DMMMSU –SLUC, AGOO, LA UNION

Task: Do Compilation Of 50 Board Type Questions With

SUBMITTED TO: ELLIE JOHN RAMOS

SUBMITTED BY: MALINDA SIRUE

BSN III,2020

SITUATION: Joel Joe Raka was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse
Jaylo

Question 1:

What specific manifestation would nurse Jaylo see in Acute close angle glaucoma that she would not
see in an open angle glaucoma?

A. Loss of peripheral vision

B. Irreversible vision loss

D. Pain

Rational:

There is NO PAIN in open angle glaucoma. A, B, C are all present in both glaucoma including the low
pressure glaucoma. Pain is absent because the increase in intra ocular pressure is not initiated abruptly.
It is gradual and progressive and will lead to unnoticed loss of peripheral vision. Pain is present in acute
close angle glaucoma because there is a sudden closure or narrowing of the canal of schlemm.
Therefore if you will be ask what s/s is common in both, answer IRREVERSIBLE LOSS OF PERIPHERAL
VISION.

Question 2:

Nurse Jaylo knew that Acute close angle glaucoma is caused by:

A. Sudden blockage of the anterior angle by the base of the iris

B. Obstruction in trabecular meshwork

C. Gradual increase of IOP

D. An abrupt rise in IOP from 8 to 15 mmHg

Rational:

Sudden blockage of the angle will cause s/s of acute angle closure glaucoma. B and C are all related to
open angle glaucoma. D is insignificant, if the client bends or cough, IOP can increase from 8 to as much
as 30 mmHg but then return again to normal.

Question 3:

Nurse Jaylo performed a TONOMETRY test to Mr. Raka. What does this test measures.

A. It measures the peripheral vision remaining on the client

B. Measures the Intra Ocular Pressure

C. Measures the Client’s Visual Acuity

D. Determines the Tone of the eye in response to the sudden increase in IOP.

Rational:

Tonometry measures the IOP. Normal range is 8 to 21 mmHg.

Question 4:
The Nurse notices that Mr. Raka cannot anymore determine RED from BLUE. The nurse knew that
which part of the eye is affected by this change?

A. IRIS

B. PUPIL

c. RODS [RETINA]

D. CONES [RETINA]

Rational:

CONES Are responsible for COLOR VISION and DAY VISION, they are very sensitive to RED LIGHT that is
why red lights are used to guide the elderly towards the bathroom when they wake up to urinate. Rods
are responsible for night vision. They are sensitive to blue and green lights.

Question 5:

Nurse Jaylo knows that Aqueous Humor is produce where?

A. In the sub arachnoid space of the meninges

B. In the Lateral ventricles

C. In the Choroids

D. In the Ciliary Body

Rational: AH is produced in the CILIARY BODY. It is filtered by the trabecular meshwork into the canal of
schlemm.

Question 6:

Nurse Jaylo wants to measure Mr. Raka’s CN II Function. What test would Nurse Jaylo implement to
measure CN II’s Acuity?

A. Slit lamp

B. Snellen’s Chart

C. Wood’s light

D. Gonioscopy

Rational:

CN II is the optic nerve. To assess its acuity, Snellen's chart is used. Slit lamp is the one you see in the
usual Eye glasses shop where in, you need to look into its binocular-like holes and the optometrist is on
the other side to magnify the structures of the eye to assess gross damage and structure. Woods light is
a BLUE LIGHT used in dermatology. It is use to mark lesions usually caused skin infection. Gonioscopy is
the angle measurement of the eye.

Question 7:

The Doctor orders pilocarpine. Nurse Jaylo knows that the action of this drug is to:

A. Contract the Ciliary muscle

B. Relax the Ciliary muscle

C. Dilate the pupils

D. Decrease production of Aqueous Humor

Rational:

When the ciliary muscles contract, pupils constrict and the angle widens causing an increase AH outflow
and decrease IOP. Relaxing the ciliary muscle will cause mydriasis or dilation, it is used as a pre op meds
for cataract surgery and eye examination to better visualize the structures behind the iris. A and C are
the same. Other drugs like betaxolol, Acetazolamide and epinephrine are the drugs used to decrease AH
production.

Question 8:

The doctor orders timolol [timoptic]. Nurse Jaylo knows that the action of this drug is:

A. Reduce production of CSF

B. Reduce production of Aqueous Humor

C. Constrict the pupil

D. Relaxes the Ciliary muscle

Rational:

All the eye drops the ends in OLOL decreases AH production. They are BETA BLOCKERS. Watch out for
the S/S of congestive heart failure, bradycardia, hypotension and arrythmias.

Question 9:

When caring for Mr. Raka, Jaylo teaches the client to avoid:

A. Watching large screen TVs

C. Reading books

D. Going out in the sun

Rational:

Bending at the waist increase IOP and should be avoided by patients with glaucoma. Treatment for
glaucoma is usually for life. Patients are given laxatives to avoid stratining at the stool. They should avoid
all activities that will lead to sudden IOP increase like bending at the waist. Clients should bend at the
knees.

Question 10:

Mr. Raka has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is
contraindicated immediately after procedure?

A. Reading newsprint

B. Lying down

C. Watching TV

D. Listening to the music

Rational:

The client had an eye angiography. Eye angiography requires the use MYDRIATICS pre-procedure. It is
done by injecting an Intravenous dye and visualizes the flow of the dye through the fluoroscopy along
the vessels of the eye. This is to assess macular degeneration or neovascularization’s [proliferation of
new vessels to compensate for continuous rupture and aneurysms of the existing vessels] Mydratics
usually takes 6 hours to a day to wear off. If client uses a mydratic, his pupil will dilate making it UNABLE
to focus on closer objects. Only A necessitates the constriction of the pupil to focus on a near object,
which Mr.Raka’s eye cannot perform at this time.

Question 11:

If Mr. Raka is receiving pilocarpine, what drug should always be available in any case systemic toxicity
occurs?

A. Atropine Sulfate

B. Pindolol [Visken]

C. Naloxone Hydrochloride [Narcan]

Rational:

Atropine sulfate is use to reverse the effects of systemic toxicity of pilocarpine. Narcan is the antidote
for respiratory depression caused by narcotics like morphine and demerol. Serentil is an antipsychotic.

SITUATION: Wide knowledge about the human ear, its parts and its functions will help a nurse assess
and analyze changes in the adult client’s health.

Question 12:

Nurse Janet is doing a caloric testing to his patient, Aida, a 55 year old university professor who
recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she
gave a failing mark. After instilling a warm water in the ear, Janet noticed a rotary nystagmus towards
the irrigated ear. What does this means?

A. Indicates a CN VIII Dysfunction

B. Abnormal

C. Normal

D. Inconclusive

Rational:

Rotary nystagmus towards the ear [if warm] or away from it [if cool] is a normal response. It indicates
that the CN VIII Vestibular branch is still intact.

Question 13:

Ear drops are prescribed to an infant, the most appropriate method to administer the ear drops is:

A. Pull the pinna up and back and direct the solution towards the eardrum

B. Pull the pinna down and back and direct the solution onto the wall of the canal

C. Pull the pinna down and back and direct the solution towards the eardrum

D. Pull the pinna up and back and direct the solution onto the wall of the canal

Rational:

Instillation for children under age 3 is CHILD: DOWN AND BACK. Directing the solution towards the
eardrum might perforate or damage the infant’s fragile tympanic membrane.
Question 14:

Nurse Janet is developing a plan of care for a patient with Menieres disease. What is the priority
nursing intervention in the plan of care for this particular patient?

A. Air, Breathing, Circulation

B. Love and Belongingness

C. Food, Diet and Nutrition

D. Safety

Rational:

Although A is priority according to Maslow, it is not specific in clients with menieres disease. The client
has an attack of incapacitating vertigo and client is high risk for injury due to falls. The client will perceive
the environment moving due to disruption of the vestibular system of the ear's normal function.

Question 15:

After mastoidectomy, Nurse Janet should be aware that the cranial nerve that is usually damage after
this procedure is:

A. CN I

B. CN II

C. CN VII

D. CN VI

Rational: The facial nerve branches from the back of the ear and spread towards the mouth, cheeks,
and eyelids and almost all over the face. In mastoidectomy, Incision is made at the back of the ears to
clear the mastoid air cells of the mastoid bone that is infected. Clients are at very high risk for CN VII
injury because of this. Observation during the post op after mastoidectomy should revolve around
assessing the client's CN VII integrity.

Question 16:

The physician orders the following for the client with Menieres disease. Which of the following should
the nurse question?

A. Dipenhydramine [Benadryl]

B. Atropine sulfate

C. Out of bed activities and ambulation

Rational:

Clients with acute attack of Menieres are required to have bed rest with side rails up to prevent injury.
During periods of incapacitating vertigo, patient's eyes will have rotary nystagmus because of the
perception that the environment is moving. Patients are also observed to hold the side rails so hard
because they thought they are going to fall. Benadryl is used in menieres due to its anti-histamine
effects. B and D are used to allay client’s anxiety and apprehension.

Question 17:

Nurse Janet is giving dietary instruction to a client with Menieres disease. Which statement if made by
the client indicates that the teaching has been successful?

A. I will try to eat foods that are low in sodium and limit my fluid intake

B. I must drink at least 3,000 ml of fluids per day

C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet

D. I will not eat turnips, red meat and raddish

Rational:

Clients are advised to limit fluid and sodium intake as not to further cause accumulation of fluids in the
end lymph. C is the diabetic diet. D are the foods not eaten when clients are about to have a guaiac test.

Question 18:

Bella was rushed by his father, Steven into the hospital admission. Bella is complaining of something
buzzing into her ears. Nurse Janet assessed Bella and found out it was an insect. What should be the
first thing that Nurse Janet should try to remove the insect out from Bella’s ear?

A. Use a flashlight to coax the insect out of Bella’s ear

B. Instill an antibiotic ear drops

C. Irrigate the ear

D. Pick out the insect using a sterile clean forceps

Rational:

Lights can coax the insect out of the child's ear. This is the first measure employed in removing a live
insect from the child’s ear. Insects are not removed ALIVE; therefore, C and D are both wrong.
Antibiotics has no effects since the child do not have any infection. If the insect did not come out after
coaxing it with light, 2nd measure employs instillation of diluted alcohol or a mineral oil to kill the insect
which is then removed using letter D.

Question 19:

Following an ear surgery, which statement if heard by Nurse Janet from the patient indicates a correct
understanding of the post-operative instructions?

A. Activities are resumed within 5 days

B. I will make sure that I will clean my hair and face to prevent infection

C. I will use straw for drinking

D. I should avoid air travel for a while

Rational:

After ear surgery, Air travel is halted for a while. There is no need to restrict activities. The client is not
allowed to shower for 7 days; Patient can clean himself using a sponge bath but avoids shampooing or
wetting the face and hair. Straws are not used after ear surgery because sips increases pressure in the
ear.

Question 20:

Nurse Janet will do a caloric testing to a client who sustained a blunt injury in the head. He instilled
cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What
does this finding indicates?

A. Indicating a Cranial Nerve VIII Dysfunction

B. The test should be repeated again because the result is vague

C. This is grossly abnormal and should be reported to the neurosurgeon

D. This indicates an intact and working vestibular branch of CN VIII

Rational: Refer to #12

Question 21:

A client with Cataract is about to undergo surgery. Nurse Janet is preparing plan of care. Which of the
following nursing diagnosis is most appropriate to address the long term need of this type of patient?

A. Anxiety R/T to the operation and its outcome

B. Sensory perceptual alteration R/T Lens extraction and replacement

C. Knowledge deficit R/T the pre-operative and post-operative self-care

Rational:

Patient does not have signs of anxiety, knowledge deficit or body image disturbance. The safest answer
is B because before cataract surgery, client has a blurry vision that alters his sensory perception. After
surgery client will be APHAKIC and again, will have an alteration in perception until the aphakic glass is
available.

Question 22:

Nurse Janet is performing a WEBERS TEST. He placed the tuning fork in the patient’s forehead after
tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the
following is a correct conclusion for nurse Janet to make?

A. He might have a sensory hearing loss in the left ear

B. Conductive hearing loss is possible in the right ear

C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left
ear.

D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.

Rational:

Webers test assesses both air and bone conduction but is not decisive enough to judge which is which.
When the tuning fork is tapped on the examiners knee, it is placed in the forehead or above the client’s
top lip. If the sound lateralizes towards the left ear, it’s either, the client has conductive hearing loss
towards the left OR a sensory hearing loss in the right ear.

Why does conductive hearing produces a louder sound?

Conductive hearing loss is a type of hearing loss where in, the ossicles hypertrophies, as in
OTOSCLEROSIS. The stape is permanently attached to the oval window and it would not bulge causing a
permanent LOUD conduction of sound using the bone because the stapes is already attached
permanently into the inner ear. In a normal stape, it will not touch the oval window unless a sound is
transmitted.

Question 23:

Mary Paul has Meniere’s disease. What typical dietary prescription would Nurse Janet expect the
doctor to prescribe?

A. A low sodium, high fluid intake

B. A high calorie, high protein dietary intake

D. low sodium and restricted fluid intake

Rational: Refer to # 17

SITUATION: A 65 year old woman was admitted for Parkinson’s disease. The charge nurse is going to
make an initial assessment.

Question 24:

Which of the following is a characteristic of a patient with advanced Parkinson’s disease?

A. Disturbed vision

B. Forgetfulness

C. Mask like facial expression

D. Muscle atrophy

Rational:

Parkinson's disease does not affect the cognitive ability of a person. It is a disorder due to the depletion
of the neurotransmitter dopamine which is needed for inhibitory control of muscular contractions.
Client will exhibit mask like facial expression, Cog wheel rigidity, Bradykinesia, Shuffling gait etc. Muscle
atrophy does not occur in Parkinson’s disease nor visual disturbances.

Question 25:

The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by:

A. Injurious chemical substances

B. Hereditary factors

C. Death of brain cells due to old age

D. Impairment of dopamine producing cells in the brain

Rational:

Dopamine producing cells in the basal ganglia mysteriously deteriorates due to unknown cause.

Question 26:

The patient was prescribed with levodopa. What is the action of this drug?
A. Increase dopamine availability

B. Activates dopaminergic receptors in the basal ganglia

C. Decrease acetylcholine availability

D. Release dopamine and other catecholamine from neurological storage sites

Rational:

Levodopa is an altered form of dopamine. It is metabolized by the body and then converted into
dopamine for brain's use thus increasing dopamine availability. Dopamine is not given directly because
of its inability to cross the BBB.

Question27:

You are discussing with the dietician what food to avoid with patients taking levodopa?

A. Vitamin C rich food

B. Vitamin E rich food

C. Thiamine rich food

D. Vitamin B6 rich food

Rational:

Vitamin b6 or pyridoxine is avoided in patients taking levodopa because levodopa increases vitamin b6
availability leading to toxicity.

Question 28:

One day, the patient complained of difficulty in walking. Your response would be:

A. You will need a cane for support

B. Walk erect with eyes on horizon

C. I’ll get you a wheelchair

D. Don’t force yourself to walk

Rational:

Telling the client to walk erect neglects the clients complain of difficulty walking. Wheelchair is as much
as possible not used to still enhance the client's motor function using a cane. Telling the client not to
force himself walk is non-therapeutic. The client wants to talk and we should help her walk using devices
such as cane to provide support and prevent injuries.
SITUATION: Mr. James Born, a client with early Dementia exhibits thought process disturbances.

Question 29:

The nurse will assess a loss of ability in which of the following areas?

A. Balance

B. Judgment

C. Speech

D. Endurance

Rational:

Perhaps this question from the JUN 2005 NLE is finding what should the nurse NOT assess because A, B
and C are all affected by dementia except ENDURANCE, which is normally lost as a person ages. There
will be alteration in balance because coordination and spatial ability gradually deteriorates. Judgment is
also impaired as the client exhibits poor memory and concentration. Speech is severely altered. Client
develops aphasia, agnosia and in at end, will lose all the ability to speak without any manifestation of
motor problem.

Question 30:

Mr. Born Isla said he cannot comprehend what the nurse was saying. He suffers from:

A. Insomnia

B. Aphraxia

C. Agnosia

D. Aphasia

Rational:

This question was RECYCLED during the last 2006 NLE. Aphasia is the INABILITY to speak or understand.
Aphraxia is the inability to carry out purposeful tasks. Agnosia is the inability to recognize familiar
objects. Insomnia is the inability to fall asleep.

Question 31:

The nurse is aware that in communicating with an elderly client, the nurse will:

A. Lean and shout at the ear of the client

C. Use a low-pitched voice

D. Use a medium-pitched voice

Rational:

Talk as normally as possible. The client has dementia and is not deaf, although hearing might be
impaired progressively as the client ages, the nurse should not alter his voice, shout or over enunciate
the words. Client will preceive these things as belittling and disrespectful.

Question 32:

As the nurse talks to the daughter of Mr. Born Isla, which of the following statement of the daughter
will require the nurse to give further teaching?

A. I know the hallucinations are parts of the disease

B. I told her she is wrong and I explained to her what is right

C. I help her do some tasks he cannot do for himself

D. I’ll turn off the TV when we go to another room

Rational:

Hallucinations and delusions are part of DEMENTIA and are termed as ORGANIC PSYCHOSES. The
daughter needs further teaching when she tries to bargain, explain, disprove or advice a client with
dementia. The client has an impaired judgment, concentration, thinking, reasoning and memory and has
inability to learn that is why institutional care for clients with dementia is always required. The disease is
progressive and is not preventable.

Question 33:

Which of the following is most important discharge teaching for Mr. James Born.

A. Emergency Numbers

B. Drug Compliance

C. Relaxation technique

D. Dietary prescription

Rational:
Drug compliance is the most important teaching for Mr. James Born to prevent the symptoms of
psychoses and to control behavioral symptoms.

Question 34:

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.Female sex

C.Obesity

D.Bronchial asthma

Rational:

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 client’s race, sex, and bronchial asthma aren’t risk factors for CVA.

Question 35:

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.take a hot bath.

B.Rest in an air-conditioned room.

C.Increase the dose of muscle relaxants.

D.Avoid naps during the day.

Rational:

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.

Question 36:
A male client is having a tonic-clonic seizures. What should the nurse do first?

A.Elevate the head of the bed.

Restrain the client’s arms and legs.

Place a tongue blade in the client’s mouth.

Take measures to prevent injury.

Rational:

Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed
would have no effect on the client’s condition or safety. Restraining the client’s arms and legs could
cause injury. Placing a tongue blade or other object in the client’s mouth could damage the teeth.

Question 37

A female client with Guillain-Barré 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. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any
sensory loss.”

C. “It must be hard to accept the permanency of your paralysis.”

D. “You’ll first regain use of your legs and then your arms.”

Rational:

The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only
temporary. Return of motor function begins proximally and extends distally in the legs.

Question 38

The nurse is working on a surgical floor. The nurse must logroll a male client following a:

A.laminectomy

B.thoracotomy

C.hemorrhoidectomy

D.cystectomy

Rational:
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.

Question 39

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What
should the nurse do when preparing the client for this test?

A.Immobilize the neck before the client is moved onto a stretcher.

B.Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

C.Place a cap over the client’s head.

D.Administer a sedative as ordered.

Rational:

Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is
allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a
suspected spinal cord injury. Placing a cap over the client’s head may lead to misinterpretation of test
results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client
can’t be expected to remain still during the CT scan.

Question 40

During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should
make sure to:

A.Use the pointed end of the reflex hammer when striking the Achilles tendon.

B.Support the joint where the tendon is being tested.

C.Tap the tendon slowly and softly

D.Hold the reflex hammer tightly.

Rational:

To prevent the attached muscle from contracting, the nurse should support the joint where the tendon
is being tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the
Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the
biceps tendon.) Tapping the tendon slowly and softly wouldn’t provoke a deep tendon reflex response.
The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can
swing in an arc.
Question 41

A female client is admitted in a disoriented and restless state after sustaining a concussion during a
car accident. Which nursing diagnosis takes highest priority in this client’s plan of care?

A.Disturbed sensory perception (visual)

B.Self-care deficient: Dressing/grooming

C.Impaired verbal communication

D.Risk for injury

Rational:

Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury.
Although the other options may be appropriate, they’re secondary because they don’t immediately
affect the client’s health or safety.

Question 42

A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so
frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?

A.Anxiety

B.Powerlessness

C.Ineffective denial

D.Risk for disuse syndrome

Rational:

This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in
syndrome, characterized by an active and functioning mind locked in a body that can’t perform even
simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with
ALS, the client’s comment specifically refers to an inability to act autonomously. A diagnosis of
Ineffective denial would be indicated if the client didn’t seem to perceive the personal relevance of
symptoms or danger.

Question 43

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory
goal is to:

A.Prevent respiratory alkalosis.

C.Promote carbon dioxide elimination.

D.Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

Rational:

The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid
environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing
respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this
case. It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate
most clients.

Question 44

Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes
to the victim and determines the need to opens the airway in this victim by using which method?

A.Flexed position

B.Head tilt-chin lift

C.Jaw thrust maneuver

D.Modified head tilt-chin lift

Rational:

If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt–chin lift
maneuver produces hyperextension of the neck and could cause complications if a neck injury is
present. A flexed position is an inappropriate position for opening the airway.

Question 45

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use
which plan to use which of the following to test the client’s peripheral response to pain?

A.Sternal rub

B.Nail bed pressure

C.Pressure on the orbital rim

D.Squeezing of the sternocleidomastoid muscle

Rational:
Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed
pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub,
placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

Question 46

A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic
resonance imaging may be done. The nurse interprets that the client may be ineligible for this
diagnostic procedure based on the client’s history of:

A.Hypertension

B.Heart failure

C.Prosthetic valve replacement

D.Chronic obstructive pulmonary disorder

Rational:

The client having a magnetic resonance imaging scan has all metallic objects removed because of the
magnetic field generated by the device. A careful history is obtained to determine whether any metal
objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm
clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this
procedure. The client may be ineligible if significant risk exists.

Question 47

A male client is having a lumbar puncture performed. The nurse would plan to place the client in
which position?

A.Side-lying, with a pillow under the hip

B.Prone, with a pillow under the abdomen

C.Prone, in slight-Trendelenburg’s position

D.Side-lying, with the legs pulled up and head bent down onto chest.

Rational:

The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the
abdomen and the head bent down onto the chest. This position helps open the spaces between the
vertebrae.

Question 48
The nurse is positioning the female client with increased intracranial pressure. Which of the following
positions would the nurse avoid?

A.Head mildline

B.Head turned to the side

C.Neck in neutral position

D.Head of bed elevated 30 to 45 degrees

Rational:

The head of the client with increased intracranial pressure should be positioned so the head is in a
neutral midline position. The nurse should avoid flexing or extending the client’s neck or turning the
head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions
promotes venous drainage from the cranium to keep intracranial pressure down.

Question 49

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse
assesses that this is cerebrospinal fluid if the fluid:

A.Is clear and tests negative for glucose

B.Is grossly bloody in appearance and has a pH of 6

C.lumps together on the dressing and has a pH of 7

D.Separates into concentric rings and test positive of glucose

Rational:

Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can
be distinguished from other body fluids because the drainage will separate into bloody and yellow
concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

Question 50

A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would
avoid which of the following measures to minimize the risk of recurrence?

A.Strict adherence to a bowel retraining program

B.Keeping the linen wrinkle-free under the client

D.Limiting bladder catheterization to once every 12 hours

Rational:

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization
should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in
the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is
important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The
nurse administers care to minimize risk in these areas.