GI toxicity
Which medication is commonly used as an adjunct for neuropathic pain?
 Answer: Gabapentin
What is a common adverse effect of opioid analgesics?
 Answer: Respiratory depression
For breakthrough pain, which class of medication is preferred?
 Answer: Fast-acting opioids
How does punctual occlusion help when administering eye drops for glaucoma?
 Answer: Reduces systemic absorption
Which chronic condition commonly requires life-long pain management?
 Answer: Osteoarthritis
Eye and Ear Disorders
What is the leading cause of blindness in adults in the U.S.?
 Answer: Glaucoma
What is the clinical manifestation of cataracts?
 Answer: Painless, blurry vision
Which test compares bone and air conduction in hearing assessment?
 Answer: Rinne test
Name one common symptom of otitis media.
 Answer: Ear pain (otalgia)
What should be avoided in patients with tympanic membrane perforation?
 Answer: Water entry into the ear

Additional Concepts
What nursing care is crucial in managing a patient with impaired vision?
 Answer: Promoting spatial orientation and safety
What precaution should a nurse take when dealing with a patient suspected of having scabies?
 Answer: Wear gloves when providing care
What is the priority for patients in the acute/intermediate phase of burn recovery?
 Answer: Preventing infection
What is the preferred route for administering pain medication in severe burn cases?
 Answer: Intravenous (IV)
Which electrolyte imbalance is commonly seen in patients with major burns?
 Answer: Hyperkalemia
What should be monitored in patients with Ménière’s disease?
 Answer: Fluid intake and low-sodium diet
Which dietary recommendation can help manage vertigo in Ménière’s disease?
 Answer: Low-sodium diet
What is the key nursing assessment for pressure injuries?
 Answer: Regular skin inspection for erythema and blanching response
Name a factor that increases the risk of pressure injuries in hospitalized patients.
 Answer: Immobility
What is the typical initial treatment for conjunctivitis?
 Answer: Antibiotic or antiviral eye drops, depending on the cause