Final Coaching: MS 2

By: Keith Kainne “D” Garino, RN, LPT, MAEd

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 1. A nurse sees smoke coming from a client’s hospital room. When
entering the room, the nurse notes that the client is standing on the far
side of the room with clothing on fire. Which action should be taken by
the nurse immediately?

A. Go find the nearest fire alarm box.

B. Grab a blanket to smother the fire.
C. Obtain water to douse the clothes.
D. Tell the client to drop and roll on the floor.

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 2. What should a nurse do first when a hospitalized client tells the
nurse about feeling a strong shock when turning on an electric
hairdryer?

A. Assess the client’s apical pulse.

B. Disconnect the hairdryer from the electrical outlet.
C. Assess the client’s skin for signs of an electrical burn.
D. Send the hairdryer to the maintenance department for inspection.

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 3. The burned client is ordered to receive intravenous cimetidine, a
histamine 2 blocking agent, during the emergent phase. When the
client’s family asks why this drug is being given, what is the nurse’s best
response?

A. “To increase the urine output and prevent kidney damage.”

B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and
prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and prevent
hypovolemic shock.”

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 4. A child is presenting with burn injuries. What should be the nurse’s
priority during the initial assessment?
A. Assess the child’s and family’s concerns regarding the child’s
appearance.
B. Assess for signs of smoke inhalation and burns to the face and neck.
C. Inspect location, extent, and shape of burn injuries.
D. Assess for signs and symptoms of infection.

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 5. A nurse is caring for a toddler with second and third-degree burns
over 20% of the body 8 hours postinjury. The most critical nursing
diagnosis for this patient is:
A. imbalanced nutrition: less than body requirements.
B. risk for imbalanced body temperature.
C. impaired physical mobility.
D. deficient fluid volume.

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 6. A nurse is assessing a 16-year-old adolescent in an emergency
department who has been admitted because of burns over 25% of the
client’s body. Upon initial examination, the nurse makes several
observations. Which observation should be most concerning to the
nurse?

A. Areas on upper extremities are mottled.

B. Areas on lower extremities are waxy white.
C. Red blistering on anterior lower extremities.
D. Areas on upper extremities are moist and red.

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 Depth/Degree Layer of Skin Appearance Sensation Healing Scarring

Superficial-
Pain eased by
thickness Epidermis Pink to red 3-6 days Negative
cooling
(1st degree)

Superficial partial-
Pink to red with Painful and
thickness Dermis 10-21 days Negative
blisters sensitive to cold air
(2nd degree)

Deep partial-
Red, white or
thickness Dermis Painful 3-6 weeks Positive
Mottled
(2nd degree)

Waxy white, deep

Full-thickness
Dermis red, yellow, brown, Reduced or absent Weeks-months Positive
(3rd degree)
or black

Deep full-thickness Muscle, fascia,

Black Absent Months Positive
(4th degree) bone, tendons
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 7. In planning the care for a client recovering from second- or third-
degree burns, which psychosocial nursing diagnosis should have the
highest priority?

A. Disturbed sensory perception.

B. Disturbed thought processes.
C. Disturbed personal identity.
D. Disturbed body image.

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 8. A client is brought to the emergency department after a severe burn
caused by a fire at home. The burns are extensive, covering greater
than 25% of the total body surface area. When the nurse reviews the
laboratory results drawn on the client, which value should the nurse
most likely expect to note?
A. Hematocrit 65%
B. Albumin 4.5 g/dL
C. Sodium 145 mEq/L
D. White blood cell count 7000 cells/mm3

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 9. A nurse is beginning client care and has been assigned to the
following four clients. Which client should the nurse plan to assess
first?
A. A 50-year-old client who has chronic pancreatitis and is reporting a
pain level of 6 out of 10 on a numeric scale.
B. A 47-year-old client with esophageal varices who has influenza and
has been coughing for the last 30 minutes.
C. A 60-year-old client who had an open cholecystectomy 15 hours ago
and has been stable through the night.
D. A 54-year-old client with cirrhosis and jaundice who is reporting
itching.

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 10. A nurse receives a change-of-shift report for four assigned clients. Which clients
should the nurse attend to first? Prioritize the order in which the nurse should plan
to attend to the clients.
I. A 44-year-old client who has questions about how to empty the Jackson-Pratt
drain at home after being discharged tomorrow.
II. A 33-year-old client who has a new order to insert a nasogastric (NG) tube and
connect to low intermittent suction.
III. A 58-year-old client requesting a pain medication for abdominal incision pain
rated at a 6 on a 0–10 scale.
IV. A usually oriented 76-year-old client diagnosed with thrombophlebitis who is
cyanotic.

A. I, II, III, IV
B. IV, III, II, I
C. IV, II, III, I
D. II, IV, III, I

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 11. A nurse is planning care for four clients. Prioritize the order in which the
nurse should plan to attend to the clients.
1. A 13-year-old client waiting to be admitted from the emergency
department after receiving stitches for facial lacerations from a dog bite
2. A 9-year-old client whose mother is present to receive teaching about
wound care for her child’s left leg skin graft in anticipation of discharge
tomorrow
3. A 5-year-old client with an infected leg wound who is scheduled for a
dressing change now
4. A 2-year-old client whose temperature has risen to 39.9°C

A. 1, 2, 3, 4 B. 4, 3, 2, 1
C. 4, 3, 1, 2 D. 1, 4, 3, 2

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 12. A triage nurse, working in an emergency department, receives four
admissions. Prioritize the order in which the nurse should assess the
clients.
1. An 18-year-old client who thinks he might have a broken ankle
2. A 40-year-old client who is diaphoretic and is feeling chest pressure
3. A 35-year-old client who cut her hand with a knife while preparing
food
4. A 60-year-old client who is dyspneic and has swollen lips after being
stung by a bee

A. 2, 4, 3, 1 B. 2, 4, 1, 3
C. 4, 2, 3, 1 D. 4, 2, 1, 3

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 13. A nurse working on a telemetry unit is planning to complete noon
assessments for four assigned clients with type 1 diabetes mellitus. All the
clients received subcutaneous Novolog at 8:00am. In which order should the
nurse assess the clients?
1. A 45-year-old client who is dyspneic and has chest pressure and new onset
atrial fibrillation
2. A 60-year-old client who is nauseous and has just vomited for the second
time
3. A 75-year-old client with a fingerstick blood glucose level of 300 mg/dL
4. A 50-year-old client with a fingerstick blood glucose level of 70 mg/dL

A. 1, 2, 3, 4 C. 1, 3, 2, 4
B. 3, 1, 2, 4 D. 2, 3, 1, 4

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 14. Which injured client of a mass casualty disaster should a triage
nurse in an emergency department establish as the priority client?
A. An unresponsive client with a penetrating head injury.
B. A partially responsive client with a sucking chest wound.
C. A client with third-degree burns over 65% of the body surface area
D. A client with a maxilla fracture and facial wounds without airway
compromise.

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Priority Color Condition Notes

Requires immediate care for a good probability of

1 Red Immediate survival.
“Red can convert to yellow after an intervention”

Requires care that can be safely delayed without

2 Yellow Urgent affecting
probability of survival.

3 Green Delayed “walking wounded”

Alive, but with little or no chance of survival given

4 White/Black Expectant/Dead current available resources.
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“Dead”
 15. A client is admitted to an emergency department with multiple injuries
from a motor vehicle accident. A nurse sees that the client’s head had been
immobilized at the scene. Prioritize the nurse’s management of the client
during admission to the emergency department.
I. Control hemorrhage.
II. Carry out a more thorough examination.
III. Establish airway patency and ventilation.
IV. Evaluate for head and neck injuries and other injuries.

A. III, I, IV, II
B. III, IV, I, II
C. I, III, II, IV
D. III, I, II, IV

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 16. A school-aged child is brought to an emergency department by
ambulance. The child is minimally responsive, hypotensive, tachycardic,
and has a high fever. Orders are written by doctor. Which order should
the nurse initiate first?
A. Saline bolus per weight-based protocol
B. Ampicillin 25 mg/kg IV q6h
C. Oxygen at 40% FIO2
D. Blood cultures

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 17. Which medication should a nurse apply topically in second- and
third-degree burns to treat bacterial and yeast infections?
A. Gold sodium thiomalate
B. Bismuth subsalicylate
C. Silver sulfadiazine
D. Arsenic trioxide

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 18. A nurse is assessing a client following a skin graft. The nurse should
suspect infection in the grafted wound when observing that the client
has:
A. elevated temperature.
B. decreased urine output.
C. serosanguineous drainage.
D. a white blood cell count (WBC) of 7000 per microliter.

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 19. An adult client is admitted to the emergency department after a
burn injury. The burn initially affected the upper half of the client’s
anterior torso, lower half of both arms, the anterior of the head, and
the upper half of the posterior torso. Using the rule of nines, the extent
of the burn injury would be what percent?
A. 31.5%
B. 22.5%
C. 36%
D. 45%

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 20. A 30-year-old female patient has deep partial thickness burns on
the front and back of the right and left leg, front of right arm, and
anterior trunk. The patient weighs 63 kg. Use the Parkland Burn
Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based
on the total you calculated?

A. 921 mL/hr
B. 922 mL/hr
C. 7,371 mL/hr
D. 14,742 mL/hr

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 21. During a hospital admission history, a nurse suspects
gastronesophageal reflux disease (GERD) when the client says:
A. “I have been waking up at night lately with a burning feeling in my
chest.”
B. “I have been experiencing headaches immediately after eating.”
C. “I have been waking up at night sweating.”
D. “Immediately after eating I feel sleepy.”

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 22. To decrease the symptoms of gastroesophageal reflux disease
(GERD), the physician orders dietary and medication management. The
nurse should teach the client that the meal alteration that would be
most appropriate would be:

A. Ingest spicy foods.

B. Divide food into six to ten meals a day.
C. Eat the last of three meals daily by 8pm.
D. Suck a peppermint candy after each meal.

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 23. The client is a 49-year-old man with a hiatal hernia, whom you are
about to counsel. Health care counseling for the client should include
which of the following?

A. Restrict intake of high-carbohydrate foods.

B. Eat three regular meals a day.
C. Increase fiber intake.
D. Increase fat intake.

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 24. The client is a 49-year-old man with a hiatal hernia, whom you are
about to counsel. Which of the following medications is
contraindicated to a client with hiatal hernia?
A. Calcium carbonate
B. Metoclopramide
C. Ranitidine
D. Atropine

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 25. A client who has been diagnosed with gastritis is admitted to the
ER. Which of the following findings would the nurse report to the
physician?
A. Hematemesis, tachycardia, and hypotension.
B. Hemoptysis, bradycardia, and hypotension.
C. Headache, hiccups, and heartburn.
D. Anorexia, nausea, and vomiting.

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 26. The nurse is taking care of a client with a diagnosis of chronic
gastritis. Which of the following interventions is inappropriate for the
client?
A. Administrations of antibiotics as ordered.
B. Instructing the client to have a bland diet.
C. Instructing the client to avoid caffeine, smoking, and alcohol.
D. Providing information about the importance of an oral vitamin B12
supplement if a deficiency is present.

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 27. A client with a diagnosis of peptic ulcer disease complains of
burning pain that occurs in the midepigastric area 2 to 3 hours after a
meal and during the night. Based on the client’s complaint, the nurse
knows that the location of the ulcer is most likely in which of the
following areas?
A. Anus
B. Stomach
C. Esophagus
D. Duodenum

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 28. A client with peptic ulcer disease was admitted to the ER. The client
reports having vomited blood for several hours. Which of the following
interventions is contraindicated for the client?
A. Monitor vital signs closely.
B. Monitor hemoglobin and hematocrit.
C. Administer blood transfusion as ordered.
D. Increasing the client’s oral fluid intake to prevent dehydration.

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 29. The nurse is having a health education session with a client who has
peptic ulcer disease. Which of the following statements, if made by the
patient, would require further teaching?
A. “I need to avoid drinking alcohol.”
B. “I need to have adequate rest and avoid stress.”
C. “I can drink coffee as long as it is decaffeinated.”
D. “I will avoid using aspirin for my stomach aches.”

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 30. The nurse is taking care of a client who has undergone gastric
surgery. Following gastric surgery, which of the following interventions
is contraindicated for the client?
A. Irrigate the NG tube when the client is nauseous.
B. Place the patient in fowler’s position.
C. Monitor for signs of bleeding.
D. Maintain NPO status.

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 31. After Billroth II surgery (gastrojejunostomy), a client experiences
weakness, diaphoresis, anxiety, and palpations 2 hours after a high
carbohydrate meal. A nurse should interpret that these symptoms
indicate the development of:
A. steatorrhea.
B. duodenal reflux.
C. postprandial hypoglycemia.
D. hypervolemic fluid overload.

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 32. A nurse is discharging a client after Billroth II surgery
(gastrojejunostomy). To assist the client to control dumping syndrome,
the client’s discharge instructions should include all of the following,
except:
A. Increasing fiber intake as tolerated.
B. Eliminate caffeine containing products.
C. Limiting intake of simple carbohydrates.
D. Increasing intake of milk and dairy products.

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 33. While reviewing a client’s medical records, a nurse notes the
diagnosis of biliary colic. Considering this diagnosis, which additional
sign will the nurse most likely find in the client’s medical record?
A. Bloody diarrhea
B. Abdominal distention
C. Severe abdominal pain
D. Heartburn and regurgitation

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 34. The nurse is evaluating the dietary counselling of a client with
cholecystitis. The nurse evaluates that the client understands the
instructions given if the client states that which food item is
acceptable?
A. Baked fish
B. Fried chicken
C. Sauces and gravies
D. Fresh whipped cream

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 35. A nurse is caring for a client who is 6 hours post–open
cholecystectomy. The client’s T-tube drainage bag is empty, and the
nurse notes slight jaundice of the sclera. Which action by the nurse is
most important?
A. Notifying the surgeon about these findings.
B. Checking the client’s blood pressure immediately.
C. Repositioning the client to promote T-tube drainage.
D. Recording the findings and continuing to monitor the client.

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 36. The serum ammonia level of a client with cirrhosis is elevated. As a
priority, a nurse should plan to:
A. observe for increasing confusion.
B. measure the urine specific gravity.
C. restrict the client’s oral fluid intake.
D. monitor the client’s temperature every 4 hours.

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 37. The nurse is caring for a male client with cirrhosis. Which
assessment findings indicate that the client has deficient vitamin K
absorption caused by this hepatic disease?

A. Ascites
B. Jaundice
C. Purpura and petechiae
D. Gynecomastia and testicular atrophy

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 38. The nurse is assigned to care for a client being admitted to the
hospital with a diagnosis of cirrhosis and ascites. Which dietary
measure should the nurse expect to be prescribed for the client?
A. Sodium restriction.
B. Increased fat intake.
C. Decreased carbohydrates.
D. Calorie restriction of 1500 daily.

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 39. A client diagnosed with cirrhosis is scheduled for a transjugular
intrahepatic portosystemic shunt (TIPS) placement. A nurse realizes the
client does not understand the procedure when the client says:
A. “I know the shunt they are placing could become occluded in the
future.”
B. “This procedure should keep me from getting so much fluid buildup
in my abdomen.”
C. “I hope my abdominal incision heals better after this procedure then
it did when I had my appendix out.”
D. “This procedure should decrease the risk that I might have another
episode of bleeding from my esophagus.”

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 40. After completing discharge education, a nurse recognizes the need
for further teaching when a client, diagnosed with cirrhosis, says:
A. “I plan to stop drinking alcohol.”
B. “I am going to work only part-time.”
C. “I know propranolol has been ordered to decrease my blood
pressure.”
D. “I know spironolactone will help to keep me from developing
abdominal swelling.”

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 41. A nurse has been caring for a client with a Sengstaken-Blakemore
tube. The physician arrives on the nursing unit and deflates the
esophageal balloon. Afterward, the nurse should monitor the client
most closely for which of the following?
A. Hematemesis
B. Bloody diarrhea
C. Swelling of the abdomen
D. An elevated temperature and a rise in blood pressure

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 42. During a hospital admission history, a nurse suspects acute
pancreatitis when a 40-year-old client reports:
A. the sudden onset of intense pain in the upper left abdominal
quadrant that radiates to the back.
B. persistent abdominal pain in the lower abdomen that has shifted to
the lower right quadrant.
C. mild upper abdominal pain and projectile vomiting.
D. bloody diarrhea and colicky abdominal pain.

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 43. While performing an assessment of a client with acute pancreatitis,
a nurse notes a bluish flank discoloration. What should be the nurse’s
interpretation of this finding?
A. Portal hypertension has developed.
B. Seepage of blood-stained exudates from the pancreas has occurred.
C. The pancreatitis has caused the stomach to bleed, and the blood is
now in the interstitial tissue.
D. An intestinal obstruction that has increased vascular pressure has
developed due to the pancreatic inflammation.

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 44. A client recovering from acute pancreatitis that has been NPO asks
a nurse when he can begin eating again. Which response by the nurse
is most accurate?
A. “As soon as you start to feel hungry you can begin eating.”
B. “When you have active bowel sounds and you are passing flatus.”
C. “When your pain is controlled, and your serum lipase level has
decreased.”
D. “Oral intake stimulates the pancreas so you will need to be NPO for
at least 2 weeks from the day your disease was diagnosed to allow the
pancreas to heal.”

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 45. A client diagnosed with pancreatitis, is concerned about pain
control. A nurse explains to the client that the initial plan for controlling
the pain of chronic pancreatitis involves the administration of:
A. NSAIDs.
B. opioid analgesic medications.
C. acetaminophen and low-carbohydrate diet.
D. pancreatic enzymes with H2 blocker medications.

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 46. The nurse is taking care of a client diagnosed with constipation-
predominant irritable bowel syndrome. Which of the following
interventions is inappropriate for the client?
A. Increasing fluid intake.
B. Increasing fiber intake.
C. Giving Alosetron as ordered.
D. Giving Lubiprostone as ordered.

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 47. A client with ulcerative colitis is admitted to the hospital. Which of
the following findings would NOT correlate with ulcerative colitis?
A. Rectal bleeding.
B. Severe diarrhea.
C. Continuous inflammation.
D. Fistula and cobble stone formation.

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 Chronic Inflammatory Bowel Disorders
(Remission, Exacerbation & Malabsorption)
Findings Crohn’s Disease Ulcerative Colitis
Inflammation Discontinuous Continuous
And Transmural with fistula and cobble stone Mucosa & sub mucosa
Infection Crampy Crampy
Location Terminal ileum Rectum
Tenesmus
Bowel movement Less severe diarrhea Severe diarrhea
Semi solid With blood
Malabsorption Malnutrition Malnutrition
Anemia Anemia
Vitamin K deficiency
Surgery
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 48. Which of the following interventions should be included in the
medical management of Crohn’s disease?
A. Administering laxatives
B. Increasing physical activity
C. Increasing oral intake of fiber
D. Using long-term steroid therapy

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 49. While conducting a home visit with a client who had a partial
resection of the ileum for Crohn’s disease 4 weeks previously, a nurse
becomes concerned when the client says:
A. “My stools float and seem to have fat in them.”
B. “I have gained 5 pounds since I left the hospital.”
C. “I only have two formed stools per day.”
D. “I am still avoiding milk products.”

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 50. While discharging a 25-year-old female client after a small bowel
resection for Crohn’s disease, a nurse overhears the client talking to her
husband and realizes that the client needs more education when the
client says:
A. “I’ll need to continue to monitor my weight.”
B. “I will probably have to take vitamin supplement.”
C. “I’m so glad I won’t ever need any more surgeries.”
D. “If I have another exacerbation, I know they will probably put me
back on hydrocortisone.”

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 51. A client who is suspected of having appendicitis is admitted to the
ER. Which of the following findings would correlate with appendicitis?
A. Decreased white blood cell count.
B. Client in side-lying position, with abdominal guarding and legs flexed.
C. Pain in the periumbilical area that descends to the left lower
quadrant.
D. Pain at the right upper quadrant upon taking a deep breath while
palpating the right subcostal area.

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 52. A doctor writes the following admission orders for a client with
possible appendicitis. Which order should the nurse question?
A. Keep client NPO (nothing per mouth).
B. Apply heat to abdomen to decrease pain.
C. Start lactated Ringer’s solution intravenously (IV) at 125 mL/hr.
D. Withhold analgesic medications to avoid masking critical changes in
symptoms.

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 53. The nurse is taking care of a client who has undergone an
appendectomy with a drain inserted. Which of the following
postoperative interventions should be included in the client's plan of
care?
A. Place the client on strict bed rest.
B. Report any profuse drainage for the first 12 hours.
C. Allow oral intake prior to the return of bowel sounds.
D. Position the client in a right side-lying or low, semi-Fowler’s position,
with legs flexed.

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 54. A nurse is assessing a client diagnosed with acute diverticulitis.
Which finding should make the nurse suspect that the client has an
intestinal perforation?
A. Elevated white blood cells (WBCs)
B. Temperature of 38.3°C
C. Absent bowel sounds
D. Abdominal pain

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 55. A client who is complaining of rectal pain, itching, and bright red
bleeding on defecation is admitted to the hospital. Which of the
following interventions is inappropriate for a client who is diagnosed
with hemorrhoids?
A. Limit fiber intake.
B. Encourage regular exercise.
C. Encourage the client to drink plenty of water.
D. Apply cold packs to the anal-rectal area followed by sitz baths as
prescribed.

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 56. A client with hyperpituitarism has undergone transsphenoidal
hypophysectomy. Which of the following postoperative interventions
should be included in the client’s plan of care?
A. Place the client in supine position.
B. Document any excess in urinary output.
C. Instruct the client to avoid blowing of the nose.
D. Instruct the client to use a hard bristled toothbrush.

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 57. A client who has undergone hypophysectomy has been diagnosed
with diabetes insipidus. Which of the following laboratory findings
would the nurse expect in the client’s medical records?
A. Serum sodium – 160 mEq/L
B. Urine specific gravity - 1.035
C. Urine osmolality – 2000 mOsm/kg
D. Serum osmolality – 200 mOsm/kg

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 58. The nurse is taking care of a client who has been diagnosed with
diabetes insipidus. Which of the following interventions is appropriate
for the client?
A. Instructing the patient to increase fluid intake when taking
vasopressin.
B. Administration of hypertonic saline as ordered.
C. Tell the client to avoid caffeinated drinks.
D. Monitoring body weight weekly.

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 59. A client has developed syndrome of inappropriate antidiuretic
hormone secondary to a pituitary tumor. The client’s symptoms include
thirst, weight gain, and fatigue. The client’s serum sodium is 120
mEq/L. Which physician order should the nurse anticipate when
treating SIADH?
A. Administration of .45% NaCl.
B. Administration of loop diuretics.
C. Administration of vasopressin antagonist.
D. Place the patient in semi-fowler’s position.

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 60. An adolescent is admitted with a diagnosis of suspected Addison’s
disease. Which assessment manifestations should the nurse expect to
find if Addison’s disease is the correct diagnosis?
A. Long history of fatigue, weight loss, and muscle tetany.
B. Sudden onset of skin hypopigmentation, polydipsia, and
hyperactivity.
C. Gradual onset of salt craving decreased pubic and axillary hair, and
irritability.
D. Sudden onset of increasing weight gain, hirsutism, and skin
hyperpigmentation.

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 61. A client who has Addison’s disease is taking Fludrocortisone. Which
of the following would you tell the client about the intake of steroids?
A. Avoid foods high in potassium.
B. Take the medication in the evening.
C. Take the medication on an empty stomach.
D. Do not stop the intake of steroids abruptly.

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 62. A nurse teaches the parents of a child diagnosed with Addison’s
disease signs of Addisonian crisis. Which sign identified by the parents
indicates that further teaching is needed?
A. Severe hypertension
B. Abdominal pain
C. Seizures
D. Coma

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 63. Which medication should a nurse plan to administer to a client
admitted in Addisonian crisis?
A. Ketoconazole
B. Regular insulin
C. Hydrocortisone
D. Sodium nitroprusside

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 64. Which clinical change should indicate to a nurse that the therapy
for a client with Addisonian crisis is effective?
A. A decrease of 25 mm Hg in the client’s systolic blood pressure
B. An increase of 25 mm Hg in the client’s systolic blood pressure
C. An increase in the client’s serum potassium level from 3.4 to 4.8
mEq/dL
D. An increase in the client’s total serum calcium level from 8.6 to 10.0
mg/dL

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 65. The nurse is taking care of a client who has Cushing’s syndrome.
Which of the following nursing diagnoses should NOT be documented
in the client’s plan of care?
A. Body image disturbance related to weight gain and facial hair.
B. Risk for infection related to a decreased inflammatory response.
C. Disturbed thought processes related to mood swings and irritability.
D. Fluid and electrolyte imbalance related to hyperkalemia and
hypernatremia.

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 66. A nurse’s assessment of a client diagnosed with Cushing’s syndrome
includes the following findings: 4+ pitting leg edema, blood glucose 140
mg/dL, irregular heart rate, and ecchymosis on the right arm. Which
action should be taken by the nurse first?
A. Weigh the client.
B. Administer insulin.
C. Notify the physician.
D. Measure the client’s abdominal girth.

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 67. A client who has been diagnosed with Conn’s syndrome was
brought to the hospital. Which of the following medications would the
nurse expect to be prescribed to the client?
A. Lasix
B. Spironolactone
C. Hydrocortisone
D. Fludrocortisone

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 68. When assessing a male client with pheochromocytoma, a tumor of
the adrenal medulla that secretes excessive catecholamine, the nurse is
most likely to detect:
A. a blood pressure of 120/70 mm Hg.
B. a blood glucose level of 120 mg/dl.
C. a blood pressure of 176/90 mm Hg.
D. bradycardia.

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 Pheochromocytoma
Cause:
•

Diagnostic test:
• Vanillylmandelic acid

Complications:

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 Pheochromocytoma
1. Classic Sign

2. Triad
•H
•P
•D

3. Glucose

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 69. A nurse is caring for a client who is experiencing symptoms
associated with pheochromocytoma. Which intervention should be
included in the care of this client?
A. Encourage frequent intake of oral fluids.
B. Offer distractions such as television or music.
C. Administer nicardipine to control hypertension.
D. Assist with ambulation at least three times a day.

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 70. The nurse is performing an assessment on a client with
pheochromocytoma. Which assessment data would indicate a potential
complication associated with this disorder?
A. A urinary output of 50 mL/hour
B. A coagulation time of 5 minutes
C. A heart rate that is 90 beats/minute and irregular
D. A blood urea nitrogen level of 20 mg/dl (7.1 mmol/L)

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 71. Which nursing diagnosis should a nurse include when developing a
plan of care for a client with hypothyroidism?
A. Diarrhea related to gastrointestinal hypermotility.
B. Activity intolerance related to increased metabolic rate.
C. Anxiety related to forgetfulness, slowed speech, and impaired
memory loss.
D. Imbalance nutrition: less than body requirements related to calorie
intake insufficient for metabolic rate.

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 72. A clinic nurse is teaching a client who has been diagnosed with
hypothyroidism. Which instructions should NOT be included by the
nurse regarding the use of levothyroxine sodium?
A. Take the medication 1 hour before or 2 hours after breakfast.
B. Report adverse effects of the medication, including weight gain, cold
intolerance, and alopecia.
C. Use levothyroxine sodium as a replacement hormone for diminished
or absent thyroid function.
D. Obtain a pulse rate before taking the medication and call the clinic if
the pulse rate is greater than 100 beats per minute.

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 73. A client taking thyroid replacement hormone was involved in an
automobile accident and was hospitalized for a femur fracture. A week
after being hospitalized, a nurse notes that the client is becoming
increasingly lethargic. Vital signs show a decreased blood pressure,
respiratory rate, temperature, and pulse. In which order should the
actions be taken by the nurse?
1. Warm the client
2. Administer intravenous fluids
3. Assist in ventilatory support
4. Administer the prescribed thyroxine
A. 4, 3, 2, 1 B. 4, 3, 1, 2
C. 3, 2, 1, 4 D. 2, 3, 4, 1

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 74. A nurse is educating the parents of a school-aged child newly
diagnosed with hyperthyroidism. Until the disease is under control,
which instruction should be included in the education provided by the
nurse?
A. Increase stimulation in the school environment.
B. Discontinue physical education classes at school.
C. Restrict the number of calories from carbohydrate foods.
D. Dress your child in cold weather clothing even in warm weather.

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 75. A client is admitted in thyrotoxic crisis. Which manifestations
should a nurse NOT expect to observe during assessment?
A. Hypothermia
B. Tachycardia
C. Vomiting
D. Delirium

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 Thyroid Storm
Assessment: “VGLant BehaviorS”
1. V/S
2. GIT
3. LOC
4. Behavioral changes
5. Seizure

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 76. A nurse is caring for a client who had a thyroidectomy 2 days ago.
The client’s calcium level is 6 mg/dL, potassium 3.8 meq/L, and sodium
136 meq/L. Based on these findings, which medication should the
nurse plan to administer first?
A. Oral potassium BID
B. Levothyroxine 50 mcg PO daily
C. Dolasetron 12.5 mg IV as needed
D. Calcium gluconate 4.5 mEq intravenously (IV)

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 77. Which instruction should a nurse include when teaching a client
who was diagnosed with hypoparathyroidism?
A. Decrease intake of foods high in calcium and phosphorus.
B. Monitor for muscle spasms, tingling around the mouth, and muscle
cramps.
C. Monitor for side effects of excess medication therapy, including dry,
scaly, coarse skin.
D. Increase environmental stimuli and encourage participation in high-
energy activities.

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 78. The nurse is conducting a health history on a client with
hyperparathyroidism. Which question asked of the client would elicit
information about this condition?
A. “Do you have tremors in your hands?”
B. “Are you experiencing pain in your joints?”
C. “Have you had problems with diarrhea lately?”
D. “Do you notice any swelling in your legs at night?”

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 79. A client who is diagnosed with hyperparathyroidism has a calcium
level of 11 mg/dL. Which of the following findings would NOT be
expected for this client?
A. Constipation.
B. Bone and joint pain.
C. Positive trousseau’s sign.
D. Increased blood pressure.

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 80. The nurse is teaching a client with hyperparathyroidism how to
manage the condition at home. Which response by the client indicates
the need for additional teaching?
A. “I should limit my fluids to 1 liter per day.”
B. “I should use my treadmill or go for walks daily.”
C. “I should follow a moderate-calcium, high fiber diet.”
D. “My alendronate helps to keep calcium from coming out of my
bones.”

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 81. The mother of an adolescent diagnosed with type 1 diabetes
mellitus tells the nurse that her child is a member of the school soccer
team and expresses concern about her child's participation in sports.
The nurse, after providing information to the mother about diet,
exercise, insulin, and blood glucose control, tells the mother:
A. To always administer less insulin on the days of soccer games.
B. That it is best not to encourage the child to participate in sports
activities.
C. That the child should eat a carbohydrate snack about a half-hour
before each soccer Game.
D. To administer additional insulin before a soccer game if the blood
glucose level is 250 mg/dL (13.3 mmol/L) or higher and ketones are
present.

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 82. The nurse in an outpatient diabetes clinic is monitoring a client with
type 1 diabetes mellitus. Today’s blood work reveals a glycosylated
hemoglobin level of 10%. The nurse creates a teaching plan based on
the understanding that this result indicates which finding?
A. A normal value that indicates that the client is managing blood
glucose control well.
B. A value that does not offer information regarding the client’s
management of the disease.
C. A high value that indicates that the client is not managing blood
glucose control very well.
D. A low value that indicates that the client is not managing blood
glucose control very well.

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 83. A nurse is teaching a client who has been newly diagnosed with
type 2 diabetes mellitus. Which teaching point should the nurse
emphasize?
A. Use the arm when self-administering NPH insulin.
B. Exercise for 30 minutes daily, preferably after a meal.
C. Consume 30% of the daily calorie intake from protein foods.
D. Eat a 30-gram carbohydrate snack prior to strenuous activity.

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 84. A nurse is planning the first home visit for a 60-year-old client
newly diagnosed with type 2 diabetes mellitus. The client has been
instructed to take 70/30 combination insulin in the morning and at
suppertime. Which interventions should be included in the client’s plan
of care?
A. Instruct the client on storing prefilled syringes in the freezer.
B. Teach the client how to perform a hemoglobin A1c test.
C. Instruct the client to eat a bedtime snack.
D. Shake the syringe prior to administration.

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 85. The client found out that the symptoms of diabetes were caused by
high levels of blood glucose, he decided to break the habit of eating
carbohydrates. With this, the nurse would be aware that the client
might develop what complication?
A. Atherosclerosis
B. Retinopathy
C. Glycosuria
D. acidosis

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 86. The nurse teaches a client with diabetes mellitus about
differentiating between hypoglycemia and ketoacidosis. The client
demonstrates an understanding of the teaching by stating that a form
of glucose should be taken if which symptom or symptoms develop?
A. Polyuria
B. Excessive thirst
C. Lightheadedness
D. Fruity breath odor

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 87. The nurse performs a physical assessment on a client with type 2
diabetes mellitus. Findings include a fasting blood glucose level of 120
mg/dL (6.8 mmol/L), temperature of 101 °F (38.3 °C), pulse of 102
beats/minute, respirations of 22 breaths/minute, and blood pressure of
142/72 mm Hg. Which finding would be the priority concern to the
nurse?
A. Pulse
B. Respiration
C. Temperature
D. Blood pressure

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 88. Insulin is prescribed for clients with type 1 diabetes mellitus. Which
of the following statements about insulin is incorrect?
A. NPH insulin should be gently rolled between the palms prior to
administration.
B. Insulin can be administered at 45-60 degrees angle in a thin person.
C. Glargine (Lantus) can be mixed with another insulin.
D. Short acting insulin can be given through IV.

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 Insulin
1. “LOG/LAG rolls Rapidly”
• Lispro (Humalog)
• Aspart (Novolog)
• Glulisine (Apidra)
2. ShoRt
• Regular
3. Ntermediate “Not clear”
• NPH
4. Long is GUDD but “Lonely”
• Glargine (LantUs)
• Ultra Lente (Humulin U)
• Detemir (Levemir)
• Degludec (Tresiba)

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 89. A 39-year-old company driver presents with shakiness, sweating,
anxiety, and palpitations and tells the nurse he has Type I Diabetes
Mellitus. Which of the follow actions should the nurse do first?
A. Give 4 to 6 oz (118 to 177 mL) of orange juice.
B. Inject 1 mg of glucagon subcutaneously.
C. Administer 50 mL of 50% glucose I.V.
D. Administer insulin.

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 90. A nurse administers 15 units of Lantus insulin at 9pm to a client
when the client’s fingerstick blood glucose reading was 110 mg/dL. At
11pm, a nursing assistant reports to the nurse that an evening snack
was not given because the client was sleeping. Which instruction by the
nurse is most appropriate?
A. “The next time the client wakes up, check a blood glucose level and
then give a snack.”
B. “You will need to wake the client to check the blood glucose and
then give a snack. All diabetics get a snack at bedtime.”
C. “It is not necessary for this client to have a snack because Lantus
insulin is absorbed very slowly over 24 hours and doesn’t have a peak.”
D. “I will need to notify the physician because a snack at this time will
affect the client’s blood glucose level and the next dose of Lantus.”

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 91. Which physician’s order should the nurse question for a newly
admitted client diagnosed with diabetic ketoacidosis?
A. D5W at 125 mL per hour
B. KCL 10 mEq in 100 mL NaCl IV now
C. Stat arterial blood gases. Administer sodium bicarbonate if pH is less
than 7.0.
D. Regular insulin infusion per protocol adjusting dose based on hourly
glucose levels

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 92. When preparing to give the child his dose of combination regular
and NPH Insulin, the nurse should:
A. Inject air into the vial of regular insulin first.
B. Use two syringes, one for each type of insulin.
C. Withdraw the NPH insulin first then withdraw the regular insulin into
one syringe.
D. Withdraw the regular insulin first then withdraw the NPH insulin into
one syringe.

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 93. Which instruction about insulin administration should a nurse give
to a client?
A. “Shake the vials before withdrawing the insulin.”
B. “Discard the intermediate-acting insulin if it appears cloudy.”
C. “Store unopened vials of insulin in the freezer at temperatures well
below freezing.”
D. “Always follow the same order when drawing the different insulins
into the syringe.”

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 94. The nurse is caring for a client admitted to the emergency
department with diabetic ketoacidosis (DKA). In the acute phase, the
nurse plans for which priority intervention?
A. Correct the acidosis.
B. Administer 5% dextrose intravenously.
C. Apply a monitor for an electrocardiogram.
D. Administer short-duration insulin intravenously.

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 95. Rotating injection sites when administering insulin prevents which
of the following complications?
A. Insulin edema
B. Insulin resistance
C. Insulin lipodystrophy
D. Systemic allergic reactions

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 96. A patient with type 2 DM is scheduled for CT scan with contrast
dye. Which of the following medications should be withheld prior to
the procedure?
A. Metformin
B. Glargine
C. Novolog
D. NPH

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 97. A nurse is evaluating a client’s outcome. The client’s nursing care
plan includes the nursing diagnosis of fluid volume deficit related to
hyperosmolar hyperglycemic nonketotic syndrome (HHNS) secondary
to severe hyperglycemia. The nurse knows that the client has a positive
outcome when which serum laboratory value has decreased to a
normal range?
A. Glucose
B. Sodium
C. Osmolality
D. Potassium

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 98. The nurse is taking care of a diabetic client. The nurse observes that
the client’s blood sugar level was elevated at bedtime and would
decrease at 2 to 3 a.m. The client also complains of night sweats and
morning headaches. The client is most likely experiencing which of the
following?
A. Diabetic acidosis
B. Dawn phenomenon
C. Somogyi phenomenon
D. Hyperosmolar Hyperglycemic Syndrome

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 99. A client with type 1 diabetes is experiencing hyperglycemia upon
awakening in the morning. Which of the following interventions is
appropriate for the client?
A. Increase bedtime snack.
B. Avoiding insulin at night.
C. Decrease in insulin dose.
D. Change in time of insulin administration.

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 100. The nurse is preparing to test the visual acuity of a client using a
Snellen chart. Which of the following identifies the accurate procedure
for this visual acuity test?
A. The right eye is tested followed by the left eye, and then both eyes
are tested.
B. Both eyes are assessed together, followed by the assessment of the
right and then the left eye.
C. The client is asked to stand at 40ft. from the chart and is asked to
read the largest line on the chart.
D. The client is asked to stand at 40ft from the chart and to read the
line that can be read 200 ft away by an individual with unimpaired
vision.

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 101. The client’s vision is tested with a Snellen chart. The client is
standing at 10ft. from the chart and can read the line that can be read
70 ft away by an individual with normal visual acuity. The nurse should
document the findings as:
A. 20/70
B. 70/20
C. 10/70
D. 70/10

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 102. A client’s eyes are tested with the use of a Snellen chart. The
assessment is documented as 20/40 in the right eye and 20/30 in the
left eye. How should a nurse interpret these results?
A. The client has presbyopia.
B. The client has elevated intraocular pressure in both eyes.
C. The client has errors of refraction in both eyes consistent with
myopia.
D. The vision in the right eye is closer to normal vision than the vision in
the left eye.

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 103. The nurse is taking care of a client with astigmatism. Which of the
following statements is accurate about the client’s condition?
A. Refractive ability of the eye is too strong for the eye length.
B. Refractive ability of the eye is too weak for the eye length.
C. Occurs because of the irregular curvature of the cornea.
D. Loss of lens elasticity because of aging.

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 Refractive Errors

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 104. An older adult with cataract is admitted to hospital. Which of the
following findings is a late sign of cataract?
A. Blurred vision
B. Nausea and vomiting
C. Decreased color perception
D. White discoloration of the eye

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 105. Which of the following post-op interventions is inappropriate for a
client who has undergone cataract extraction?
A. Assist client with ambulation.
B. Turn the client to the back or operative side.
C. Elevate the head of the bed 30 to 45 degrees.
D. Position the client’s personal belongings to the nonoperative side.

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 106. A client with close-angle glaucoma was sent to the ER. Which of
the following findings would not correlate to close-angle glaucoma?
A. Blurred vision
B. Ocular erythema
C. Halos around lights
D. Painless and increased IOP

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 107. Which of the following medications is contraindicated for a client
with glaucoma?
A. Acetazolamide
B. Pilocarpine
C. Betaxolol
D. Atropine

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 Glaucoma

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 108. A hospitalized client recently diagnosed with glaucoma tells a
nurse that he finds it difficult to remember to administer the
prescribed eye drops. The client states that he does not feel any pain or
notice any vision changes if he forgets the drops. The best response by
the nurse is:
A. “Tell me about your usual day so you can fit the eye drops into your
schedule.”
B. “I know this must be hard for you. Not everyone is able to remember
everything.”
C. “You should be diligent in administering those eye drops, or you will
need surgery or laser treatments.”
D. “The medication controls the eye pressure. High pressure in the eye
leads to gradual, painless nerve damage affecting sight. Tell me how it’s
been for you since your diagnosis of glaucoma.”
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 109. A client with detached retina was sent to the ER. Which of the
following findings would not correlate with retinal detachment?
A. Flashes of light
B. Floaters or black spots
C. Increased in blurred vision.
D. Painful loss of a portion of the visual field.

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 110. Which of the following interventions is inappropriate for a client
with retinal detachment?
A. Allow client to ambulate.
B. Avoid jerky head movements.
C. Speak to the client before approaching.
D. Cover both eyes with patches as prescribed.

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 111. A client tells a nurse that he has been diagnosed with macular
degeneration, “wet type.” Based on the nurse’s knowledge of this
diagnosis, the nurse, examining this client’s eyes using an
ophthalmoscope, should expect to observe:
A. clouding of the lens of the eye.
B. atrophy of structures in the macula.
C. growth of abnormal blood vessels in the macula.
D. a thin, grayish-white area on the edge of the cornea.

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 112. A client diagnosed with macular degeneration is told the condition
is progressing to an advanced stage. When completing the client’s
health assessment, which findings should the nurse expect the client to
report?
A. Curtain appearance over part of the visual field
B. Visual distortions in the central vision
C. Loss of peripheral vision
D. Clouding of the lens

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 113. A client who has had a vehicular accident was sent to the ER. The
client has hyphema. Which of the following interventions is
inappropriate for the client?
A. Avoid sudden eye movements for 3 to 5 days.
B. Administer cycloplegic eye drops as prescribed.
C. Allow the client to read and watch television for a long period of
time.
D. Instruct the client in the use of eye shields or eye patches as
prescribed.

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 114. A client with penetrating eye injury was sent to the ER. Which of
the following interventions is appropriate for the client?
A. Remove the object immediately to lessen the damage.
B. Cover the eye with a cup and tape in place.
C. Place the patient in supine position.
D. Apply pressure to the affected eye.

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 115. A client arrives in the emergency department after sustaining a
chemical splash to the eye. The client tells the nurse that a bottle of
nail polish remover fell of the counter when bending over to open a
cabinet and that the polish remover splashed into the right eye. Which
of the following interventions is appropriate for the client?
A. Flush the eyes with water for at least 15 to 20 minutes.
B. Use a cotton applicator to remove the chemical.
C. Apply pressure to the affected eye.
D. Blow air into the affected eye.

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 116. The nurse is taking care of a client with conductive hearing loss.
Which of the following problems will not lead to conductive hearing
loss?
A. Otitis media
B. Otosclerosis
C. Otitis externa
D. Meniere’s syndrome

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 117. Which of the following interventions would facilitate
communication with a client with hearing loss?
A. Talk in a crowded area.
B. Talk directly to the client’s ear.
C. Talking in normal volume and at a lower pitch.
D. Moving close to the client and speaking quickly and clearly

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 118. A client was diagnosed with otosclerosis. Which of the following
findings would correlate to otosclerosis?
A. Pinkish discoloration of the tympanic membrane.
B. Slowly progressing sensorineural hearing loss.
C. Ear pain when chewing.
D. Unilateral hearing loss.

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 119. A client is diagnosed with a problem involving the inner ear. Which
is the most common client complaint associated with a problem
involving this part of the ear?
A. Pruritus
B. Tinnitus
C. Burning in the ear
D. Conductive hearing loss

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 120. The client sustains a contusion of the eyeball following a traumatic
injury with a blunt object. Which intervention would be initiated
immediately?
A. Notify the doctor.
B. Apply ice to the affected eye.
C. Irrigate the eye with cool water.
D. Bring the client to the emergency department.

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 121. The nurse notes that the doctor has documented a diagnosis of
presbycusis on a client’s chart. Based on this information, what action
would the nurse take?
A. Speak loudly but mumble or slur the words.
B. Speak loudly and clearly while facing the client.
C. Speak at normal tone and pitch, slowly and clearly.
D. Speak loudly and directly into the client’s affected ear.

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 122. A client with Ménière’s disease is experiencing severe vertigo.
Which instruction would the nurse give to the client to assist in
controlling the vertigo?
A. Increase sodium in the diet.
B. Avoid sudden head movements.
C. Lie still and watch the television.
D. Increase fluid intake to 3000 mL a day.

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 123. A client diagnosed with Ménière’s disease tells a nurse that
medication treatment for vertigo has been prescribed and provides the
nurse with a list of medications recently received. Which medication is
most likely prescribed for treating the vertigo?
A. Meclizine
B. Megestrol
C. Metoprolol
D. Meropenem

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 124. A client with otosclerosis had undergone a stapedectomy with
fenestration. Which of the following postoperative interventions is
appropriate?
A. Instruct the client to move the head rapidly when changing positions
to prevent vertigo.
B. Instruct the client to avoid persons with urinary tract infections.
C. Instruct the client to avoid blowing of the nose.
D. Instruct the client to shower regularly.

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 125. Betaxolol hydrochloride eye drops have been prescribed for a
client with glaucoma. Which nursing action is most appropriate related
to monitoring for side and adverse effects of this medication?
A. Assessing for edema
B. Monitoring temperature
C. Monitoring blood pressure
D. Assessing blood glucose level

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 126. A nurse overhears a person say: “I’m having a senior moment
because I forgot....” How should the nurse interpret this statement?
A. A stereotypical reference to older adults that can be termed ageism.
B. Reflects age-related knowledge since memory decreases with age.
C. A derogatory remark, but one that reflects a truism.
D. A comical statement without age bias.

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 127. When assessing the cardiovascular system of a 75-year-old male, a
nurse auscultates a systolic heart murmur. This is the only abnormality
noted. Which analysis by the nurse is correct?
A. Indication for valve replacement
B. Indication that the client has congestive heart failure (CHF)
C. Usually representative of some kind of underlying heart disease
D. Common due to age-related calcification and stiffening of the heart
valves.

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 128. When an office nurse completes height measurement for a 62-
year-old female client, the woman says that she has lost half an inch.
Which explanation by the nurse is most accurate?
A. “As we age, we lose muscle mass.”
B. “Bone loss is due to lack of exercise.”
C. “Aging changes in the cartilage of the knees and hips result in
shortening stature.”
D. “The vertebral column shortens due to compression and thinning of
the vertebrae with aging.”

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 129. A nurse should evaluate the hydration status of an older adult
client by assessing all of the following except:
A. urine specific gravity.
B. 24-hour fluid intake and urine output
C. serum blood urea nitrogen (BUN) and creatinine.
D. serum white blood cell (WBC) and differential count.

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 130. For which age-related skin changes should a nurse assess an 81-
year-old hospitalized client to best protect the client from developing
decubitus ulcer?
A. Increased tissue vascularity
B. Increase in subcutaneous tissue.
C. Loss of skin thickness and elasticity
D. Increased rate of cellular replacement

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 131. A nurse reports to a health-care provider that a client has
decreased peripheral vision. An ophthalmologist consult is ordered,
and the client is diagnosed with chronic open-angle glaucoma. The
client cries when told the diagnosis. Which of the following is the
priority nursing diagnosis?
A. Deficient knowledge related to glaucoma causes and treatment.
B. Anxiety related to fear of vision loss and changes in quality of life.
C. Dressing and grooming self-care deficit related to visual impairment.
D. Sensory/perceptual alterations (visual) related to decreased
peripheral vision.

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 132. A 76-year-old client is admitted to a surgical unit following a right
colectomy for a small tumor. The client has lactated Ringer’s solution
infusing intravenously at 125 mL/hr, O2 per nasal cannula at 3 L, and a
right abdominal dressing. A nurse analyzes the client’s assessment
information and identifies the nursing diagnosis: Risk for infection
(pneumonia) due to age related functional changes in the respiratory
system. Which age-related assessment most likely prompted the nurse
to establish the nursing diagnosis?
A. Decreased residual volume
B. Decreased cough reflex
C. Increased vital capacity
D. Increased PaO2

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 133. An 84-year-old client, hospitalized for repair of a fractured hip, is
incontinent of urine, is sometimes confused, and is not eating well. A
nurse notes nonblanchable erythema of the intact skin over the client’s
coccyx. The nurse’s interventions to prevent further skin breakdown
should include:
A. relieving pressure under the coccyx with an inflatable “donut.”
B. keeping the head-of-bed raised above 30 degrees.
C. repositioning the client at least every 2 hours.
D. offering foods, the client likes to eat.

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 134. A nurse obtains information for a 75-year-old client and concludes
that some findings are not age related and require further follow-up
because the client is at risk for falls. Which report by the client
represents a non-age-related finding that requires additional
investigation?
A. Reports experiencing a decreased ability to see at night.
B. Reports having difficulty distinguishing some colors.
C. Reports seeing halos around lights.
D. Reports diminished visual acuity.

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 135. The home care nurse is visiting an older client whose spouse died
6 months ago. Which behaviors by the client indicates ineffective
coping?
A. Neglecting personal grooming
B. Looking at old snapshots of family
C. Participating in a senior citizens program
D. Visiting the spouse’s grave once a month

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 136. The nurse is providing an educational session to new employees,
and the topic is abuse of the older client. The nurse helps the
employees identify which client is most typical of a victim of abuse?
A. A 75-year-old man with moderate hypertension
B. A 68-year-old man with newly diagnosed cataracts
C. A 70-year-old woman with early diagnosed tuberculosis.
D. A 90-year-old woman with advanced Parkinson's disease.

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 137. The nurse is careful in the use of medical jargon while talking with
an older adult patient because the use of medical jargon might become
a(n):
A. effective abbreviated communication shortcut.
B. opportunity to instruct the patient.
C. indicator of formal communication.
D. communication barrier.

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 138. Which of the following is the physiologic change occurring in the
hearing of an elderly?
A. Presbyopia
B. Presbycusis
C. Meniere’s disease
D. Sensory neural hearing loss

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 139. Which of the following is not an expected physiologic change in
the elderly?
A. decreased bladder capacity
B. decreased vital capacity
C. myocardial atrophy
D. sarcopenia

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 140. The nurse reminds the older adult who is taking drugs for
hypertension that to prevent falls from orthostatic hypotension, the
patient should:
A. avoid hot baths.
B. avoid climbing stairs.
C. ambulate with a walker.
D. sit on the side of the bed for a moment before ambulation.

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 141. The nurse is aware that a fall prevention exercise program for the
residents in a long-term care facility is focused on:
A. improving balance.
B. improving circulation.
C. use of assistive devices.
D. increase in the knowledge base about falls.

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 142. The nurse keeps the environment warmer for older adults because
they are more sensitive to cold because of the age-related changes in
their:
A. metabolic rate.
B. subcutaneous tissue.
C. musculoskeletal system.
D. peripheral vascular system.

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 143. The nurse cautions the Nursing Assistant to use care when
transferring or handling older adults because their vascular fragility will
cause:
A. altered blood pressure.
B. pressure ulcers.
C. senile purpura.
D. pruritus.

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 144. Which of the following will help maintain the self-esteem of an
elderly client?
A. Provide as much independence as possible, with consideration to
safety.
B. Do hygiene measures for the elderly to promote sense of well-being.
C. Plan for routine activities of daily living to be followed by the client.
D. Always assist the client to accept the need for seeking help.

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 145. The nurse is taking care of a client diagnosed with
hypopituitarism. Which of the following findings would correlate to the
client’s condition?
A. Protruding eyeball
B. Increased height
C. Body wasting
D. Obesity

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 146. All the following medication may be given to a client with
hypopituitarism, except:
A. Hydrocortisone
B. Levothyroxine
C. Methimazole
D. Somatropin

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 147. The nurse is taking care of a patient with acromegaly. Which of the
following findings would the nurse expect from this client?
A. Puffiness of the face.
B. A low blood glucose level.
C. Excess fat around the abdomen.
D. Thickening and protrusion of the jaw.

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 148. Which of the following medications is given to clients with
acromegaly?
A. Octreotide
B. Somatropin
C. Desmopressin
D. Demeclocycline

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 149. A client was brought to the emergency room. The client has
tenderness located two-thirds the distance from the umbilicus to the
right anterior superior iliac spine. Which of the following clinical
manifestations is the client most likely experiencing?
A. McBurney’s sign
B. Obturation sign
C. Dunphy’s sign
D. Psoas sign

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 Psoas sign

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 Obturator sign

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 150. The nurse is taking care of a client with acute cholecystitis. The
client was placed in a supine position. The client experienced pain in
the right upper quadrant of the abdomen when taking a deep breath
while the nurse was palpating the right subcostal area. Which of the
following clinical manifestations is the client most likely experiencing?
A. Boas sign
B. Cullen’s sign
C. Murphy’s sign
D. Charcot’s triad

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