1. A nurse in the emergency department is implementing a plan of care for a conscious
client who has a suspected cervical cord injury. Which of the following immediate
interventions should the nurse implement? (Select all that apply.
✓✓✓ Hypotension
Polyuria
Hyperthermia
✓✓✓ Absence of bowel sounds
✓✓✓ Weakened gag reflex
Rationale: <b>Hypotension is correct.</b> Lack of sympathetic input can cause a
decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or
above to adequately perfuse the spinal cord.</br></br><b>Polyuria is incorrect.</b> The
nurse should check the client for bladder distention and inability to urinate due to
ineffective function of the bladder muscles.</br></br><b>Hyperthermia is incorrect.</b>
The nurse should monitor the client for hypothermia caused by a lack of lack of
sympathetic input.</br></br><b>Absence of bowel sounds is correct.</b> Spinal shock
leads to decreased peristalsis, which could cause the client to develop a paralytic
ileus.</br></br><b>Weakened gag reflex is correct.</b> The nurse should monitor the
client for difficulty swallowing, or coughing and drooling noted with oral intake.
2. A nurse is performing discharge teaching for a client who has seizures and a new
prescription for phenytoin. Which of the following statements by the client indicates a
need for further teaching?
✓✓✓ "I'll be glad when I can stop taking this medicine."
Rationale: Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on
anticonvulsant medications commonly require them for lifetime administration, and phenytoin
should not be stopped without the advice of the client's provider.
,3. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle
glaucoma and a new
Prescription for timolol eye drops. Which of the following instructions should the nurse
provide?
✓✓✓ The medication should be applied on a regular schedule for the rest o f the client's life.
Rationale: Medications prescribed for open angle glaucoma are intended to enhance aqueous
outflow, or decrease its production, or both. The client must continue the eye drops on an
uninterrupted basis for life to maintain intraocular pressure at an acceptable level.
4. A nurse is in a client's room when the client begins having a tonic-clonic seizure.
Which of the following actions should the nurse take first?
✓✓✓ Turn the client's head to the side.
Rationale: The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to turn the client's head to the side. This action keeps the client's airway
clear of secretion to prevent aspiration.
5. A nurse is caring for a client following cataract surgery. Which of the following
comments from the client should the nurse report to the client's provider?
✓✓✓ "I need something for the pain in my eye. I can't stand it."
Rationale: Following cataract surgery, the client should expect only mild pain and should
immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe
eye pain after surgery might indicate increased intraocular pressure or hemorrhage.
C. "It's hard to see with a patch on one eye. I'm afraid of falling."
6. A nurse is caring for a client who is 1 day postoperative following a transsphenoidal
hypophysectomy. While assessing the client, the nurse notes a large area of clear
drainage seeping from the nasal packing. Which of the following should be the
nurse‟s initial action?
✓✓✓ Check the drainage for glucose.
Rationale: A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage.
Fluid leakage from the nose is a sign that this complication has occurred. The first action the
nurse should take using the nursing process is to assess the drainage for the presence of
glucose, which would indicate that the drainage is CSF.
,7. A nurse is caring for a client who has expressive aphasia following a cerebrovascular
accident (CVA). Which of the following parameters should the nurse use first in order
to assess the client's pain level?
✓✓✓ a self-report pain rating scale
Rationale: Expressive aphasia results from damage to an area of the frontal lobe and is a
motor speech problem. The client who has expressive aphasia is able to understand what is
said but is unable to communicate verbally. However, this does not necessarily mean that a
client is unable to reliably report pain. Evidence-based practice indicates the nurse should
first attempt to obtain the client‟s self- report of pain. When assessing a client for pain, the
nurse should utilize the hierarchy of pain measures which begins with self-report. It is always
better to use a subjective method, such as a client report, instead of an objective m ethod,
such as something that is observable by the nurse, which is much less reliable.
8. A nurse is caring for a client who reports a throbbing headache after a lumbar
puncture. Which of the following actions is most likely to facilitate resolution of the
headache?
✓✓✓ Increase fluid intake.
Rationale:
The client who has had a lumbar puncture is at risk for continued leaking of CSF from the
puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is
helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and
increasing fluids will facilitate resolution of the headache. The client should also be instructed
to remain in a prone position for 6 hours to prevent leaking of CSF fluid.
9. A nurse is teaching a class of older adults about the expected physiologic changes of
aging. Which of the following changes should the nurse include in the discussion?
(Select all that apply.)
✓✓✓ More difficulty seeing due to a greater sensitivity to glare
✓✓✓ Decreased cough reflex
, ✓✓✓ Decreased bladder capacity
Decreased systolic blood pressure
✓✓✓ Dehydration of intervertebral discs
Rationale: <b>More difficulty seeing due to a greater sensitivity to glare is
correct.</b> Older adults have an increased susceptibility to glare,
greater difficulty in seeing at low levels of illumination, and alterations
in color perception.<br><br><b>Decreased cough reflex is
correct.</b> Older adults have a decreased cough reflex, increased
airway resistance, fewer alveoli, and a greater risk for respiratory
infections.<br><br><b>Decreased bladder capacity is correct.</b>
Older adults have a decreased bladder capacity and a reduction in renal
blood flow.<br><br><b>Decreased systolic blood pressure is
incorrect.</b> Older adults have increased systolic blood pressure,
thickening of blood-vessel walls, and decreased peripheral
circulation.<br><br><b>Dehydration of intervertebral discs is
correct.</b> Older adults have dehydration of intervertebral discs,
decreased muscle strength and mass, and decalcification of bones.
10. A nurse enters a client's room and finds the client on the floor having a seizure.
Which of the following actions should the nurse take?
✓✓✓ Place the client on his side
.
Rationale: The nurse should place the client on his side. This position drops the tongue to
the side of the client's mouth and prevents the client's airway from being obstructed.
11. A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis
and a new prescription for an ophthalmic ointment. Which of the following
instructions should the nurse provide?
✓✓✓ administered (in a thin line) into the conjunctival sac
Rationale: The medication should be administered (in a thin line) into the conjunctival
sac, rather than being placed directly on the globe of the eye. This ensures that more of
the medication comes in contact with the surfaces of the eye when the child blinks. If
applied to the globe of the eye, most of the medication will end up in the child's lashes
when the child closes her eye
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