EASY

1) A group conducted a ward class to parents

of children with seizure disorder. The
student nurse is correct when which of the
following is definition of seizure disorder is
stated by the SN?
a. An excessive and unorganized
neuronal discharges in the brain
b. An acute encephalopathy that
follows a viral illness
c. An imbalance in the CSF absorption
or production caused by
malformations, tumors,
hemorrhage, infections, or trauma
d. It arises from a specific area in the
brain and cause limited symptoms
2) A nurse is caring for a child recently
diagnosed with cerebral palsy, and the
parents of the child ask the nurse about
the disorder. The nurse bases her response
on her understanding that cerebral palsy
is:
a. An infectious disease of the central
nervous system
b. An inflammation of the brain as a
result of a viral illness
c. A congenital condition that results
in moderate to severe retardation
d. A chronic disability characterized by
impaired muscle movement and
posture
3) A nurse is reviewing the record of a child
with increased intracranial pressure and

DIFFICULT
1) A nurse is assigned to care for an 8- year
old child with a diagnosis of a basilar skull
fracture. The nurse reviews the physicians
prescriptions and contacts the physician to
question which prescriptions?
a. Suction as needed
b. Obtain daily weight
c. Provide clear liquid intake
d. Maintain a patent intravenous line

VERY DIFFICULT
1) When talking with the parents of a Down
syndrome child, which of the following
goals would be most appropriate for the
child and family?
a. Teaching the child one new thing
every day
b. Encouraging self-care skills in the
child
c. Establishing more lenient behavior
standards
d. Achieving age-appropriate social
skills

2) A nurse is caring for an infant with a

diagnosis of hydrocephalus.
Preoperatively, a priority nursing
intervention is to:
a. Test the urine for protein
b. Reposition the infant frequently
c. Provide a stimulating environment
d. Assess blood pressure every 15
minutes

4) A nurse develops a plan of care for a child

at risk for tonic- clonic seizures. In the plan
of care, the nurse identifies seizure
precautions and documented that which
item(s) need to be placed at the childs
bedside?
a. Emergency cart
b. Tracheostomy set
c. Padded tongue blade
d. Suctioning equipment and oxygen

3) A child is diagnosed with Reyes syndrome.

A nurse develops a nursing care plan for

3) You are preparing to admit a patient with a

seizure disorder. Which of the following

notes that the child has exhibited signs of

decerebrate posturing. On assessment of
the child, the nurse expects to note which
of the following if this type of posturing is
present?
a. Flaccid paralysis
b. Adduction of the arms at the
shoulders
c. Rigid extension and pronation of
the arms and legs
d. Abnormal flexion of the upper
extremities and extension and
adduction of the lower
extremities
For numbers 4-7, the following are the
choices
a. Spina Bifida
b. Spina bifida occulta
c. Spina bifida cystica
d. Meningocele
e. Myelomenigocele
4) The protrusion which involves meninges
and a sac- like cyst that contains CSF
usually in the lumbosacral area.

5) Posterior vertebral arches fail to close in

the lumbosacral area.

the child and includes which intervention

in the plan?
a. Assessing hearing loss
b. Monitoring urine output
c. Changing body position every 2
hours
d. Providing a quiet atmosphere with
dimmed lighting

4) The client is having a lumbar puncture

performed. The nurse would plan to place
the client in which position for the
procedure?
a. Side-lying, with legs pulled up and
head bent down onto the chest
b. Side-lying, with a pillow under the
hip
c. Prone, in a slight Trendelenburgs
position
d. Prone, with a pillow under the
abdomen

For numbers 5-7, refer to this situation:

A 6- year old child accidentally fell off
the stairs while playing hide-and-seek
with his classmates.

actions can you delegate to LPN/LVN?

a. Complete admission assessment
b. Set up oxygen and suction
equipment
c. Place a padded tongue blade at
bedside
d. Pad the side rails before patient
arrives

4) The nurse answers a call bell and finds a

frightened mother whose child, the
patient, is having a seizure. Which of these
actions should the nurse take?
a. The nurse should insert a padded
tongue blade in the patients mouth
to prevent the child from swallowing
or choking on his tongue
b. The nurse should help the mother
restrain the child to prevent him
from injuring himself
c. The nurse should call the operator
to page for seizure assistance
d. The nurse should clear the area and
position the client safely
5) The health care provider has ordered
mannitol (Osmitrol) for a child with a head
injury. The best indicator that this
medication has been effective is:

6) Protrusion of the meninges, CSF, nerve

roots, and a portion of the spinal cord.

5) Which of the following should the school

nurse do first?
a. Assess Injuries
b. Immobilize the neck and spine
c. Initiate seizure precaution
d. Monitor the airway and administer
oxygen as prescribed.
6) The clinical instructor determines that the
SN needs further teaching when one of the
following is performed when taking care of
clients with spinal injury:
a. Have patient lie flat on bed
b. Kept leg elevated
c. Place patient on Trendelenburg
position
d. Place on prone position

7) Protrusion of the spinal cord or its

meninges.

7) The SN suspects brainstem involvement if

all of the following is manifested by
patient, except:
a. Sluggish, dilated, unequal pupils
b. Deep, rapid gasping respirations
c. Altered bladder and bowel function
d. Slowing of pulse

8) A lumbar puncture is performed on a child

suspected of having bacterial meningitis.
CSF is obtained for analysis. A nurse
reviews the results of the CSF analysis and
determines that which of the following
results would verify the diagnosis?

8) Nurse G is taking care of a child with spina

bifida. He is correct when he included
which of the following interventions in his
care plan?
a. Place in patient in prone position
b. Place a pillow or folded blanket

a.
b.
c.
d.

Increased urine output

Improved level of consciousness
Decreased facial swelling
Decreased intracranial pressure

6) A 10-year-old child is admitted for

suspected infratentorial brain tumor.
During the childs admission, which action
should the nurse anticipate doing first?
a. Implement seizure precautions
b. Introduce child to other children the
same age
c. Prepare child and parents for
diagnostic procedures
d. Eliminate the childs anxiety using
distraction techniques
7) Which assessment detail is most important
for the clinic nurse to make regarding a
school-age child who has a sore throat,
arm weakness, muscle tenderness, and
generally feeling unwell?
a. Diet intake for last 24 hours
b. Exposure to illnesses
c. Difficulty urinating
d. Swallowing ability
8) Which of the following findings would
indicate to the nurse that spinal shock was
resolving in an adolescent with a spinal
cord injury?
a. Widening pulse pressure
b. Hyperactive reflexes
c. Atonic urinary bladder

a. Cloudy CSF, decreased protein, and

decreased glucose
b. Cloudy CSF, elevated protein, and
decreased glucose
c. Clear CSF, elevated protein, and
decreased glucose
d. Clear CSF, decreased pressure, and
elevated protein
9) A 6- month old infant was brought to the
hospital. The nurse suspects meningitis if
which of the following is manifested by the
patient?
a. Negative Brudzinkis sign
b. Positive Kernigs sign
c. Non responsiveness
d. Progressive neurologic
deterioration

10)
The nurse explains to the parents of
child that the definitive diagnosis to
confirm meningitis is:
a. Needle Biopsy
b. CT scan
c. MRI
d. Lumbar puncture

2) A 10- year old child is rushed to the ED

under the childs head

c. Turn the child to one side
d. Remain with the child until the child
fully recovers

9) All of the following Nurse G should initiate

when taking care of a patient with
recurrent seizure, except:
a. Have suction equipment and oxygen
available
b. Remove the pillow under patients
head
c. Loosen clothing
d. Remain with the child until he/she
recovers

10)
Which nursing action should be a
priority when the parents first meet their
infant with an open spinal defect?
a. Have the parents feed the infant
b. Encourage discussion of fears and
concerns
c. Provide written information
reinforcing health care provider
education
d. Emphasize the infants normal and
positive features
11)
A child with a known seizure disorder is

d. Flaccid paralysis

9) The RN identifies that the client's father

understands the teaching about Reye's
syndrome by which comment?
a. "I will give my son Triaminicin cold
products for his next cold."
b. "I realize I will need to check labels
on all medications to look for
salicylates in them."
c. "I am going to give my son Pepto
Bismol when his stomach is upset."
d. "I understand that Reye's syndrome
is caused by bacterial
contamination."
10)
The nurse would suspect worsening of
the pediatric client's condition if the
Glasgow Coma Scale:
a. Suddenly reflected a positive
response to verbal command
b. Increased to 10 in a few hours
c. Leveled off at 5 for several days
d. Dropped to 4 in a few hours

11)

The LVN/LPN would expect which

after being hit by a car and sustained a

head injury. The nurse understands that
which of the following should be assessed
that provides an early indication of a
deterioration of the childs neurologic
condition?
a. Decerebrate posturing
b. Level of Consciousness
c. Bradycardia
d. Cheyne- strokes respiration

Cheney Jane Roche

hospitalized for an unrelated procedure.

Upon walking the child back from the
restroom, the nurse notes tonic-clonic
movements. Which action should the
nurse take first?
a. Note the time
b. Ease the child to the floor
c. Clear the area of objects and pad
the head
d. Roll the child to side-lying position
to protect the airway

preparations for a pediatric client with a

major, closed head injury? (Select all that
apply.)
a. Have an airway and suction
equipment available at bedside
b. Have a padded tongue blade at the
head of the bed
c. Apply padding to the side rails
d. Keep Dilantin at the bedside in case
it is needed
e. Have intravenous equipment ready
for quick insertion if needed

Anelio A. Licayan III

ELDERLY
Easy Questions
1. If a male client experienced a cerebrovascular accident (CVA) that damaged the
hypothalamus, the nurse would anticipate that the client has problems with:
A.
B.
C.
D.

body temperature control.

balance and equilibrium.
visual acuity.
thinking and reasoning.
2. A female client admitted to an acute care facility after a car accident develops signs
and symptoms of increased intracranial pressure (ICP). The client is intubated and
placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP
caused by suctioning, the nurse anticipates administering which drug endotracheally
before suctioning?

A.
B.
C.
D.

phenytoin (Dilantin)
mannitol (Osmitrol)
lidocaine (Xylocaine)
furosemide (Lasix)
3. After striking his head on a tree while falling from a ladder, a young man age 18 is
admitted to the emergency department. Hes unconscious and his pupils are
nonreactive. Which intervention would be the most dangerous for the client?

A.
B.
C.
D.

Give him a barbiturate.

Place him on mechanical ventilation.
Perform a lumbar puncture.
Elevate the head of his bed.
4. When obtaining the health history from a male client with retinal detachment, the
nurse expects the client to report:

A.
B.
C.
D.

light flashes and floaters in front of the eye.

a recent driving accident while changing lanes.
headaches, nausea, and redness of the eyes.
frequent episodes of double vision.

5. Which nursing diagnosis takes highest priority for a client with Parkinsons crisis?
A.
B.
C.
D.

Imbalanced nutrition: Less than body requirements

Ineffective airway clearance
Impaired urinary elimination
Risk for injury
6. To encourage adequate nutritional intake for a female client with Alzheimers disease,
the nurse should:

A.
B.
C.
D.

stay with the client and encourage him to eat.

help the client fill out his menu.
give the client privacy during meals.
fill out the menu for the client.
7. The nurse is performing a mental status examination on a male client diagnosed with
subdural hematoma. This test assesses which of the following?

A.
B.
C.
D.

Cerebellar function
Intellectual function
Cerebral function
Sensory function
8. Shortly after admission to an acute care facility, a male client with a seizure disorder
develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat.
How soon can the nurse administer a second dose of diazepam, if needed and
prescribed?

A.
B.
C.
D.

In 30 to 45 seconds
In 10 to 15 minutes
In 30 to 45 minutes
In 1 to 2 hours
9. A female client complains of periorbital aching, tearing, blurred vision, and
photophobia in her right eye. Ophthalmologic examination reveals a small, irregular,
nonreactive pupil a condition resulting from acute iris inflammation (iritis). As part of
the clients therapeutic regimen, the physician prescribes atropine sulfate (Atropisol),
two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which
drug classification?

A.
B.
C.
D.

Parasympathomimetic agent
Sympatholytic agent
Adrenergic blocker
Cholinergic blocker

10. Emergency medical technicians transport a 27-year-old iron worker to the

emergency department. They tell the nurse, He fell from a two-story building. He has a
large contusion on his left chest and a hematoma in the left parietal area. He has a
compound fracture of his left femur and hes comatose. We intubated him and hes
maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manualresuscitation bag. Which intervention by the nurse has the highest priority?
A.
B.
C.
D.

Assessing the left leg

Assessing the pupils
Placing the client in Trendelenburgs position
Assessing level of consciousness
11. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers
irrigate his eyes with water for 20 minutes, and then take him to the emergency
department of a nearby hospital, where he receives emergency care for corneal injury.
The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops
of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour;
and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the
conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic
effect by:

A.
B.
C.
D.

increasing the exudative reaction of ocular tissue.

decreasing leukocyte infiltration at the site of ocular inflammation.
inhibiting the action of carbonic anhydrase.
producing a miotic reaction by stimulating and contracting the sphincter muscles
of the iris.

Difficult Questions
12.Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago.
Which of the following findings should the nurse consider abnormal?
A.
B.
C.
D.

More back pain than the first postoperative day

Paresthesia in the dermatomes near the wounds
Urine retention or incontinence
Temperature of 99.2 F (37.3 C)
13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The
physician prescribes pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d.
Based on this prescription, the nurse should teach the client or a family member to
administer the drug by:

A.
B.
C.
D.

instilling one drop of pilocarpine 0.25% into both eyes daily.

instilling one drop of pilocarpine 0.25% into both eyes four times daily.
instilling one drop of pilocarpine 0.25% into the right eye daily.
instilling one drop of pilocarpine 0.25% into the left eye four times daily.
14. A female client whos paralyzed on the left side has been receiving physical therapy
and attending teaching sessions about safety. Which behavior indicates that the client
accurately understands safety measures related to paralysis?

A.
B.
C.
D.

The client leaves the side rails down.

The client uses a mirror to inspect the skin.
The client repositions only after being reminded to do so.
The client hangs the left arm over the side of the wheelchair.
15. A male client in the emergency department has a suspected neurologic disorder. To
assess gait, the nurse asks the client to take a few steps; with each step, the clients
feet make a half circle. To document the clients gait, the nurse should use which term?

A.
B.
C.
D.

Ataxic
Dystrophic
Helicopod
Steppage
16. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be
the best choice for this client?

A.
B.
C.
D.

A private room down the hall from the nurses station

An isolation room three doors from the nurses station
A semiprivate room with a 32-year-old client who has viral meningitis
A two-bed room with a client who previously had bacterial meningitis
17. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine
(Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase
agent, the nurse reviews the clients history. Which preexisting condition would
contraindicate the use of pyridostigmine?

A.
B.
C.
D.

Ulcerative colitis
Blood dyscrasia
Intestinal obstruction
Spinal cord injury

18. A female client is admitted to the facility for investigation of balance and coordination
problems, including possible Mnires disease. When assessing this client, the nurse
expects to note:
A.
B.
C.
D.

vertigo, tinnitus, and hearing loss.

vertigo, vomiting, and nystagmus
vertigo, pain, and hearing impairment.
vertigo, blurred vision, and fever.
19. A male client with a conductive hearing disorder caused by ankylosis of the stapes
in the oval window undergoes a stapedectomy to remove the stapes and replace the
impaired bone with a prosthesis. After the stapedectomy, the nurse should provide
which client instruction?

A.

Lie in bed with your head elevated, and refrain from blowing your nose for 24
hours.
B.
Try to ambulate independently after about 24 hours.
C.
Shampoo your hair every day for 10 days to help prevent ear infection.
D.
Dont fly in an airplane, climb to high altitudes, make sudden movements, or
expose yourself to loud sounds for 30 days.
20. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium).
Which adverse reaction is most common?
A.
B.
C.
D.

Excessive tearing
Urine retention
Muscle weakness
Slurred speech
21. The nurse is monitoring a male client for adverse reactions to atropine sulfate
(Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the
conjunctiva can cause which adverse reaction?

A.
B.
C.
D.

Tachycardia
Increased salivation
Hypotension
Apnea
22. A male client is admitted with a cervical spine injury sustained during a diving
accident. When planning this clients care, the nurse should assign highest priority to
which nursing diagnosis?

A.

Impaired physical mobility

B.
C.
D.

Ineffective breathing pattern

Disturbed sensory perception (tactile)
Self-care deficient: Dressing/grooming

Very Difficult Questions

23. A male client has a history of painful, continuous muscle spasms. He has taken
several skeletal muscle relaxants without experiencing relief. His physician prescribes
diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful
muscle spasms, diazepam also is recommended for:
A.
B.
C.
D.

long-term treatment of epilepsy.

postoperative pain management of laminectomy clients.
postoperative pain management of diskectomy clients
treatment of spasticity associated with spinal cord lesions.
24. A female client who was found unconscious at home is brought to the hospital by a
rescue squad. In the intensive care unit, the nurse checks the clients oculocephalic
(dolls eye) response by:

A.
B.
C.
D.

introducing ice water into the external auditory canal.

touching the cornea with a wisp of cotton.
turning the clients head suddenly while holding the eyelids open.
shining a bright light into the pupil.
25. While reviewing a clients chart, the nurse notices that the female client has
myasthenia gravis. Which of the following statements about neuromuscular blocking
agents is true for a client with this condition?

A.
B.
C.
D.

The client may be less sensitive to the effects of a neuromuscular blocking agent.
Succinylcholine shouldnt be used; pancuronium may be used in a lower dosage.
Pancuronium shouldnt be used; succinylcholine may be used in a lower dosage.
Pancuronium and succinylcholine both require cautious administration.
26. A male client is color blind. The nurse understands that this client has a problem
with:

A.
B.
C.

rods.
cones.
lens.

D.

aqueous humor.
27. A female client who was trapped inside a car for hours after a head-on collision is
rushed to the emergency department with multiple injuries. During the neurologic
examination, the client responds to painful stimuli with decerebrate posturing. This
finding indicates damage to which part of the brain?

A.
B.
C.
D.

Diencephalon
Medulla
Midbrain
Cortex
28. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which
of the following symptoms would the nurse expect to find?

A.
B.
C.
D.

Vision changes
Absent deep tendon reflexes
Tremors at rest
Flaccid muscles
29. The nurse is caring for a male client diagnosed with a cerebral aneurysm who
reports a severe headache. Which action should the nurse perform?

A.
B.
C.
D.

Sit with the client for a few minutes.

Administer an analgesic.
Inform the nurse manager.
Call the physician immediately.
30. During recovery from a cerebrovascular accident (CVA), a female client is given
nothing by mouth, to help prevent aspiration. To determine when the client is ready for a
liquid diet, the nurse assesses the clients swallowing ability once each shift. This
assessment evaluates:

A.
B.
C.
D.

cranial nerves I and II.

cranial nerves III and V.
cranial nerves VI and VIII.
cranial nerves IX and X.
31. A white female client is admitted to an acute care facility with a diagnosis of
cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous
obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?

A.

Caucasian race

B.
C.
D.

Female sex
Obesity
Bronchial asthma
32. The nurse is teaching a female client with multiple sclerosis. When teaching the
client how to reduce fatigue, the nurse should tell the client to:

A.
B.
C.
D.

take a hot bath.

rest in an air-conditioned room
increase the dose of muscle relaxants.
avoid naps during the day
33. A male client is having a tonic-clonic seizures. What should the nurse do first?

A.
B.
C.
D.

Elevate the head of the bed.

Restrain the clients arms and legs.
Place a tongue blade in the clients mouth.
Take measures to prevent injury.
34. A female client with Guillain-Barr syndrome has paralysis affecting the respiratory
muscles and requires mechanical ventilation. When the client asks the nurse about the
paralysis, how should the nurse respond?

A.

You may have difficulty believing this, but the paralysis caused by this disease is
temporary.
B.
Youll have to accept the fact that youre permanently paralyzed. However, you
wont have any sensory loss.
C.
It must be hard to accept the permanency of your paralysis.
D.
Youll first regain use of your legs and then your arms.
35. The nurse is working on a surgical floor. The nurse must logroll a male client
following a:
A.
B.
C.
D.

laminectomy.
thoracotomy.
hemorrhoidectomy.
cystectomy.

Answers and Rationales

1.

2.

3.

4.

5.

6.

7.

8.

Answer A. The bodys thermostat is located in the hypothalamus; therefore,

injury to that area can cause problems of body temperature control. Balance and
equilibrium problems are related to cerebellar damage. Visual acuity problems would
occur following occipital or optic nerve injury. Thinking and reasoning problems are the
result of injury to the cerebrum.
Answer C. Administering lidocaine via an endotracheal tube may minimize
elevations in ICP caused by suctioning. Although mannitol and furosemide may be
given to reduce ICP, theyre administered parenterally, not endotracheally. Phenytoin
doesnt reduce ICP directly but may be used to abolish seizures, which can increase
ICP. However, phenytoin isnt administered endotracheally.
Answer C. The clients history and assessment suggest that he may have
increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldnt be
done because it can quickly decompress the central nervous system and, thereby,
cause additional damage. After a head injury, barbiturates may be given to prevent
seizures; mechanical ventilation may be required if breathing deteriorates; and elevating
the head of the bed may be used to reduce ICP.
Answer A. The sudden appearance of light flashes and floaters in front of the
affected eye is characteristic of retinal detachment. Difficulty seeing cars in another
driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma.
Headache, nausea, and redness of the eyes are signs of acute (angle-closure)
glaucoma. Double vision is common in clients with cataracts.
Answer B. In Parkinsons crisis, dopamine-related symptoms are severely
exacerbated, virtually immobilizing the client. A client confined to bed during such a
crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk
of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective
airway clearance takes highest priority. Although the other options also are appropriate,
they arent immediately life-threatening.
Answer A. Staying with the client and encouraging him to feed himself will
ensure adequate food intake. A client with Alzheimers disease can forget how to eat.
Allowing privacy during meals, filling out the menu, or helping the client to complete the
menu doesnt ensure adequate nutritional intake.
Answer C. The mental status examination assesses functions governed by the
cerebrum. Some of these are orientation, attention span, judgment, and abstract
reasoning. Intellectual functioning isnt the only cerebral activity. Cerebellar function
testing assesses coordination, equilibrium, and fine motor movement. Sensory function
testing involves assessment of pain, light-touch sensation, and temperature
discrimination.
Answer B. When used to treat status epilepticus, diazepam may be given every
10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the
regimen in 2 to 4 hours, if necessary, but the total dose shouldnt exceed 100 mg in 24
hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore,

the dose cant be repeated in 30 to 45 seconds because the first dose wouldnt have
been administered completely by that time. Waiting longer than 15 minutes to repeat the
dose would increase the clients risk of complications associated with status epilepticus.
9.
Answer D. Atropine sulfate is a cholinergic blocker. It isnt a
parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker.
10.
Answer A. In the scenario, airway and breathing are established so the nurses
next priority should be circulation. With a compound fracture of the femur, there is a high
risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic
assessment is a secondary concern to airway, breathing, and circulation. The nurse
doesnt have enough data to warrant putting the client in Trendelenburgs position.
11.
Answer B. Dexamethasone exerts its therapeutic effect by decreasing leukocyte
infiltration at the site of ocular inflammation. This reduces the exudative reaction of
diseased tissue, lessening edema, redness, and scarring. Dexamethasone and other
anti-inflammatory agents dont inhibit the action of carbonic anhydrase or produce any
type of miotic reaction.
12.
Answer C. Urine retention or incontinence may indicate cauda equina syndrome,
which requires immediate surgery. An increase in pain on the second postoperative day
is common because the long-acting local anesthetic, which may have been injected
during surgery, will wear off. While paresthesia is common after surgery, progressive
weakness or paralysis may indicate spinal nerve compression. A mild fever is also
common after surgery but is considered significant only if it reaches 101 F (38.3 C).
13.
Answer B. The abbreviation gtt stands for drop, i is the apothecary symbol for
the number 1, OU signifies both eyes, and q.i.d. means four times a day. Therefore,
one drop of pilocarpine 0.25% should be instilled into both eyes four times daily.
14.
Answer B. Using a mirror enables the client to inspect all areas of the skin for
signs of breakdown without the help of staff or family members. The client should keep
the side rails up to help with repositioning and to prevent falls. The paralyzed client
should take responsibility for repositioning or for reminding the staff to assist with it, if
needed. A client with left-side paralysis may not realize that the left arm is hanging over
the side of the wheelchair. However, the nurse should call this to the clients attention
because the arm can get caught in the wheel spokes or develop impaired circulation
from being in a dependent position for too long.
15.
Answer C. A helicopod gait is an abnormal gait in which the clients feet make a
half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait,
the client waddles with the legs far apart. In a steppage gait, the feet and toes raise high
off the floor and the heel comes down heavily with each step.
16.
Answer B. A client with bacterial meningitis should be kept in isolation for at least
24 hours after admission and, during the initial acute phase, should be as close to the
nurses station as possible to allow maximal observation. Placing the client in a room
with a client who has viral meningitis may cause harm to both clients because the
organisms causing viral and bacterial meningitis differ; either client may contract the
others disease. Immunity to bacterial meningitis cant be acquired; therefore, a client
who previously had bacterial meningitis shouldnt be put at risk by rooming with a client
who has just been diagnosed with this disease.
17.
Answer C. Anticholinesterase agents such as pyridostigmine are contraindicated
in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or

hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and

spinal cord injury dont contraindicate use of the drug.
18.
Answer A. Mnires disease, an inner ear disease, is characterized by the
symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo,
vomiting, and nystagmus suggests labyrinthitis. Mnires disease rarely causes pain,
blurred vision, or fever.
19.
Answer D. For 30 days after a stapedectomy, the client should avoid air travel,
sudden movements that may cause trauma, and exposure to loud sounds and pressure
changes (such as from high altitudes). Immediately after surgery, the client should lie
flat with the surgical ear facing upward; nose blowing is permitted but should be done
gently and on one side at a time. The clients first attempt at postoperative ambulation
should be supervised to prevent falls caused by vertigo and light-headedness. The
client must avoid shampooing and swimming to keep the dressing and the ear dry.
20.
Answer C. The most common adverse reaction to dantrolene is muscle
weakness. The drug also may depress liver function or cause idiosyncratic hepatitis.
Muscle weakness is rarely severe enough to cause slurring of speech, drooling, and
enuresis. Although excessive tearing and urine retention are adverse reactions
associated with dantrolene use, they arent as common as muscle weakness
21.
Answer A. Systemic absorption of atropine sulfate can cause tachycardia,
palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption,
the client should apply digital pressure over the punctum at the inner canthus for 2 to 3
minutes after instilling the drops. The drug also may cause dry mouth. It isnt known to
cause hypotension or apnea.
22.
Answer B. Because a cervical spine injury can cause respiratory distress, the
nurse should take immediate action to maintain a patent airway and provide adequate
oxygenation. The other options may be appropriate for a client with a spinal cord injury
particularly during the course of recovery but dont take precedence over a
diagnosis of Ineffective breathing pattern.
23.
Answer D. In addition to relieving painful muscle spasms, diazepam also is
recommended for treatment of spasticity associated with spinal cord lesions.
Diazepams use is limited by its central nervous system effects and the tolerance that
develops with prolonged use. The parenteral form of diazepam can treat status
epilepticus, but the drugs sedating properties make it an unsuitable choice for long-term
management of epilepsy. Diazepam isnt an analgesic agent.
24.
Answer C. To elicit the oculocephalic response, which detects cranial nerve
compression, the nurse turns the clients head suddenly while holding the eyelids open.
Normally, the eyes move from side to side when the head is turned; in an abnormal
response, the eyes remain fixed. The nurse introduces ice water into the external
auditory canal when testing the oculovestibular response; normally, the clients eyes
deviate to the side of ice water introduction. The nurse touches the clients cornea with a
wisp of cotton to elicit the corneal reflex response, which reveals brain stem function;
blinking is the normal response. Shining a bright light into the clients pupil helps
evaluate brain stem and cranial nerve III functions; normally, the pupil responds by
constricting.
25.
Answer D. The nurse must cautiously administer pancuronium, succinylcholine,
and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a

client isnt less sensitive to the effects of a neuromuscular blocking agent. Either
succinylcholine or pancuronium can be administered in the usual adult dosage to a
client with myasthenia gravis.
26.
Answer B. Cones provide daylight color vision, and their stimulation is
interpreted as color. If one or more types of cones are absent or defective, color
blindness occurs. Rods are sensitive to low levels of illumination but cant discriminate
color. The lens is responsible for focusing images. Aqueous humor is a clear watery
fluid and isnt involved with color perception.
27.
Answer C. Decerebrate posturing, characterized by abnormal extension in
response to painful stimuli, indicates damage to the midbrain. With damage to the
diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful
stimulus is applied. Damage to the medulla results in flaccidity.
28.
Answer A. Vision changes, such as diplopia, nystagmus, and blurred vision, are
symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive
not absent. Babinskis sign may be positive. Tremors at rest arent characteristic of
multiple sclerosis; however, intentional tremors, or those occurring with purposeful
voluntary movement, are common in clients with multiple sclerosis. Affected muscles
are spastic, rather than flaccid.
29.
Answer D. The headache may be an indication that the aneurysm is leaking.
The nurse should notify the physician immediately. Sitting with the client is appropriate
but only after the physician has been notified of the change in the clients condition. The
physician will decide whether or not administration of an analgesic is indicated.
Informing the nurse manager isnt necessary.
30.
Answer D. Swallowing is a motor function of cranial nerves IX and X. Cranial
nerves I, II, and VIII dont possess motor functions. The motor functions of cranial nerve
III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor
function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.
31.
Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of
ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the
cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral
contraceptive use, emotional stress, family history of CVA, and advancing age. The
clients race, sex, and bronchial asthma arent risk factors for CVA
32.
Answer B. Fatigue is a common symptom in clients with multiple sclerosis.
Lowering the body temperature by resting in an air-conditioned room may relieve
fatigue; however, extreme cold should be avoided. A hot bath or shower can increase
body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity,
can cause drowsiness and fatigue. Planning for frequent rest periods and naps can
relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis
include treating depression, using occupational therapy to learn energy conservation
techniques, and reducing spasticity.
33.
Answer D. Protecting the client from injury is the immediate priority during a
seizure. Elevating the head of the bed would have no effect on the clients condition or
safety. Restraining the clients arms and legs could cause injury. Placing a tongue blade
or other object in the clients mouth could damage the teeth.

34.

Answer A. The nurse should inform the client that the paralysis that
accompanies Guillain-Barr syndrome is only temporary. Return of motor function
begins proximally and extends distally in the legs.
35.
Answer A. The client who has had spinal surgery, such as laminectomy, must be
logrolled to keep the spinal column straight when turning. The client who has had a
thoracotomy or cystectomy may turn himself or may be assisted into a comfortable
position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure,
and the client may resume normal activities immediately after surgery.

Laurice Lizzette P. Tamolang

Neuromuscular Disorders (ADULT)

EASY
1. Which of the following reduces cerebral edema
by constricting cerebral veins?
a. Dexamethasone (Decadron)
b. Mechanical hyperventilation
c. Mannitol (Osmitrol)
d. Ventriculostomy

DIFFICULT
1. An adult has a medical diagnosis of increased
intracranial pressure and is being cared for on the
neurology unit. The nursing care plan includes
elevating the head of bed and positioning the
clients head in proper alignment. What is the
reason for this action?
a. Makes it easier for the client to breathe
b. Promotes venous drainage
c. Prevents Valsalva maneuver
d. Reduces pain

VERY DI
1. A client with a closed h
drowsy, and has unequal
following nursing diagnos
this time?
a. Altered level of c
b. High risk for inju
c. Altered cerebral
d. Sensory percept

2. A nurse is assessing a 28-year old client who is

unable to extend the legs without pain, has a
temperature of 103F and on flexion of the neck
also flexes the hip and knee. Based on this
assessment, what condition does the nurse
suspect?
a. Meningitis
b. Brain abscess
c. Brain tumor
d. Epilepsy

2. The nurse is caring for a confused client who

sustained a head injury resulting in a subdural
hematoma. The clients blood pressure is 100/60
mm Hg and he is unresponsive. Select the most
effective position for the client as the nurse
transports him to the operating room.
a. Semi-Fowlers
b. Trendelenburg
c. High-Fowlers
d. Supine

2. A 24-year old client is a

injury. To monitor hypotha
should monitor what para
a. Temperature and
b. Gastric aspirate
c. Heart rate and p
d. Respiratory rate

3. A client presents with symptoms of increased

intracranial pressure, papilledema, and headache.
No history of trauma is found. Vital signs are: BP
110/60, HR 80, T 98.9F, RR 24. What condition

3. A nurse is assessing a client with head injury.

The client has clear drainage from the nose and
ears. How can the nurse determine if the
drainage is cerebrospinal fluid (CSF)?

3. A 29-year old client ha

rigidity, pain on extension
opisthotonos. What would
diagnosis?

does the nurse suspect?

a. Brain tumor
b. Meningitis
c. Skull fracture
d. Encephalitis

a. Measure the pH of the fluid

b. Measure the specific gravity of the fluid
c. Test for glucose
d. Test for chloride

a. Acute pain
b. Ineffective tissue
c. Anxiety
d. Risk for injury

4. When comparing a cerebrovascular accident

(CVA) to a transient ischemic attack (TIA), what is
unique about TIA?
a. It has permanent long-term focal deficits
b. It is intermittent with spontaneous
resolution of the neurologic deficit
c. It is intermittent with permanent motor
and sensory deficits
d. It has permanent long-term neurologic
deficit

4. A client is admitted with a C7 complete

transection. What must the nurse plan for in the
immediate post-injury period?
a. Bladder and bowel training
b. Possible ventilator support
c. Complications of autonomic dysreflexia
d. Diaphragmatic pacing

4. The nurse is teaching a

aspirin therapy. Which sta
indicates understanding o
aspirin therapy?
a. I must take the
prevent the headache tha
this disorder.
b. If I take aspirin,
develop bleeding in my b
c. The aspirin will
having stroke.
d. Taking aspirin r
chances of having heart a

5. A client with Parkinsons disease is receiving

combination therapy with Levodopa (L-dopa) and
carbidopa (Sinemet). Which of the following
manifestations indicates to the nurse that an
adverse drug reaction is occurring?
a. Involuntary head movement
b. Bradykinesia
c. Shuffling gait
d. Depression

5. A client with Bells palsy asks the nurse why

artificial tears were ordered by the physician.
Select the best reply by the nurse.
a. When your affected eye fails to make
tears, the eye can become irritated and
ulcerated.
b. Because your eye remains closed,
foreign matter can be trapped beneath the lid.
c. Artificial tears from your eye, which
speeds healing.
d. Because you cannot blink the affected
eye, it becomes dry and irritated.

5. A nurse is teaching a fa
Parkinsons disease. Whic
statements by the family
education?
a. We can buy lots
b. We are teachin
c. Dad is going to
(ROM) exercises three tim
d. The bath bars w
Dad comes home.

6. A client is admitted post craniotomy. Decadron

4 mg IV is ordered every 6 hours. What is the
purpose for this medication?
a. Stabilize the blood sugar
b. Decrease cerebral edema
c. Prevent seizures
d. Maintain integrity of the gastric mucosa

6. A nurse is caring for a client with Guillain-Barre

syndrome. Which of the following strategies is of
the most importance in the plan of care?
a. Range of motion exercises three to four
times per day
b. Frequent measurement of vital capacity
c. Use of artificial tears
d. starting an enteral feeding

7. The client begins to have Cheyne-Stokes

respirations. What is the correcy explanation for
this occurrence?
a. Makes it easier for the client to breathe
b. Rhythmic waxing and waning of both rate
and depth of respiration with brief periods of
interspeed apnea.
c. reduces pain
d. prevents valsalva maneuver

7. The home health nurse observes an aide who is

transferring a client with hemiplegia from a sitting
position in the bed to the wheelchair. Which
action by the aide requires correction?
a. Grasping the clients arms to pull the
client to a standing position.
b. Reminding the client to lean forward
before rising.
c. Moving the client toward the unaffected
side.
d. Bracing the affected knee and foot to
assist the client to stand.

7. Which nursing diagnos

priority when caring for a
gravis (MG)?
a. Pain
b. Risk for Injury
c. Ineffective copin
d. Ineffective airwa

8. A client with a C6 spinal cord injury 2 months

ago now complains of a pounding headache. The
pulse is 64 and the BP is 220/110 mm Hg. Which
of the following actions should the nurse take
first?
a. Give analgesic as ordered
b. Check the clients output
c. Elevate the clients head and lower legs

8. The nurse has explaine

methylsulfate (Prostigmin
myasthenia gravis. Which
indicates the need for fur
a. I need to take t
even when I feel strong.
b. I should take th
at bedtime.

8. Regular oral hygiene is an essential intervention

for the client who has had a stroke. Which of the
following nursing measures is inappropriate when
providing oral hygiene?
a. Placing the client on the back with a small
pillow under the head.

6. Which client would the

most at risk for experienc

a. A 55-year-old African A
b. An 84-year-old Japanes
c. A 67-year-old Caucasia
d. A 39-year-old pregnant

d. Notify the physician

b. Keeping portable suctioning equipment at the
bedside.
c. Opening the clients mouth with a padded
tongue blade.
d. Cleaning the clients mouth and teeth with a
toothbrush.

9.During the first 24 hours after thrombolytic

therapy for ischemic stroke, the primary goal is to
control the clients:
a. Pulse
b. Respirations
c. Blood pressure
d. Temperature

10. What is the expected outcome of thrombolytic

drug therapy?
a. Increased vascular permeability.
b. Vasoconstriction.
c. Dissolved emboli.
d. Prevention of hemorrhage

9. Which assessment data would indicate to the

nurse that the client would be at risk for a
hemorrhagic stroke?
1.
2.
3.
4.

c. If I take too mu
become weak and have b
d. I may have diffi
saliva if I take too much m

A blood glucose level of 480 mg/dl.

A right-sided carotid bruit.
A blood pressure of 220/120 mmHg.
The presence of bronchogenic carcinoma.

10. What should the nurse include in the plan of

care for a newly admitted client with an
infratentorial craniotomy for a brain tumor?
a. Keep the head of bed elevated 30-45
degree angle and a large pillow under the clients
head and shoulder
b. Keep the head of bed flat with a small
pillow under the nape of the neck
c. Assess vital signs and pupils every four
hours
d. Flex neck every 2 hours to prevent
stiffness.

11. A client arrives in the emergency department

with an ischemic stroke and receives tissue
plasminogen activator (t-PA) administration.
Which is the priority nursing assessment?
a. Current medications.
b. Complete physical and history.

9. A 36-year old female re

visual loss, muscular wea
hands, fatigue, tremors, a
on this report, what does
a. Parkinsons dise
b. Myasthenia Grav
c. Amyotrophic late
d. Multiple sclerosi

10. The nurse has presen

amyotrophic lateral sclero
diagnosed client. Which q
indicated that he underst
disease?
a. How can I avoid
the virus?
b. How can I exec

c. Time of onset of current stroke.

d. Upcoming surgical procedures.

11. The client diagnosed with atrial fibrillation has

experienced a transient ischemic attack (TIA).
Which medication would the nurse anticipate
being ordered for the client on discharge?
a. An oral anticoagulant medication.
b. A beta-blocker medication.
c. An anti-hyperuricemic medication.
d. A thrombolytic medication.

c. How can I preve

the disease?
d. How many peo
with chemotherapy?

11. The nurse is evaluatin

with trigeminal neuralgia
treatment that has been
following behaviors by th
effective in controlling ma
a. Exercise the faci
daily
b. Put the affected
motion daily
c. Avoid extremes
and drink
d. Use proper body
bending

Laurice Lizzette P. Tamolang

RATIONALE
EASY
1.
2.
3.
4.
5.

B. to reduce CO2 levels to 25mmHg produces cerebral vasoconstriction and thereby decreases ICP.
A. these are some of the symptoms of Meningitis.
A. these findings are consistent with brain tumor.
B. A TIA is a temporary loss of function due to cerebral ischemia.
D. it is one of the adverse effects that can occur with prolonged use of L-dopa.

6. C. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.

7. B. Cheynes-Stokes respirations are a pattern of breathing in which phases of hyperapnea regularly alternate
with apnea.
8. A. . A helpless client should be positioned on the side, not on the back. This lateral position helps secretions
escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction, so having
suction equipment at the bedside is necessary. Padded tongue blades are safe to use. A toothbrush is
appropriate to use.
9. C. Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect
of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the
clients ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the
priority is blood pressure.
10.C. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.

11.A. Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to prevent
thrombi formation; and oral (warfarin [Coumadin]) at discharge verses intravenous. Beta blockers slow the
heart rate and lower the blood pressure. Anti-hyperuricemic medication is given to clients with gout.
Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at
discharge.

DIFFICULT
1.
2.
3.
4.

C. It decreases ICP by promoting venous drainage from the head by gravity.

A. to lower ICP which may be dangerously elevated n a subdural hematoma.
C. CSF is positive for glucose.
B. edema above the area of the lesion can cause respiratory depression and arrest.

5. D. Bells plasy may cause paralysis of the eyelid and loss of the blink reflex on the affected side.
6. B. patient having Guillain-Barre Syndrome have respiratory muscle weakness and respiratory failure.
7. A. pulling the paralyzed arm can result in shoulder subluxation and pain. The unaffected hand must be free to
reach for the arm of the wheelchair.
8. C. the client is showing signs of autonomic dysreflexia.
9. C. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the
cranium. A bruit in the carotid artery would predispose a client to an embolic or ischemic stroke. High blood
glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic. Cancer is not a precursor to
stroke.
10.B. this is the correct position for an infratentorial approach.

11.C. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better
outcomes. A complete history is not possible in emergency care. Upcoming surgical procedures will need to be
delay if t-PA is administered. Current medications are relevant, but onset of current stroke takes priority.
.

VERY DIFFICULT
1.
2.
3.
4.

C. the client is manifesting symptoms of ICP.

A. ICP causes hypothalamic dysfunction creating hypo/hyperthermia, SIADH, and Diabetes Insipidus.
B. it is related to the ICP and inflammatory process.
C. Platelet-inhibiting drugs are taken prophylactically to prevent cerebral infarction secondary to embolism
and thrombosis.
5. A. the client should have semi-solid, thickened food. Soup is thin in texture and may aspirate the client.
6. A. African Americans have twice the rate of CVAs as Caucasians; males are more likely to have strokes than
females except in advanced years. Orientals have a lower risk, possibly due to their high omega-3 fatty acids.
Pregnancy is a minimal risk factor for CVA.
7. D. Client with MG have respiratory muscle failure.
8. B. The anticholinesterase medication should be taken 30 minutes prior to meals to enhance muscle strength
needed for chewing and swallowing.
9. D. these are signs and symptoms of Multiple Sclerosis
10.B. the nurse should explore the clients wishes and facilitate discussion within the family.
11.C. extremes of temperature of food and drink can trigger paroxysms of severe facial pain along the pathways
of the trigeminal nerve. Meals are better tolerated if served at room temperature.