82 - Nursing Exams QAs

 

Question 5141) 

How should a nurse walk a client who is blind? 

A. Stand slightly behind the client and tell her when to turn 

B. Stand slightly behind and to the side of the client and guide her by holding her hand 

C. Walk slightly ahead with the client’s arm inside the nurse’s arm 

D. Walk beside the client and gently guide her by grasping her elbow 

Answer: C 

Explanation: Walking slightly ahead of the client allows the nurse to see what is in the way. The client feels more in control if her arm is through the nurse’s rather than the other way around. 

Question 5142) 

The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken? 

A. Encourage him to walk as far as he comfortably can 

B. Suggest that he practice bending and stretching exercises 

C. Walk with him, holding his arm 

D. Tell him to take deep breaths while he is ambulating 

Answer: C 

Explanation: The client is apt to be dizzy after ear surgery. For safety, the nurse should be with him. 

Question 5143) 

A client complains of tinnitus and dizziness and has a diagnosis of Ménière’s disease. She asks the nurse, “What is the cause of Ménière’s disease?” What is the nurse’s best response? 

A. “Ménière’s disease is caused by a virus.” 

B. “The cause of Ménière’s disease is unknown.” 

C. “Ménière’s disease frequently follows a streptococcal infection 

D. It is hereditary - both parents are having affected genes. 

Answer: B 

Explanation: The cause of Ménière’s disease is unknown. Glomerulonephritis and rheumatic fever follow a streptococcal infection. As far as is known, Ménière’s disease is not hereditary and is not caused by a virus. 

Question 5144) 

An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his tem perature is slightly elevated. What does this suggest? 

A. Increased cerebral blood flow 

B. Respiratory depression 

C. Increased intracranial pressure 

D. Hyperoxygenation of the cerebrum 

Answer: C 

Explanation: These are classic manifestations of increased intracranial pressure. 

Question 5145) 

The physician has ordered mannitol IV for a client with a head injury. What should the nurse closely monitor because the client is receiving mannitol? 

A. Deep tendon reflexes 

B. Urine output 

C. Level of orientation 

D. Pulse rate 

Answer: B 

Explanation: Mannitol is an osmotic diuretic. Urine output should increase. He must be on intake and output. 

Question 5146) 

A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician’s orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, “I can’t believe I really had a seizure. My mom says she was in the room when it happened, but I don’t even remember it.” What is the best interpretation of his comments? 

A. They indicate an initial denial mechanism, but he will begin to remember the seizure later. 

B. Anoxia suffered during the seizure has damaged part of his cerebral cortex. 

C. Inability to remember the seizure is a normal response of a person who has had a seizure. D. They are an indication that he would rather not talk about his seizure at this time. Answer: C 

Explanation: People seldom remember a seizure; this is a normal response. 

Question 5147) 

What should the nurse include when teaching the client with Parkinson’s disease? 

A. He should try to continue working as long as he can remain sitting most of the day. 

B. Drooling may be reduced somewhat if he remembers to swallow frequently 

C. He should return monthly for lab tests, which will predict the progression of the disease. 

D. Emotional stress has no effect on voluntary muscle control in clients with Parkinson’s disease. 

Answer: B 

Explanation: Swallowing may reduce drooling. Sitting most of the day causes stiffness. There is no lab test to determine disease progression. Emotional stress can aggravate the symptoms. 

Question 5148)

A 68-year-old woman is brought to the emergency room by ambulance. She was found by her husband slumped in her chair and unresponsive. Tentative diagnosis is cerebrovascular accident (CVA). The physician orders a 15% solution of mannitol IV. The nurse knows that this drug is given for what purpose? 

A. To increase urine output 

B. To dissolve clots 

C. To reduce blood pressure 

D. To decrease muscle spasms 

Answer: A 

Explanation: Mannitol is an osmotic diuretic that increases urine output and will decrease intracranial pressure. Streptokinase and tPA dissolve clots and might be ordered for this client. Antihypertensive medications may also be ordered for this client. 

Question 5149) 

An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss? 

A. Place frequently used items on the affected side 

B. Position her so that her affected side is toward the activity in the room 

C. Encourage her to turn her head from side to side to scan the environment on the affected side 

D. Stand on the affected side while assisting her in ambulating 

Answer: C 

Explanation: Encouraging her to turn her head from side to side will do the most to help her learn a skill that will compensate for loss of the visual field. With homonymous hemianopia, the client does not see on the affected or paralyzed side. Choices 1 and 2 will make life more difficult for her. If the nurse stands on the affected side, the client will be unaware of the nurse. 

Question 5150) 

A client asks the nurse what causes Parkinson’s disease. The nurse’s correct reply would be that Parkinson’s disease is thought to be due to: 

A. a deficiency of dopamine in the brain. 

B. a demyelinating process affecting the central nervous system. 

C. atrophy of the basal ganglia 

D. insufficient uptake of acetylcholine in the body. 

Answer: A 

Explanation: A deficiency of dopamine is thought to be the cause of Parkinson’s disease. Multiple sclerosis is caused by demyelination of the central nervous system. Alzheimer’s disease involves atrophy of the basal ganglia. Myasthenia gravis is caused by insufficient uptake of acetylcholine in the body. 

Question 5151) 

The nurse is caring for a client who is very hard of hearing. How should the nurse communicate with this person? 

A. Speak loudly and talk in his better ear 

B. Stand in front of him and speak clearly and distinctly 

C. Yell at him using a high-pitched voice 

D. Write all communication on a note pad or magic slate 

Answer: B 

Explanation: Standing in front of him and speaking clearly and distinctly will allow him to read lips. Speaking loudly is usually not the best approach. Most persons with difficulty hearing hear lowpitched sounds better than highpitched ones; yelling and speaking loudly tend to raise the pitch of the voice. Written communication might become necessary for some persons; however, that would only be a last resort after all other methods of communication have failed. 

Question 5152) 

The day following a stapedectomy, the client tells the nurse that he cannot hear much in the operative ear and thinks the stapedectomy was a failure. What is the best response for the nurse to make? 

A. “There is packing in your ear. You will not hear well for a few days.” 

B. “The doctors have not yet turned on the stapes replacement.” 

C. “You may not have hearing, but you will now be free of pain.” 

D. “You seem upset that you aren’t hearing well.” 

Answer: A 

Explanation: Packing in the ear will reduce sound wave transmission. Hearing will be muffled until the packing is removed. The stapes replacement does not need to be turned on. The purpose of a stapedectomy is to restore some hearing. Otosclerosis, for which the stapedectomy was performed, is not a painful condition. It is more appropriate to give the client the information that he needs regarding hearing rather than to focus on the client’s feelings. 

Question 5153)

A cataract extraction is performed on a client’s right eye. What is the priority nursing care immediately postoperative? 

A. Assist her to turn, cough, and deep breathe every two hours. 

B. Keep her NPO for four hours. 

C. Assist her in moving her arms and legs in ROM. 

D. Position client on her right side. 

Answer: C 

Explanation: Of these answers, moving arms and legs is the best answer because it will help to prevent thrombophlebitis. The client should not cough because this will increase intraocular pressure. There is no need to keep her NPO. She should not be positioned on the operative side because this will increase intraocular pressure. 

Question 5154) 

A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis? 

A. “I am a vegetarian.” 

B. “My mother and grandmother have diabetes.” 

C. “I take aspirin several times a day for tension headaches.” 

D. “I take multivitamin and iron tablets every day.” 

Answer: C 

Explanation: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Being a vegetarian does not cause ulcers. Ulcers are not known to be inherited. Multivitamins and iron do not cause ulcers. 

Question 5155) 

An upper GI series is ordered for a client. Which action is essential for the nurse before the test? 

A. Check to see if the client has an allergy to shellfish. 

B. Instruct the client to have nothing to eat after midnight the night before the test. 

C. Encourage the client to drink plenty of liquids before the test. 

D. Be sure the client does not eat fat-containing foods for 18 hours before the test. 

Answer: B 

Explanation: Preparation for an upper GI series is NPO for eight hours. In an upper GI series, the client swallows barium, a radiopaque substance. An iodine dye is not used, so it is not necessary to ask about iodine allergies (shellfish). Fats are restricted before gallbladder x-rays, not for an upper GI series. 

Question 5156) 

The client with a duodenal ulcer is ready for discharge. Which statement made by the client indicates a need for more teaching about his diet? 

A. “It’s a good thing I gave up drinking alcohol last year.” 

B. “I will have to drink lots of milk and cream every day.” 

C. “I will stay away from cola drinks after I am discharged.” 

D. “Eating three nutritious meals and snacks every day is okay.” 

Answer: B 

Explanation: Milk and cream are now known to cause rebound acidity and are not prescribed for ulcer clients. The other choices all indicate good knowledge. He should not drink alcohol or cola. Three meals and snacks will help keep the stomach from staying empty for long periods. 

Question 5157) 

The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney’s point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response? 

A. “The next time the doctor comes in, we should ask him what he meant by that.” 

B. “I’ve felt that I don’t understand the doctor at times either.” 

C. “That is the term used to indicate that the pain has traveled to the right lower side.” 

D. “McBurney’s point refers to severe pain for which surgery is the only treatment.” 

Answer: C 

Explanation: McBurney’s point is the area in the right lower quadrant where the appendix is. The client asked for information that the nurse should be able to provide. Answer 4 is not correct. McBurney’s point refers to the location of the appendix, not the severity of the pain. 

Question 5158) 

Which blood test results would confirm a diagnosis of appendicitis? 

A. WBC of 13,000 

B. RBC of 4.5 million 

C. Platelet count of 300,000 

D. Positive heterophil antibody test 

Answer: A 

Explanation: An elevated WBC count indicates appendicitis. The RBC and platelet levels given are normal but are not specifically related to appendicitis. A positive heterophil antibody test indicates infectious mononucleosis. 

Question 5159) 

The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is it essential to ask? 

A. “When did you last eat?” 

B. “Have you had surgery before?” 

C. “Have you ever had this type of pain before?” 

D. “What do you usually take to relieve your pain?” 

Answer: A 

Explanation: When a person is admitted with possible appendicitis, the nurse should anticipate surgery. It will be important to know when she last ate when considering the type of anesthesia so that the chance of aspiration can be minimized. The other information is “nice to know” but not essential. 

Question 5160) 

The client with appendicitis asks the nurse for a laxative to help relieve her constipation. The nurse explains to her that laxatives are not given to persons with possible appendicitis. What is the primary reason for this?

A. Laxatives will decrease the spread of infection. 

B. Laxatives are not given prior to any type of surgery. 

C. The client does not have true constipation. She only has pressure. 

D. Laxatives could cause a rupture of the appendix. 

Answer: D 

Explanation: Laxatives cause increased peristalsis, which may cause the appendix to rupture. Answer 2 is not a true statement. Laxatives may well be given prior to gynecological, rectal, and colon surgery. Answer 3 is true but is not the primary reason why laxatives are not given when a person has appendicitis.