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1. A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further instruction about the use of crutches?

• Advancing both crutches with the weaker leg
• Leaning axillae on the crutches to support the body’s weight
• Transferring the crutches into one hand when sitting in a chair
• Moving the crutches before the unaffected leg when descending stairs

2. During an annual physical assessment a client reports not being able to smell coffee and most foods. Which cranial nerve function should the nurse assess?

• I
• II
• X
• VII

3. What should the nurse do for a client who just had cataract surgery?

• Instruct the client to avoid driving for several weeks.
• Teach the client coughing and deep-breathing techniques.
• Advise the client to refrain from vigorous brushing of the teeth and hair.
• Encourage the client to perform eye exercises to strengthen the ocular musculature.

4. A nurse should expect to identify a loss of which ability when assessing an unconscious client?

• Hearing voices
• Moving spontaneously
• Controlling elimination
• Reacting to painful stimuli

5. When caring for a client who has sustained a head injury, it is important that the nurse assess for which clinical indicator?

• Slowing of the heart rate
• Decreased carotid pulses
• Bleeding from the oral cavity
• Absence of deep tendon reflexes

6. When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury?

• Insert an oral airway.
• Monitor the seizure activity.
• Turn the client on the left side.
• Begin oxygen by mask at 8 L/min.

7. A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin (Dilantin) for 10 years. When planning care for this client, what should the nurse do first?

• Place an airway and restraints at the bedside.
• Obtain a history of seizure type and incidence.
• Ask the client to remove any dentures and eyeglasses.
• Observe the client for increased restlessness and agitation.

8. When transporting a client on a stretcher, the nurse makes certain that the client’s arms do not hang down over the edge. To which nerve plexus does the nurse avoid injury by taking this precaution?

• Solar
• Celiac
• Basilar
• Brachial

9. A nurse places a client with severe burns on a circulating air bed. What is the primary reason why the nurse implements this action?

• Increase mobility
• Prevent contractures
• Limit orthostatic hypotension
• Prevent pressure on peripheral blood vessels

10. A nurse performs a Rinne test during physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. What conclusion should the nurse make about these results?

• This represents an expected finding.
• The client may have a sensorineural deficit.
• This is evidence of a conductive hearing loss.
• The client has an inflammation of the mastoid.

11. A nurse is caring for a client during the first few hours after admission to the burn unit with partial-thickness burns of the trunk and head. Which potential problem is the least concern for the nurse during the emergent phase of a burn injury?

• Pain
• Leukopenia
• Laryngeal edema
• Fluid volume deficit

12. After a brain attack a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

• Frontal
• Parietal
• Occipital
• Temporal

13. A client is to have a parotidectomy to remove a cancerous lesion. For which postoperative complication that may be permanent should the nurse monitor?

• A tracheostomy
• Frey syndrome
• An increase in salivation
• Facial nerve dysfunction

14. A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching was effective?

• Promote growth of new retinal cells
• Adhere the sclera to the choroid layer
• Graft a healthy piece of retina in place
• Create a scar that aids in healing retinal holes

15. Which clinical indicator does a nurse identify when assessing a client with hemiplegia?

• Paresis of both lower extremities
• Paralysis of one side of the body
• Paralysis of both lower extremities
• Paresis of upper and lower extremities

16. What clinical indicator does the nurse expect to identify when assessing a client with a brain tumor in the occipital lobe?

• Hemiparesis
• Receptive aphasia
• Personality changes
• Visual hallucinations

17. A client has a craniotomy for a meningioma. For what response should the nurse assess the client in the postanesthesia care unit?

• Dehydration
• Blurred vision
• Wound infection
• Narrowing pulse pressure

18. A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the health care provider should the nurse question?

• Colloids
• Potassium
• Hypertonic saline
• Lactated Ringer solution

19. A nurse is developing a teaching plan for a client with otosclerosis. What information should the nurse include in the teaching plan?

• Stapedectomy is the procedure of choice.
• Hearing aids usually restore some hearing.
• The client is usually unable to hear bass tones.
• Air conduction is more effective than bone conduction.

20. A client is admitted with paresis of the ciliary muscles of the left eye. What function should the nurse expect to be affected?

• Closing the eyelids
• Convergence of both eyes
• Ability to discriminate colors
• Focusing the lens on near objects

21. A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?

• Decreasing CVP readings
• Urinary output of 15 to 20 mL/hr
• Slowing of a previously rapid pulse
• Hematocrit level increasing from 50% to 55%

22. After sustaining a head trauma, a client reports hearing ringing noises. The nurse considers that an injury to what part of the body is likely to cause this clinical indicator?

• Frontal lobe
• Occipital lobe
• Sixth cranial nerve (abducent)
• Eighth cranial nerve (vestibulocochlear)

23. A nurse is assessing a client whose mouth is drawn over to the left. The nurse should consider damage to which cranial nerve to be the most likely explanation for this clinical finding?

• Left facial nerve
• Right facial nerve
• Left abducent nerve
• Right trigeminal nerve

24. When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse’s conclusion?

• Inability to stand with feet together when eyes are closed
• Fanning of toes when the sole of the foot is firmly stroked
• Dilation of pupils when focusing on an object in the distance
• Movement of eyes toward the opposite side when head is turned

25. What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema?

• Improved renal blood flow
• Decreased intracranial pressure
• Maintenance of circulatory volume
• Prevention of the development of thrombi

26. A client who is receiving phenytoin (Dilantin) to control a seizure disorder questions the nurse regarding this medication after discharge. The nurse’s best response is “This medication:

• will probably be continued for life.”
• prevents the occurrence of seizures.”
• needs to be taken during periods of emotional stress.”
• can usually be stopped after a year’s absence of seizures.”

27. A client who has a history of seizures is scheduled for an arteriogram at 10 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9 AM. What should the nurse do?

• Omit the 9 AM dose of the drug.
• Give the same dosage of the drug rectally.
• Administer the drug with 30 mL of water at 9 AM.
• Ask the health care provider if the drug can be given IV.

28. A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

• Thready, weak pulse
• Narrowing pulse pressure
• Regular, shallow breathing
• Lowered level of consciousness

29. A nurse identifies which clinical indicator of parasympathetic dominance in a client under stress?

• Constipation
• Goose bumps
• Excess epinephrine secretion
• Increased gastrointestinal secretions

30. What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

• Monitor the client for signs of brain injury.
• Check for hemorrhaging from the oral and nasal cavities.
• Elevate the foot of the bed if the client develops symptoms of shock.
• Observe for clinical indicators of decreased intracranial pressure and temperature.

31. Soon after admission to the hospital with a head injury, a client’s temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to what structure?

• Thalamus
• Hypothalamus
• Temporal lobe
• Globus pallidus

32. A severely burned client has been hospitalized for 2 days. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does the nurse conclude the client is most likely developing?

• Kidney failure
• Fluid overload
• Cerebral hypoxia
• Metabolic acidosis

33. The nurse assists the health care provider to perform a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the health care provider to document?

• Homan
• Romberg
• Chvostek
• Queckenstedt

34. Several clients are admitted to the emergency department with brain injuries as a result of an automobile collision. The nurse concludes that the client with an injury to which part of the brain will most likely not survive?

• Pons
• Medulla
• Midbrain
• Thalamus

35. When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve?

• Third
• Fourth
• Second
• Seventh

36. What is the primary responsibility of a nurse during a client’s generalized motor seizure?

• Inserting a plastic airway between the teeth
• Determining whether an aura was experienced
• Administering the prescribed prn anticonvulsant
• Clearing the immediate environment for client safety

37. Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure method?

• Bathing will not be permitted.
• Aseptic techniques are required.
• Dressings will be changed every 3 days.
• Room temperature must be kept at 7T F.

38. A client regains consciousness and has expressive aphasia. What should the nurse include as part of long-range planning for this client?

• Provide positive feedback when the client uses a word correctly.
• Wait for the client to verbally state needs regardless of how long it takes.
• Suggest that the client get help at home because the disability is permanent.
• Help the family to accept the fact that the client cannot participate in verbal communication.

39. A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

• Dry skin
• Skin pallor
• Constriction of pupils
• Pulse rate of 60 beats/min

40. The school nurse is attending to a student athlete who reports muscle pain after a practice session. What should the nurse identify as a cause of this pain when providing instruction to the student?

• Lactic acid
• Butyric acid
• Acetoacetic acid
• Hydrochloric acid

41. A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which response supports this conclusion?

• Hypokalemia
• Hypoglycemia
• Decreased blood pressure
• Increased urine specific gravity

42. A client is scheduled for a labyrinthectomy to treat Meniere syndrome. What expected outcome of the procedure should be included in preoperative teaching?

• Absence of pain
• Decreased cerumen
• Loss of sense of smell
• Permanent irreversible deafness

43. A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium?

• Pelvic warmth
• Feeling flushed
• Shortness of breath
• Salty taste in the mouth

44. Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

• Constant blurring
• Abrupt attacks of acute pain
• Sudden, complete loss of vision
• Impairment of peripheral vision

45. A client’s relative asks the nurse what a cataract is. What explanation should the nurse provide?

• An opacity of the lens
• A thin film over the cornea
• A crystallinization of the pupil
• An increase in the density of the conjunctiva

46. A client with glaucoma asks a nurse about future treatment and precautions. What information should the nurses explanation include?

• Avoidance of cholinergics
• Surgical replacement of lens
• Continuation of therapy for life
• Prevention of high blood pressure

47. A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which should the nurse conclude is an appropriate classification for these burns?

• Eschar
• Full-thickness
• Deep partial-thickness
• Superficial partial-thickness

48. A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons?

• Absent reflexes
• Flaccid muscles
• Trousseau sign
• Babinski response

49. A nurse is caring for a client who has a disturbed body image as a result of a burn injury. Which is an important nursing intervention for this client?

• Conveying a positive attitude toward the client
• Arranging for the client to meet other clients with burns
• Removing mirrors until the client’s physical appearance has improved
• Reminding family members to avoid comments about the client’s appearance

50. A nurse is caring for a client who sustained a partialthickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. A primary short-term outcome established by the nurse and client is “The client’s:

• airway will remain patent.”
• burns will heal free of infection.”
• urine output will exceed 30 mL every hour.”
• pain will remain at 2 or less on a scale of 0 to 10.”

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75 questions