81 - Nursing Exams QAs

 

Question 5131) 

A 27-year-old woman is admitted to the hospital complaining of numbness in both legs, difficulty walking, and double vision of one week in duration. Multiple sclerosis is suspected. Orders include bed rest with bathroom privileges, brain scan, EEG, lumbar puncture, adrenocorticotropic hormone (ACTH) 40 units intramuscularly (IM) bid × 3 days, then 30 units IM bid × 3 days, then 20 units IM bid × 3 days; and passive range of motion (ROM) progressing to active ROM as tolerated. In planning care for this client, which activity is most important to include? 

A. Encouraging her to perform all care activities for herself 

B. Frequent ambulation to retain joint mobility 

C. Scheduling frequent rest periods between physical activity 

D. Feeding the client to reduce energy needs 

Answer: C 

Explanation: She will need rest periods between activities. She may be too weak to perform all self activities. Her orders include bed rest, not ambulating ad lib. Feeding her is not necessary and is likely to cause her to be upset. 

Question 5132) 

The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test? 

A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis. 

B. This is of diagnostic value in only 25% of patients with myasthenia gravis. 

C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis. 

D. Tensilon works by blocking the action of acetylcholine at the myoneural junction. Answer: A Explanation: Tensilon works almost immediately to cause an increase in muscle strength by increasing the amount of acetylcholine at the myoneural junction. The test is of value in almost all clients suspected of having myasthenia gravis. 

Question 5133) 

When planning care for a woman with myasthenia gravis, the nurse asks her what time of day she feels strongest. The nurse would expect which of the following replies? 

A. “I can wash up and comb my hair before breakfast because I feel best in the morning.” 

B. “I only feel good for about an hour after I take my medication.” 

C. “I feel strongest in the evening, so I would prefer to take a shower before bedtime.” 

D. “I feel best after lunch after I’ve been moving around a little 

Answer: A 

Explanation: Muscle strength is best early in the day. Weakness usually progresses during the day and is at its worst in the evening. 

Question 5134) 

Which of the following would not be included in the nursing care plan for a client with Parkinson’s disease? 

A. Restricting his intake of oral fluids 

B. Range of motion exercises 

C. Allowing him to carry out activities of daily living by himself even though he is very slow D. Providing him with diversionary tasks that require motor coordination of hands 

Answer: A 

Explanation: Fluids should be encouraged because he has a tendency to drool and lose fluid. Encouraging the client to perform activities of daily living is desirable. He should be encouraged to move frequently to prevent joint contractures. Activities requiring hand coordination will help him to retain function. 

Question 5135) 

The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following? 

A. Aspiration pneumonia 

B. Decubitus ulcers 

C. Bladder distention 

D. Hypertensive crisis 

Answer: A 

Explanation: Because he is having difficulty swallowing and talking, he is at high risk for aspiration pneumonia. He is also at risk for decubitus ulcers, but this is of lesser priority than the airway. Bladder distention is a possibility but not as high a priority as the risk of aspiration pneumonia. There is no evidence that he is at risk for hypertensive crisis. 

Question 5136) 

An adult client is admitted for removal of a cataract from her right eye. Which of the following would the client likely have experienced as a result of the cataracts? 

A. Acute eye pain 

B. Redness and constant itching of the right eye 

C. Gradual blurring of vision 

D. Severe headaches and dizziness 

Answer: C 

Explanation: Cataracts are characterized by a gradual blurring of vision. Acute eye pain is characteristic of acute glaucoma or foreign objects in the eye. Redness and itching is more characteristic of an eye infection. Severe headaches and dizziness are not characteristic of cataracts. 

Question 5137) 

A client has had a cataract extraction performed. Which statement would indicate that the client needs more teaching? 

A. “I will take a stool softener daily.” 

B. “I’m going to start doing calisthenic exercises as soon as I get home.” 

C. “I’m going to my daughter’s for a few weeks until I am recovered.” 

D. “I am looking forward to watching television during my recovery period.” 

Answer: B 

Explanation: Bending, stooping, and lifting should be avoided for several weeks following eye surgery. A stool softener is recommended so that the client will not strain at stool. Television and reading are not restricted following cataract extraction. Eye movement is restricted following surgery for detached retina. 

Question 5138) 

A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have? 

A. Severe eye pain 

B. Constant blurred vision 

C. Severe headaches, nausea, and vomiting 

D. Severe headaches, nausea, and vomiting 

Answer: D 

Explanation: Chronic glaucoma is characterized by halos around objects. Severe eye pain and severe headaches, nausea, and vomiting are more characteristic of acute glaucoma. Constant blurred vision is characteristic of cataracts. 

Question 5139) 

The nurse is administering eye drops to a client. Which action is correct? 

A. Ask the client to report any blurring of vision and difficulty focusing that occurs after the administration of eye drops. 

B. Apply gentle pressure to the nasolacrimal canal for one to two minutes after instillation to prevent systemic absorption. 

C. Have the client lie down with eyes closed for 45 minutes after giving drops. 

D. Gently pull the lower lid down and place medicine in the center of the eye. 

Answer: B 

Explanation: This action will prevent systemic absorption of eye medication and prevent the nose from running. Blurred vision and difficulty focusing are normal immediately after administering eye drops. There is no need to lie down after eye drops are given. Eye drops should be placed in the conjunctival sac, not the center of the eye. 

Question 5140) 

A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there’s something in it. What should the nurse do before taking him to the emergency room? 

A. Thoroughly examine his eyes 

B. Put a pressure dressing on his right eye. 

C. Cover both eyes lightly with gauze 

D. Flush his right eye with water for 20 minutes 

Answer: C 

Explanation: Covering both eyes lightly with gauze prevents tracking by the affected eye, which would occur if the unaffected eye was not covered. Examining the eyes should be done only in the emergency room by a physician. A pressure dressing would further damage the eye if broken glass is in the eye. Flushing is appropriate for chemical spills in the eye.