Chapter 12: Genetics
1. The sister of a patient diagnosed with BRCA generelated breast cancer asks the nurse,
Do you think I should be tested for the gene? Which response by the nurse is most
appropriate?
a. In most cases, breast cancer is not caused by the BRCA gene.
b. It depends on how you will feel if the test is positive for the BRCA gene.
c. There are many things to consider before deciding to have genetic testing.
d. You should decide first whether you are willing to have a bilateral mastectomy.
ANS: C
2. When counseling a couple in which the man has an autosomal recessive disorder and the
woman has no gene for the disorder, the nurse uses Punnett squares to show the couple the
probability of their having a child with the disorder. Which statement by the nurse is most
appropriate?
a. You should consider adoption.
b. Your children will be carriers of the disorder.
c. Your female children will display characteristics of the disorder.
d. Your first-born child will likely display characteristics of the disorder.
ANS: B
3. A patient with a family history of cystic fibrosis (CF) asks for information about genetic
testing. Which response by the nurse is most appropriate?
a. Refer the patient to a qualified genetic counselor.
b. Ask the patient why genetic testing is so important.
c. Remind the patient that genetic testing has many social implications.
d. Tell the patient that cystic fibrosis is an autosomal recessive disorder.
ANS: A
4. A male patient with hemophilia asks the nurse if his children will be hemophiliacs.
Which response by the nurse is appropriate?
a. All of your children will be at risk for hemophilia.
b. Hemophilia is a multifactorial inherited condition.
c. Only your male children are at risk for hemophilia.
d. Your female children will be carriers for hemophilia.
ANS: D
5. When caring for a young adult patient who has abnormalities in the cytochrome P450
(CYP 450) gene, which action will the nurse include in the patients plan of care?
a. Teach that some medications may not work as effectively.
b. Teach about genetic risk for cystic fibrosis in any children.
c. Suggest that the patient make heart healthy lifestyle choices.
d. Discuss the need for screening mammograms starting at age 30.
ANS: A
6. A patient tells the nurse, I would like to use a home genetic test to see if I will develop
breast cancer. Which response by the nurse is best?
a. Home genetic testing is very expensive.
b. Are you concerned about developing breast cancer?
c. Wont you be depressed if the testing shows a positive result?
d. Genetic testing can only determine if you are at higher risk for breast cancer.
ANS: B
7. The nurse in the outpatient clinic has obtained health histories for these new patients.
Which patient may need referral for genetic testing?
a. 35-year-old patient whose maternal grandparents died after strokes at ages 90 and 96
b. 18-year-old patient with a positive pregnancy test whose first child has cerebral palsy
c. 34-year-old patient who has a sibling with newly diagnosed polycystic kidney disease
d. 50-year-old patient with a history of cigarette smoking who is complaining of dyspnea
ANS: C
Chapter 58: Chronic Neurologic Problems
1. The nurse determines that teaching about management of migraine headaches has been
effective when the patient says which of the following?
a. I can take the (Topamax) as soon as a headache starts.
b. A glass of wine might help me relax and prevent a headache.
c. I will lie down someplace dark and quiet when the headaches begin.
d. I should avoid taking aspirin and sumatriptan (Imitrex) at the same time.
ANS: C
2. The nurse will assess a 67-year-old patient who is experiencing a cluster headache for
a. nuchal rigidity.
b. unilateral ptosis.
c. projectile vomiting.
d. throbbing, bilateral facial pain.
ANS: B
3. While the nurse is transporting a patient on a stretcher to the radiology department, the
patient begins having a tonic-clonic seizure. Which action should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the patients arms and legs to prevent injury during the seizure.
c. Time and observe and record the details of the seizure and postictal state.
d. Avoid touching the patient to prevent further nervous system stimulation.
ANS: C
4. A high school teacher who has just been diagnosed with epilepsy after having a
generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will be too
upsetting if I have a seizure at work. Which response by the nurse is best?
a. You might benefit from some psychologic counseling.
b. Epilepsy usually can be well controlled with medications.
c. You will want to contact the Epilepsy Foundation for assistance.
d. The Department of Vocational Rehabilitation can help with work retraining.
ANS: B
5. A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse
take when evaluating for adverse effects of the medication?
a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel tones.
d. Check pupil reaction to light.
ANS: A
6. A patient reports feeling numbness and tingling of the left arm before experiencing a
tonic-clonic seizure. The nurse determines that this history is consistent with what type of
seizure?
a. Focal
b. Atonic
c. Absence
d. Myoclonic
ANS: A
7. When obtaining a health history and physical assessment for a 36-year-old female
patient with possible multiple sclerosis (MS), the nurse should
a. assess for the presence of chest pain.
b. inquire about urinary tract problems.
c. inspect the skin for rashes or discoloration.
d. ask the patient about any increase in libido.
ANS: B
8. A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks
associated with pregnancy. Which response by the nurse is accurate?
a. MS symptoms may be worse after the pregnancy.
b. Women with MS frequently have premature labor.
c. MS is associated with an increased risk for congenital defects.
d. Symptoms of MS are likely to become worse during pregnancy.
ANS: A
9. A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer
acetate (Copaxone). Which information will the nurse include in patient teaching?
a. Recommendation to drink at least 4 L of fluid daily
b. Need to avoid driving or operating heavy machinery
c. How to draw up and administer injections of the medication
d. Use of contraceptive methods other than oral contraceptives
ANS: C
10. Which information about a 60-year-old patient with MS indicates that the nurse should
consult with the health care provider before giving the prescribed dose of dalfampridine
(Ampyra)?
a. The patient has relapsing-remitting MS.
b. The patient walks a mile a day for exercise.
c. The patient complains of pain with neck flexion.
d. The patient has an increased serum creatinine level.
ANS: D
11. Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis
(MS) who has urinary retention caused by a flaccid bladder?
a. Decrease the patients evening fluid intake.
b. Teach the patient how to use the Cred method.
c. Suggest the use of adult incontinence briefs for nighttime only.
d. Assist the patient to the commode every 2 hours during the day.
ANS: B
12. A 73-year-old patient with Parkinsons disease has a nursing diagnosis of impaired
physical mobility related to bradykinesia. Which action will the nurse include in the plan of
care?
a. Instruct the patient in activities that can be done while lying or sitting.
b. Suggest that the patient rock from side to side to initiate leg movement.
c. Have the patient take small steps in a straight line directly in front of the feet.
d. Teach the patient to keep the feet in contact with the floor and slide them forward.
ANS: B
13. A 62-year-old patient who has Parkinsons disease is taking bromocriptine (Parlodel).
Which information obtained by the nurse may indicate a need for a decrease in the dose?
a. The patient has a chronic dry cough.
b. The patient has four loose stools in a day.
c. The patient develops a deep vein thrombosis.
d. The patients blood pressure is 92/52 mm Hg.
ANS: D
14. The nurse advises a patient with myasthenia gravis (MG) to
a. perform physically demanding activities early in the day.
b. anticipate the need for weekly plasmapheresis treatments.
c. do frequent weight-bearing exercise to prevent muscle atrophy.
d. protect the extremities from injury due to poor sensory perception.
ANS: A
15. Which medication taken by a patient with restless legs syndrome should the nurse
discuss with the patient?
a. Multivitamin (Stresstabs)
b. Acetaminophen (Tylenol)
c. Ibuprofen (Motrin, Advil)
d. Diphenhydramine (Benadryl)
ANS: D
16. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with
pneumonia. Which nursing action will be included in the plan of care?
a. Assist with active range of motion (ROM).
b. Observe for agitation and paranoia.
c. Give muscle relaxants as needed to reduce spasms.
d. Use simple words and phrases to explain procedures.
ANS: A
17. A 40-year-old patient is diagnosed with early Huntingtons disease (HD). When teaching
the patient, spouse, and children about this disorder, the nurse will provide information
about the
a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms.
b. prophylactic antibiotics to decrease the risk for aspiration pneumonia.
c. option of genetic testing for the patients children to determine their own HD risks.
d. lifestyle changes of improved nutrition and exercise that delay disease progression.
ANS: C
18. When a 74-year-old patient is seen in the health clinic with new development of a
stooped posture, shuffling gait, and pill rollingtype tremor, the nurse will anticipate
teaching the patient about
a. oral corticosteroids.
b. antiparkinsonian drugs.
c. magnetic resonance imaging (MRI).
d. electroencephalogram (EEG) testing.
ANS: B
19. A 22-year-old patient seen at the health clinic with a severe migraine headache tells the
nurse about having other similar headaches recently. Which initial action should the nurse
take?
a. Teach about the use of triptan drugs.
b. Refer the patient for stress counseling.
c. Ask the patient to keep a headache diary.
d. Suggest the use of muscle-relaxation techniques.
ANS: C
20. A hospitalized patient complains of a bilateral headache, 4/10 on the pain scale, that
radiates from the base of the skull. Which prescribed PRN medications should the nurse
administer initially?
a. Lorazepam (Ativan)
b. Acetaminophen (Tylenol)
c. Morphine sulfate (Roxanol)
d. Butalbital and aspirin (Fiorinal)
ANS: B
21. A 46-year-old patient tells the nurse about using acetaminophen (Tylenol) several times
every day for recurrent bilateral headaches. Which action will the nurse plan to take first?
a. Discuss the need to stop taking the acetaminophen.
b. Suggest the use of biofeedback for headache control.
c. Describe the use of botulism toxin (Botox) for headaches.
d. Teach the patient about magnetic resonance imaging (MRI).
ANS: A
22. The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yearold male patient with migraine headaches. Which information obtained by the nurse is
most important to report to the health care provider?
a. The patient drinks 1 to 2 cups of coffee daily.
b. The patient had a recent acute myocardial infarction.
c. The patient has had migraine headaches for 30 years.
d. The patient has taken topiramate (Topamax) for 2 months.
ANS: B
23. The nurse observes a patient ambulating in the hospital hall when the patients arms
and legs suddenly jerk and the patient falls to the floor. The nurse will first
a. assess the patient for a possible head injury.
b. give the scheduled dose of divalproex (Depakote).
c. document the timing and description of the seizure.
d. notify the patients health care provider about the seizure.
ANS: A
24. Which prescribed intervention will the nurse implement first for a patient in the
emergency department who is experiencing continuous tonic-clonic seizures?
a. Give phenytoin (Dilantin) 100 mg IV.
b. Monitor level of consciousness (LOC).
c. Obtain computed tomography (CT) scan.
d. Administer lorazepam (Ativan) 4 mg IV.
ANS: D
25. The home health registered nurse (RN) is planning care for a patient with a seizure
disorder related to a recent head injury. Which nursing action can be delegated to a
licensed practical/vocational nurse (LPN/LVN)?
a. Make referrals to appropriate community agencies.
b. Place medications in the home medication organizer.
c. Teach the patient and family how to manage seizures.
d. Assess for use of medications that may precipitate seizures.
ANS: B
26. A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for
Parkinsons disease. Which information is most important for the nurse to report to the
health care provider?
a. Shuffling gait
b. Tremor at rest
c. Cogwheel rigidity of limbs
d. Uncontrolled head movement
ANS: D
27. Which nursing diagnosis is of highest priority for a patient with Parkinsons disease who
is unable to move the facial muscles?
a. Activity intolerance
b. Self-care deficit: toileting
c. Ineffective self-health management
d. Imbalanced nutrition: less than body requirements
ANS: D
28. Which assessment is most important for the nurse to make regarding a patient with
myasthenia gravis?
a. Pupil size
b. Grip strength
c. Respiratory effort
d. Level of consciousness
ANS: C
29. Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives
the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea
and severe abdominal cramps. Which action should the nurse take first?
a. Auscultate the patients bowel sounds.
b. Notify the patients health care provider.
c. Administer the prescribed PRN antiemetic drug.
d. Give the scheduled dose of prednisone (Deltasone).
ANS: B
30. A hospitalized 31-year-old patient with a history of cluster headache awakens during
the night with a severe stabbing headache. Which action should the nurse take first?
a. Start the ordered PRN oxygen at 6 L/min.
b. Put a moist hot pack on the patients neck.
c. Give the ordered PRN acetaminophen (Tylenol).
d. Notify the patients health care provider immediately.
ANS: A
31. Which intervention will the nurse include in the plan of care for a patient with primary
restless legs syndrome (RLS) who is having difficulty sleeping?
a. Teach about the use of antihistamines to improve sleep.
b. Suggest that the patient exercise regularly during the day.
c. Make a referral to a massage therapist for deep massage of the legs.
d. Assure the patient that the problem is transient and likely to resolve.
ANS: B
32. Which information about a 72-year-old patient who has a new prescription for
phenytoin (Dilantin) indicates that the nurse should consult with the health care provider
before administration of the medication?
a. Patient has generalized tonic-clonic seizures.
b. Patient experiences an aura before seizures.
c. Patients most recent blood pressure is 156/92 mm Hg.
d. Patient has minor elevations in the liver function tests.
ANS: D
33. After change-of-shift report, which patient should the nurse assess first?
a. Patient with myasthenia gravis who is reporting increased muscle weakness
b. Patient with a bilateral headache described as like a band around my head
c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin)
d. Patient with Parkinsons disease who has developed cogwheel rigidity of the arms
ANS: A
1. A 27-year-old patient who has been treated for status epilepticus in the emergency
department will be transferred to the medical nursing unit. Which equipment should the
nurse have available in the patients assigned room (select all that apply)?
a. Side-rail pads
b. Tongue blade
c. Oxygen mask
d. Suction tubing
e. Urinary catheter
f. Nasogastric tube
ANS: A, C, D
2. A patient with Parkinsons disease is admitted to the hospital for treatment of
pneumonia. Which nursing interventions will be included in the plan of care (select all that
apply)?
a. Use an elevated toilet seat.
b. Cut patients food into small pieces.
c. Provide high-protein foods at each meal.
d. Place an armchair at the patients bedside.
e. Observe for sudden exacerbation of symptoms.
ANS: A, B, D
Chapter 59: Dementia and Delirium
1. A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3
days after admission. Which information indicates that the patient is experiencing delirium
rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patients speech is fragmented and incoherent.
c. The patient is oriented to person but disoriented to place and time.
d. The patient has a history of increasing confusion over several years.
ANS: A
2. Which intervention will the nurse include in the plan of care for a patient with moderate
dementia who had an appendectomy 2 days ago?
a. Provide complete personal hygiene care for the patient.
b. Remind the patient frequently about being in the hospital.
c. Reposition the patient frequently to avoid skin breakdown.
d. Place suction at the bedside to decrease the risk for aspiration.
ANS: B
3. When administering a mental status examination to a patient with delirium, the nurse
should
a. wait until the patient is well-rested.
b. administer an anxiolytic medication.
c. choose a place without distracting stimuli.
d. reorient the patient during the examination.
ANS: C
4. The nurse is concerned about a postoperative patients risk for injury during an episode
of delirium. The most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
b. ask the health care provider to order an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.
ANS: D
5. A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive
impairment (MCI). Which action will the nurse include in the plan of care?
a. Suggest a move into an assisted living facility.
b. Schedule the patient for more frequent appointments.
c. Ask family members to supervise the patients daily activities.
d. Discuss the preventive use of acetylcholinesterase medications.
ANS: B
6. The nurse is administering a mental status examination to a 48-year-old patient who has
hypertension. The nurse suspects depression when the patient responds to the nurses
questions with
a. Is that right?
b. I dont know.
c. Wait, let me think about that.
d. Who are those people over there?
ANS: B
7. A 68-year-old patient is diagnosed with moderate dementia after multiple strokes.
During assessment of the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. loss of recent and long-term memory.
d. fluctuating ability to perform simple tasks.
ANS: C
8. Which action will help the nurse determine whether a new patients confusion is caused
by dementia or delirium?
a. Administer the Mini-Mental Status Exam.
b. Use the Confusion Assessment Method tool.
c. Determine whether there is a family history of dementia.
d. Obtain a list of the medications that the patient usually takes.
ANS: B
9. A 72-year-old female patient is brought to the clinic by the patients spouse, who reports
that she is unable to solve common problems around the house. To obtain information
about the patients current mental status, which question should the nurse ask the patient?
a. Are you sad?
b. How is your self-image?
c. Where were you were born?
d. What did you eat for breakfast?
ANS: D
10. A patient is being evaluated for Alzheimers disease (AD). The nurse explains to the
patients adult children that
a. the most important risk factor for AD is a family history of the disorder.
b. new drugs have been shown to reverse AD dramatically in some patients.
c. a diagnosis of AD is made only after other causes of dementia are ruled out.
d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the
diagnosis of AD.
ANS: C
11. Which nursing action will be most effective in ensuring daily medication compliance for
a patient with mild dementia?
a. Setting the medications up monthly in a medication box
b. Having the patients family member administer the medication
c. Posting reminders to take the medications in the patients house
d. Calling the patient weekly with a reminder to take the medication
ANS: B
12. A patient who has severe Alzheimers disease (AD) is being admitted to the hospital for
surgery. Which intervention will the nurse include in the plan of care?
a. Encourage the patient to discuss events from the past.
b. Maintain a consistent daily routine for the patients care.
c. Reorient the patient to the date and time every 2 to 3 hours.
d. Provide the patient with current newspapers and magazines.
ANS: B
13. A 71-year-old patient with Alzheimers disease (AD) who is being admitted to a longterm care facility has had several episodes of wandering away from home. Which action
will the nurse include in the plan of care?
a. Reorient the patient several times daily.
b. Have the family bring in familiar items.
c. Place the patient in a room close to the nurses station.
d. Ask the patient why the wandering episodes have occurred.
ANS: C
14. The day shift nurse at the long-term care facility learns that a patient with dementia
experienced sundowning late in the afternoon on the previous two days. Which action
should the nurse take?
a. Keep blinds open during the daytime hours.
b. Provide hourly orientation to time and place.
c. Have the patient take a brief mid-morning nap.
d. Move the patient to a quieter room late in the afternoon.
ANS: A
15. The nurses initial action for a patient with moderate dementia who develops increased
restlessness and agitation should be to
a. reorient the patient to time, place, and person.
b. administer a PRN dose of lorazepam (Ativan).
c. assess for factors that might be causing discomfort.
d. assign unlicensed assistive personnel (UAP) to stay in the patients room.
ANS: C
16. When administering the Mini-Cog exam to a patient with possible Alzheimers disease,
which action will the nurse take?
a. Check the patients orientation to time and date.
b. Obtain a list of the patients prescribed medications.
c. Ask the person to use a clock drawing to indicate a specific time.
d. Determine the patients ability to recognize a common object such as a pen.
ANS: C
17. Which hospitalized patient will the nurse assign to the room closest to the nurses
station?
a. Patient with Alzheimers disease who has long-term memory deficit
b. Patient with vascular dementia who takes medications for depression
c. Patient with new-onset confusion, restlessness, and irritability after surgery
d. Patient with dementia who has an abnormal Mini-Mental State Examination
ANS: C
18. After change-of-shift report on the Alzheimers disease/dementia unit, which patient will
the nurse assess first ?
a. Patient who has not had a bowel movement for 5 days
b. Patient who has a stage II pressure ulcer on the coccyx
c. Patient who is refusing to take the prescribed medications
d. Patient who developed a new cough after eating breakfast
ANS: D
1. The spouse of a 67-year-old male patient with early stage Alzheimers disease (AD) tells
the nurse, I am exhausted from worrying all the time. I dont know what to do. Which
actions are best for the nurse to take next (select all that apply)?
a. Suggest that a long-term care facility be considered.
b. Offer ideas for ways to distract or redirect the patient.
c. Teach the spouse about adult day care as a possible respite.
d. Suggest that the spouse consult with the physician for antianxiety drugs.
e. Ask the spouse what she knows and has considered about dementia care options.
ANS: B, C, E
2. Which nursing actions could the nurse delegate to a licensed practical/vocational nurse
(LPN/LVN) who is part of the team caring for a patient with Alzheimers disease (select all
that apply)?
a. Develop a plan to minimize difficult behavior.
b. Administer the prescribed memantine (Namenda).
c. Remove potential safety hazards from the patients environment.
d. Refer the patient and caregivers to appropriate community resources.
e. Help the patient and caregivers choose memory enhancement methods.
f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.
ANS: B, C
Chapter 60: Spinal Cord and Peripheral Nerve Problems
1. The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal
neuralgia will ask the patient about
a. visual problems caused by ptosis.
b. triggers leading to facial discomfort.
c. poor appetite caused by loss of taste.
d. weakness on the affected side of the face.
ANS: B
2. Which action should the nurse take when assessing a patient with trigeminal neuralgia?
a. Have the patient clench the jaws.
b. Inspect the oral mucosa and teeth.
c. Palpate the face to compare skin temperature bilaterally.
d. Identify trigger zones by lightly touching the affected side.
ANS: B
3. When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal
neuralgia, the nurse will
a. assess whether the patient is doing daily facial exercises.
b. question whether the patient is using an eye shield at night.
c. ask the patient about social activities with family and friends.
d. remind the patient to chew on the unaffected side of the mouth.
ANS: C
4. Which action will the nurse include in the plan of care for a 62-year-old patient who is
experiencing pain from trigeminal neuralgia?
a. Assess fluid and dietary intake.
b. Apply ice packs for 20 minutes.
c. Teach facial relaxation techniques.
d. Spend time talking with the patient.
ANS: A
5. The nurse identifies a patient with type 1 diabetes and a history of herpes simplex
infection as being at risk for Bells palsy. Which information should the nurse include in
teaching the patient?
a. You may be able to prevent Bells palsy by doing facial exercises regularly.
b. Prophylactic treatment of herpes with antiviral agents prevents Bells palsy.
c. Medications to treat Bells palsy work only if started before paralysis onset.
d. Call the doctor if you experience pain or develop herpes lesions near the ear.
ANS: D
6. A 32-year-old pregnant patient with Bells palsy refuses to eat while others are present
because of embarrassment about drooling. The best response by the nurse is to
a. respect the patients feelings and arrange for privacy at mealtimes.
b. teach the patient to chew food on the unaffected side of the mouth.
c. offer the patient liquid nutritional supplements at frequent intervals.
d. discuss the patients concerns with visitors who arrive at mealtimes.
ANS: A
7. Which nursing action will the home health nurse include in the plan of care for a patient
with paraplegia at the T4 level in order to prevent autonomic dysreflexia?
a. Support selection of a high-protein diet.
b. Discuss options for sexuality and fertility.
c. Assist in planning a prescribed bowel program.
d. Use quad coughing to strengthen cough efforts.
ANS: C
8. Which assessment data for a patient who has Guillain-Barr syndrome will require the
nurses most immediate action?
a. The patients triceps reflexes are absent.
b. The patient is continuously drooling saliva.
c. The patient complains of severe pain in the feet.
d. The patients blood pressure (BP) is 150/82 mm Hg.
ANS: B
9. A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barr syndrome has
numbness and weakness of both feet. The nurse will anticipate teaching the patient about
a. intubation and mechanical ventilation.
b. administration of corticosteroid drugs.
c. insertion of a nasogastric (NG) feeding tube.
d. infusion of immunoglobulin (Sandoglobulin).
ANS: D
10. A construction worker arrives at an urgent care center with a deep puncture wound
after an old nail penetrated his boot.. The patient reports having had a tetanus booster 6
years ago. The nurse will anticipate
a. IV infusion of tetanus immune globulin (TIG).
b. administration of the tetanus-diphtheria (Td) booster.
c. intradermal injection of an immune globulin test dose.
d. initiation of the tetanus-diphtheria immunization series.
ANS: B
11. The nurse is admitting a patient with a neck fracture at the C6 level to the intensive
care unit. Which assessment finding(s) indicate(s) neurogenic shock?
a. Hyperactive reflex activity below the level of injury
b. Involuntary, spastic movements of the arms and legs
c. Hypotension, bradycardia, and warm, pink extremities
d. Lack of sensation or movement below the level of injury
ANS: C
12. A patient has an incomplete left spinal cord lesion at the level of T7, resulting in BrownSquard syndrome. Which nursing action should be included in the plan of care?
a. Assessment of the patient for right arm weakness
b. Assessment of the patient for increased right leg pain
c. Positioning the patients left leg when turning the patient
d. Teaching the patient to look at the right leg to verify its position
ANS: C
13. The nurse will explain to the patient who has a T2 spinal cord transection injury that
a. use of the shoulders will be limited.
b. function of both arms should be retained.
c. total loss of respiratory function may occur.
d. tachycardia is common with this type of injury.
ANS: B
14. A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic
reflexic bladder. Which action will the nurse include in the plan of care?
a. Teach the patient the Cred method.
b. Instruct the patient how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the patient to the toilet every 2 hours.
ANS: B
15. When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6
spinal cord injury, an appropriate goal is that the patient will be able to
a. drive a car with powered hand controls.
b. push a manual wheelchair on a flat surface.
c. turn and reposition independently when in bed.
d. transfer independently to and from a wheelchair.
ANS: B
16. A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells
the nurse I want to be transferred to a hospital where the nurses know what they are
doing! Which action by the nurse is best?
a. Clarify that abusive language will not be tolerated.
b. Request that the patient provide input for the plan of care.
c. Perform care without responding to the patients comments.
d. Reassure the patient about the competence of the nursing staff.
ANS: B
17. A 38-year-old patient has returned home following rehabilitation for a spinal cord
injury. The home care nurse notes that the spouse is performing many of the activities that
the patient had been managing unassisted during rehabilitation. The most appropriate
action by the nurse at this time is to
a. remind the patient about the importance of independence in daily activities.
b. tell the spouse to stop because the patient is able to perform activities independently.
c. develop a plan to increase the patients independence in consultation with the patient and the
spouse.
d. recognize that it is important for the spouse to be involved in the patients care and encourage
that participation.
ANS: C
18. A patient is admitted with possible botulism poisoning after eating home-canned green
beans. Which intervention ordered by health care provider will the nurse question?
a. Encourage oral fluids to 3 L/day
b. Document neurologic symptoms
c. Position patient lying on the side
d. Observe respiratory status closely
ANS: A
19. Which nursing action has the highest priority for a patient who was admitted 16 hours
previously with a C5 spinal cord injury?
a. Cardiac monitoring for bradycardia
b. Assessment of respiratory rate and effort
c. Application of pneumatic compression devices to legs
d. Administration of methylprednisolone (Solu-Medrol) infusion
ANS: B
20. A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The
most essential assessment for the nurse to carry out is
a. determining level of consciousness.
b. checking strength of the extremities.
c. observing respiratory rate and effort.
d. monitoring the cardiac rate and rhythm.
ANS: C
21. Before administering botulinum antitoxin to a patient in the emergency department, it
is most important for the nurse to
a. obtain the patients temperature.
b. administer an intradermal test dose.
c. document the neurologic symptoms.
d. ask the patient about an allergy to eggs.
ANS: B
22. A patient who had a C7 spinal cord injury a week ago has a weak cough effort and
audible rhonchi. The initial intervention by the nurse should be to
a. administer humidified oxygen by mask.
b. suction the patients mouth and nasopharynx.
c. push upward on the epigastric area as the patient coughs.
d. encourage incentive spirometry every 2 hours during the day.
ANS: C
23. A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells
the nurse, I have a pounding headache and I feel sick to my stomach. Which action should
the nurse take first?
a. Check for a fecal impaction.
b. Give the prescribed analgesic.
c. Assess the blood pressure (BP).
d. Notify the health care provider.
ANS: C
24. A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding
by the nurse requires the most immediate action?
a. The patient has new onset weakness of both legs.
b. The patient complains of chronic severe back pain.
c. The patient starts to cry and says, I feel hopeless.
d. The patient expresses anxiety about having surgery.
ANS: A
25. Which of these nursing actions for a 64-year-old patient with Guillain-Barr syndrome is
most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel
(UAP)?
a. Nasogastric tube feeding q4hr
b. Artificial tear administration q2hr
c. Assessment for bladder distention q2hr
d. Passive range of motion to extremities q4hr
ANS: D
26. Which action will the nurse take when caring for a 46-year-old patient who develops
tetanus from an injectable substance use?
a. Avoid use of sedatives.
b. Provide a quiet environment.
c. Check pupil reaction to light every 4 hours.
d. Provide range-of-motion exercises several times daily.
ANS: B
27. Following a cauda equina spinal cord injury, which action will the nurse include in the
plan of care?
a. Catheterize patient every 3 to 4 hours.
b. Assist patient to ambulate several times daily.
c. Administer medications to reduce bladder spasm.
d. Stabilize the neck when repositioning the patient.
ANS: A
28. A nurse who works on the neurology unit just received change-of-shift report. Which
patient will the nurse assess first?
a. Patient with botulism who is experiencing difficulty swallowing
b. Patient with Bells palsy who has herpes vesicles in front of the ear
c. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes
d. Patient with an abscess caused by injectable drug use who needs tetanus immune globulin
ANS: A
29. Which finding in a patient with a spinal cord tumor is most important for the nurse to
report to the health care provider?
a. Back pain that increases with coughing
b. Depression about the diagnosis of a tumor
c. Decreasing sensation and ability to move the legs
d. Anxiety about scheduled surgery to remove the tumor
ANS: C
30. A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be
able to be sexually active. Which initial response by the nurse is best?
a. Reflex erections frequently occur, but orgasm may not be possible.
b. Sildenafil (Viagra) is used by many patients with spinal cord injury.
c. Multiple options are available to maintain sexuality after spinal cord injury.
d. Penile injection, prostheses, or vacuum suction devices are possible options.
ANS: C
1. When caring for a patient who experienced a T2 spinal cord transection 24 hours ago,
which collaborative and nursing actions will the nurse include in the plan of care (select all
that apply)?
a. Urinary catheter care
b. Nasogastric (NG) tube feeding
c. Continuous cardiac monitoring
d. Maintain a warm room temperature
e. Administration of H2 receptor blockers
ANS: A, C, D, E