Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 6 th Edition
Test Bank
Chapter 42: Nursing Management: Liver, Biliary Tract, and Pancreas Problems
1.
A health care provider who has never been immunized for hepatitis B is exposed to the hepatitis B virus through
a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the
exposure should include
1. evaluation of liver function tests in 60 days.
2. active immunization with hepatitis B vaccine.
3. hepatitis B immune globulin (HBIG) injection.
4. both the hepatitis B vaccine and hepatitis B immune globulin.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1112
2.
A patient contracts hepatitis from food contaminated by a worker with hepatitis in a fast food restaurant. During
the icteric phase of the patient’s illness, the nurse would expect serologic testing to reveal
1. HBsAg.
2. anti-HBc IgM.
3. anti-HAV IgG.
4. anti-HAV IgM.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1109
3.
While the nurse is obtaining a nursing history from a patient diagnosed with hepatitis C, information reported
by the patient that indicates the highest risk factor for hepatitis C includes
1. sexual exposure.
2. intravenous drug abuse.
3. eating contaminated shellfish.
4. recent travel to an underdeveloped country.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1107
4.
During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B
vaccine has been effective when a specimen of the patient’s blood reveals
1. HBsAg.
2. anti-HBs.
3. anti-HBcAg.
4. anti-HBc IgM.
Answer: 2
Nursing Process: Evaluation
Cognitive Level: Application
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1109
5.
Serologic testing of a patient reveals the presence of anti-HDV. The nurse recognizes that the patient
1. has immunity to hepatitis D.
2. is susceptible to acquiring hepatitis C.
3. has an active, acute hepatitis D infection.
4. is infected with both hepatitis B and hepatitis D viruses.
Answer: 4
Nursing Process: Analysis/Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 1107, 1109
6.
A homeless person is hospitalized with severe anorexia and fatigue. She has mild jaundice and hepatomegaly,
and her liver function tests are abnormal. The physician suspects viral hepatitis. In planning care for the patient,
the nurse assigns the highest priority to the patient outcome of
1. maintains adequate nutrition.
2. adapts to changes in appearance.
3. gradually increases tolerance for activity.
4. identifies source of exposure to hepatitis virus.
Answer: 1
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 1112, 1114
7.
A patient with acute hepatitis B asks the nurse if treatment is available for the condition. The nurse explains to
the patient that
1. patients with acute hepatitis B can be given hepatitis B immune globulin to help reduce the symptoms.
2. a variety of antiviral drugs are available to treat acute hepatitis B but serious side effects limit their use.
3. because no medication is available for treatment of acute viral hepatitis, adequate nutrition and rest are the
most important treatments.
4. lamivudine (Epivir) can decrease viral load and liver damage in those with acute hepatitis B but it must be
taken for at least 1 year.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1110
8.
Combination therapy of α-interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a patient with
human immunodeficiency virus (HIV). One effect of this drug regimen that the nurse must monitor in the
patient is
1. increased blood glucose.
2. decreased platelet counts.
3. decreased CD4 cell counts.
4. increased BUN and serum creatinine.
Answer: 3
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1111
9.
During the icteric phase of hepatitis, the nurse would expect the patient’s laboratory results to include
1. increased stool urobilinogen.
2. increased direct serum bilirubin.
3. increased indirect serum bilirubin.
4. increased direct and indirect serum bilirubin.
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1117
10. A 68-year-old patient has an abrupt onset of anorexia, nausea and vomiting, hepatomegaly, and abnormal liver
function studies. Serologic testing is negative for viral causes of hepatitis. During assessment of the patient, it is
most important for the nurse to question the patient regarding
1. any prior exposure to people with jaundice.
2. the use of all prescription and OTC medications.
3. treatment of chronic diseases with corticosteroids.
4. exposure to children recently immunized for hepatitis B.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1116
11. When teaching a patient recovering from hepatitis B about management of the illness, the nurse determines that
additional teaching is needed when the patient says
1. “I should not drink alcohol for at least a year.”
2. “When I have recovered from this infection, I should have lifelong immunity to the virus.”
3. “When the jaundice is gone, I have recovered from my illness and the infection is cured.”
4. “I should use a condom during sexual intercourse until my tests for the virus are negative.”
Answer: 3
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1115
12. The nurse assesses a patient with cirrhosis and finds 4+ pitting edema of the feet and legs and massive ascites.
The nurse recognizes that one factor contributing to edema and ascites in patients with cirrhosis is
1. increased osmotic pressure caused by elevated blood ammonia levels.
2. decreased renin-angiotensin response related to decreased renal blood flow.
3. hyperaldosteronism caused by decreased degradation of the hormone by the liver.
4. decreased portocaval pressure with development of collateral circulation in the gastrointestinal vessels.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1119
13. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. In teaching the patient about the
disease, it is important for the nurse to inform her that the disease may be reversed at this point with
1.
2.
3.
4.
vitamin B supplements.
abstinence from alcohol.
maintenance of a nutritious diet.
long-term, low-dose corticosteroids.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1116
14. A patient with cirrhosis is being treated with spironolactone (Aldactone) tid and furosemide (Lasix) bid. The
patient’s most recent laboratory results indicate a serum sodium of 134 mEq/L (134 mmol/L) and a serum
potassium of 3.2 mEq/L (3.2 mmol/L). Before notifying the physician, the nurse should
1. administer only the furosemide.
2. administer both drugs as ordered.
3. administer only the spironolactone.
4. withhold the furosemide and spironolactone.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1121
15. When assessing a patient for signs of impending coma resulting from hepatic encephalopathy, the nurse asks the
patient to
1. stand on one foot.
2. extend the arm and hand.
3. ambulate with the eyes closed.
4. perform the Valsalva maneuver.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1120
16. When lactulose (Cephulac) 30 ml qid is ordered for a patient with advanced cirrhosis, he complains that it
causes diarrhea. The nurse explains to the patient that it is still important for him to take the drug because the
drug will
1. promote fluid loss.
2. prevent constipation.
3. prevent gastrointestinal bleeding.
4. improve nervous system function.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1124
17. A patient with advanced liver disease has marked ascites and signs of hepatic encephalopathy. Following
instruction about his diet, the nurse determines that teaching has been effective when the patient’s choice of
foods from the menu includes
1. cheese omelet with mushrooms and milk.
2.
3.
4.
pancakes with butter and honey and orange juice.
baked beans with ham, cornbread, sweet potatoes, and coffee.
baked chicken with french-fried potatoes, low-protein bread, and tea.
Answer: 2
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1125
18. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the
nurse gives the highest priority to the goal of
1. control of the bleeding.
2. maintenance of the airway.
3. maintenance of fluid volume.
4. relief of the patient’s anxiety.
Answer: 2
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1122
19. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, nursing
responsibilities include
1. maintaining balloon pressure at 60 mm Hg.
2. inserting the tube and verifying its position.
3. minimizing the risk of aspiration of gastric contents.
4. deflating the esophageal balloon for 5 minutes every hour.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1129
20. A patient with cirrhosis has an episode of bleeding esophageal varices that is controlled with administration of
vasopressin and endoscopic sclerotherapy. To detect possible complications of the bleeding episode, it is most
important for the nurse to monitor
1. the prothrombin time.
2. serum bilirubin levels.
3. serum ammonia levels.
4. serum potassium levels.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 1120, 1122
21. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has
ascites and 4+ pitting edema of the feet and legs. An appropriate nursing intervention for this problem is to
1. restrict dietary protein intake.
2. turn the patient every 4 hours.
3. perform passive range of motion qid.
4. arrange for a special pressure-relieving mattress.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1129
22. A shunting procedure is considered for a patient with cirrhosis following an episode of bleeding esophageal
varices. The nurse understands that these procedures
1. improve patient survival rates.
2. increase the risk of hepatic encephalopathy.
3. require surgery to redirect blood flow around the liver.
4. are first-line therapies for portal hypertension and esophageal varices.
Answer: 2
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 1120, 1123-1124
23. A patient with cancer of the liver has severe ascites that is causing shortness of breath and difficulty breathing.
The physician plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the
procedure, the nurse
1. asks the patient to empty the bladder.
2. positions the patient flat on the right side.
3. obtains informed consent for the procedure.
4. has the patient lie flat with a small pillow under the small of the back.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1129
24. A patient with end-stage liver disease is to undergo a liver transplant. She tells the nurse that she has a friend
who had to have two kidney transplants because of rejection and that she hopes she does not have problems
with rejection. The nurse’s best response to the patient is
1. “Perhaps your friend did not have a good tissue match with the first kidney.”
2. “You are in good physical condition, and rejection won’t be a problem for you.”
3. “The problem of rejection is not as common in liver transplants as in kidney transplants.”
4. “Rejection is always a possibility, but every day there are better immunosuppressive drugs.”
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1132
25. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. The
nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum
1. calcium.
2. bilirubin.
3. lipid levels.
4. amylase and lipase.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1134
26. In planning care for a patient with acute pancreatitis, the nurse assigns the highest priority to the patient
outcome of
1. develops no complications.
2. maintains normal respiratory function.
3. expresses satisfaction with pain control.
4. maintains adequate fluid and electrolyte balance.
Answer: 4
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1134
27. A patient with acute pancreatitis has an NG tube to suction and is NPO. The nurse explains to the patient that
the expected outcome of this treatment is
1. relief from nausea and vomiting.
2. reduction of pancreatic secretion.
3. removal of the precipitating irritants.
4. control of fluid and electrolyte imbalance.
Answer: 2
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1135
28. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with
severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte imbalances associated with
acute pancreatitis include
1. hypotension.
2. hyperglycemia.
3. muscle twitching and digit numbness.
4. paralytic ileus and abdominal distention.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Analysis
NCLEX: Physiologic Integrity
Text Reference: p. 1134
29. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically
about a history of
1. smoking.
2. alcohol use.
3. diabetes mellitus.
4. high-fat dietary intake.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1133
30. The physician prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The nurse teaches the
patient that the drug is considered effective if the patient experiences
1. normal stools.
2. decreased jaundice.
3. an improved appetite
4. decreased abdominal pain.
Answer: 1
Nursing Process: Evaluation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1139
31. When the nurse is caring for the patient with pancreatic cancer, a major goal is
1. preventing narcotic addiction because of unrelenting pain.
2. helping the patient and family through the grieving process.
3. maintaining adequate tissue perfusion to prevent skin breakdown.
4. assessing for fluid and electrolyte imbalances caused by fluid loss into the peritoneal cavity.
Answer: 2
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1141
32. A patient is admitted to the hospital with a sudden onset of severe right upper quadrant pain that radiates to the
right shoulder. She has a history of fat intolerance and heartburn. The nurse recognizes that the patient most
likely has a biliary tract obstruction when the patient reports experiencing
1. spider angiomas.
2. clay-colored stools.
3. dilute, bright yellow urine.
4. epigastric pain relieved by vomiting.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1142
33. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the
highest priority on the patient outcome of
1. turns, coughs, and deep breathes q2hr.
2. chooses low-fat foods from the menu.
3. performs leg exercises qhr while awake.
4. ambulates the evening of the operative day.
Answer: 1
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1146
34. An appropriate collaborative problem for the nurse to identify for a patient with cholelithiasis and obstruction of
the common bile duct is
1.
2.
3.
4.
potential complication: bleeding.
potential complication: gastritis.
potential complication: biliary cirrhosis.
potential complication: thromboembolism.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1142
35. When providing discharge instructions to a patient following a laparoscopic cholecystectomy at an outpatient
surgical center, the nurse recognizes that teaching has been effective when the patient states
1. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
2. “I can expect some reddish yellow drainage from the incisions for a few days.”
3. “I should remove the bandages on my incisions tomorrow and take a shower.”
4. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”
Answer: 3
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
MULTIPLE CHOICE
1. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV)
through a needle stick from an infected patient. The infection control nurse informs the individual that treatment
for the exposure should include
a. baseline hepatitis B antibody testing now and in 2 months.
b. active immunization with hepatitis B vaccine.
c. hepatitis B immune globulin (HBIG) injection.
d. both the hepatitis B vaccine and HBIG injection.
Correct Answer: D
Rationale: The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both
HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity.
Antibody testing may also be done, but this would not provide protection from the exposure.
Cognitive Level: Application
Text Reference: p. 1096
Nursing Process: Implementation NCLEX: Physiological Integrity
2. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient’s illness, the
nurse would expect serologic testing to reveal
a. hepatitis B surface antigen (HBsAg).
b. anti-hepatitis B core immunoglobulin M (anti-HBc IgM).
c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
Correct Answer: D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the
acute phase of hepatitis A. The patient would not have antigen or antibodies for hepatitis B. Anti-HAV IgG would
indicate past infection and lifelong immunity.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1089
NCLEX: Physiological Integrity
3. During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B
vaccine has been effective when a specimen of the patient’s blood reveals
a. HBsAg.
b. anti-HBs.
c. anti-HBc IgM.
d. anti-HBc IgG
Correct Answer: B
Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine.
The other laboratory values indicate current infection with HBV.
Cognitive Level: Application
Text Reference: pp. 1089, 1093
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance
4. A patient in the outpatient clinic has positive serologic testing for anti-HCV. Which action by the nurse is
appropriate?
a. Schedule the patient for HCV genotype testing.
b. Teach the patient that the HCV will resolve in 2 to 4 months.
c. Administer immune globulin and the HCV vaccine.
d. Instruct the patient on self-administration of -interferon.
Correct Answer: A
Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy with
-interferon or other medications is started. HCV has a high percentage of conversion to the chronic state so the
nurse should not teach the patient that the HCV will resolve in 2 to 4 months. Immune globulin or vaccine is not
available for HCV.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1092
NCLEX: Physiological Integrity
5. A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with viral hepatitis
and has just been admitted to the hospital. In planning care for the patient, the nurse assigns the highest priority
to the patient outcome of
a. maintaining adequate nutrition.
b. establishing a stable home environment.
c. increasing activity level.
d. identifying the source of exposure to hepatitis.
Correct Answer: A
Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte
regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate
activities, but they do not have as high a priority as having adequate nutrition. Although the patient’s activity level
will be gradually increased, rest is indicated during the acute phase of hepatitis.
Cognitive Level: Application
Text Reference: p. 1097
Nursing Process: Planning
NCLEX: Physiological Integrity
6. A patient with acute hepatitis B asks the nurse if treatment is available for the condition. The nurse explains to
the patient that
a. because no medication is available to treat acute viral hepatitis, adequate nutrition and rest are the
most important treatments.
b. lamivudine (Epivir) can decrease viral load and liver damage in patients with acute hepatitis B, but
it must be taken for at least 1 year.
c. patients with acute hepatitis B can be given HBIG to help reduce the symptoms.
d. various antiviral drugs are available to treat acute hepatitis B, but serious side effects limit their use.
Correct Answer: A
Rationale: There are no drug therapies to treat acute hepatitis, although -interferon and nucleoside analogs (i.e.,
lamivudine) may be used to treat chronic hepatitis B. Immune globulin may be given within 24 hours after exposure
to prevent hepatitis B, but it is not used to decrease symptoms for patients with acute hepatitis.
Cognitive Level: Application
Text Reference: p. 1093
Nursing Process: Implementation NCLEX: Physiological Integrity
7.
a.
b.
c.
d.
Combination therapy of -interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a patient with
human immunodeficiency virus (HIV). The nurse will plan to monitor
blood glucose.
lymphocyte count.
potassium level.
serum creatinine.
Correct Answer: B
Rationale: Therapy with ribavirin and -interferon may decrease lymphocyte counts. The other laboratory values
should not be changed by the drug therapy.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1095
NCLEX: Physiological Integrity
8. When taking a health history for a new patient, which information given by the patient would indicate that
screening for hepatitis C is appropriate?
a. The patient had a blood transfusion after surgery in 1998.
b. The patient reports a one-time use of IV drugs 20 years ago.
c. The patient eats frequent meals in fast-food restaurants.
d. The patient recently traveled to an undeveloped country.
Correct Answer: B
Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after
1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not
spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped
countries.
Cognitive Level: Application
Text Reference: pp. 1090, 1098
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
9. A patient is admitted with an abrupt onset of jaundice, nausea and vomiting, hepatomegaly, and abnormal liver
function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most
appropriate?
a. “Have you been around anyone with jaundice?”
b. “Do you use any prescription or over-the-counter (OTC) drugs?”
c. “Are you taking corticosteroids for any reason?”
d. “Is there any history of IV drug use?”
Correct Answer: B
Rationale: The patient’s symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic
hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Exposure to a
jaundiced individual and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not
cause the symptoms listed.
Cognitive Level: Application
Text Reference: pp. 1099-1100
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
10. When teaching a patient recovering from hepatitis B about management of the illness, the nurse determines that
additional teaching is needed when the patient says
a. “I should not drink alcohol for at least the next year.”
b. “My family members should be tested for hepatitis B.”
c. “When the jaundice is gone, I have recovered from my illness and the infection is cured.”
d. “Until my tests for the virus are negative, I should use a condom for sexual intercourse.”
Correct Answer: C
Rationale: After the acute (icteric) phase, there is a convalescent phase lasting several months. The other patient
statements are correct and indicate that teaching has been effective.
Cognitive Level: Application
Text Reference: pp. 1091, 1098
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance
11. A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. The data indicate that it is
most important for the nurse to monitor the patient’s
a. temperature.
b. albumin level.
c. hemoglobin.
d. activity level.
Correct Answer: B
Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the
development of ascites and edema. The other parameters should also be monitored, but they are not contributing
factors to the patient’s current symptoms.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1104
NCLEX: Physiological Integrity
12. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning patient teaching,
the priority information for the nurse to include is the need for
a. vitamin B supplements.
b. abstinence from alcohol.
c. maintenance of a nutritious diet.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
d.
long-term, low-dose corticosteroids.
Correct Answer: B
Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may
be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient
is to stop the progression of the disease.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 1114-1115
NCLEX: Physiological Integrity
13. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a
serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L (3.2 mmol/L). Before
notifying the health care provider, the nurse should
a. administer the furosemide and withhold the spironolactone.
b. give both drugs as scheduled.
c. administer the spironolactone.
d. withhold both drugs until talking with the health care provider.
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient’s potassium level.
The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider
should be notified about the low potassium value. The furosemide will further decrease the patient’s potassium level
and should be held until the nurse talks with the health care provider.
Cognitive Level: Application
Text Reference: p. 1107
Nursing Process: Implementation NCLEX: Physiological Integrity
14. When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the
patient to
a. stand on one foot.
b. ambulate with the eyes closed.
c. extend both arms.
d. perform the Valsalva maneuver.
Correct Answer: C
Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The
other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic
encephalopathy.
Cognitive Level: Comprehension Text Reference: p. 1106
Nursing Process: Assessment
NCLEX: Physiological Integrity
15. When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis, the patient complains
that it causes diarrhea. The nurse explains to the patient that it is still important to take the drug because the
lactulose will
a. promote fluid loss.
b. prevent constipation.
c. prevent gastrointestinal (GI) bleeding.
d. improve nervous system function.
Correct Answer: D
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent
encephalopathy. Although the medication may promote fluid loss through the stool, prevent constipation, and
prevent bearing down during bowel movements (which could lead to esophageal bleeding), the medication is not
ordered for these purposes for this patient.
Cognitive Level: Application
Text Reference: p. 1109
Nursing Process: Implementation NCLEX: Physiological Integrity
16. A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions about appropriate
diet. The nurse determines that the teaching has been effective when the patient’s choice of foods from the
menu includes
a. an omelet with cheese and mushrooms and milk.
b. pancakes with butter and honey and orange juice.
c. baked beans with ham, cornbread, potatoes, and coffee.
d. baked chicken with french-fries, low-fiber bread, and tea.
Correct Answer: B
Rationale: The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia
levels. The other choices are all higher in protein and would not be as appropriate for this patient. In addition, the
patient’s ascites indicate that a low-sodium diet is needed and the other choices are all high in sodium.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 1110
NCLEX: Physiological Integrity
17. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the
nurse gives the highest priority to the goal of
a. controlling bleeding.
b. maintenance of the airway.
c. maintenance of fluid volume.
d. relieving the patient’s anxiety.
Correct Answer: B
Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is
compromised by the bleeding in the esophagus and aspiration easily occurs. The other goals would also be important
for this patient, but they are not as high a priority as airway maintenance.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 1107, 1114
NCLEX: Physiological Integrity
18. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, which
nursing action will be included in the plan of care?
a. Encourage the patient to cough and deep breathe.
b. Insert the tube and verify its position q4hr.
c. Monitor the patient for shortness of breath.
d. Deflate the gastric balloon q8-12hr.
Correct Answer: C
Rationale: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric
balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure
on the varices and increases the risk for bleeding. The health care provider inserts the tube and verifies the position.
The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the
esophageal balloon may occlude the airway.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Cognitive Level: Application
Text Reference: p. 1114
Nursing Process: Implementation NCLEX: Physiological Integrity
19. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications
of the bleeding episode, it is most important for the nurse to monitor
a. prothrombin time.
b. bilirubin levels.
c. ammonia levels.
d. potassium levels.
Correct Answer: C
Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level
since the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels should also be
monitored, but these will not be affected by the bleeding episode.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1113
NCLEX: Physiological Integrity
20. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has
ascites and 4+ pitting edema of the feet and legs. An appropriate nursing intervention for this problem is to
a. restrict dietary protein intake.
b. arrange for a pressure-relieving mattress.
c. perform passive range of motion QID.
d. turn the patient every 4 hours.
Correct Answer: B
Rationale: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Dietary protein
intake may be increased in patients with ascites to improve oncotic pressure. Turning the patient every 4 hours will
not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum
that are vulnerable to breakdown.
Cognitive Level: Application
Text Reference: p. 1111
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
21. A portocaval shunt is considered for a patient with cirrhosis following an episode of bleeding esophageal
varices. The nurse plans to teach the patient that this procedure
a. is likely to improve the patient’s life expectancy.
b. will increase the risk of hepatic encephalopathy.
c. will help to decrease the incidence of peritonitis.
d. is a first-line therapy for portal hypertension.
Correct Answer: B
Rationale: The risk for hepatic encephalopathy increases after shunt procedures because blood bypasses the portal
system and ammonia is diverted past the liver and into the systemic circulation. Life expectancy is not improved.
The risk for peritonitis is not decreased by a surgical procedure, which will increase infection risk. First-line
procedures for portal hypertension are medications such as diuretics and albumin.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1108
NCLEX: Physiological Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
22. A patient with cancer of the liver has severe ascites, and the health care provider plans a paracentesis to relieve
the fluid pressure on the diaphragm. To prepare the patient for the procedure, the nurse
a. asks the patient to empty the bladder.
b. positions the patient on the right side.
c. obtains informed consent for the procedure.
d. assists the patient to lie flat in bed.
Correct Answer: A
Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure.
The patient would be positioned in Fowler’s position and would not be able to lie flat without compromising
breathing. The health care provider is responsible for obtaining informed consent.
Cognitive Level: Application
Text Reference: p. 1111
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
23. A patient with end-stage liver disease who is to undergo a liver transplant tells the nurse, “I have a friend who
has already rejected two kidney transplants. I am concerned that I will reject this liver.” The nurse’s best
response to the patient is
a. “Perhaps your friend did not have a good tissue match with the kidney transplants.”
b. “You would not be scheduled for a transplant if there was a concern about rejection.”
c. “The problem of rejection is not as common in liver transplants as in kidney transplants.”
d. “It is easier to get a good tissue match with liver transplants than with kidney transplants.”
Correct Answer: C
Rationale: The liver is less susceptible to rejection than the kidney. The other statements are inaccurate or will not
decrease the patient’s anxiety.
Cognitive Level: Application
Text Reference: p. 1118
Nursing Process: Implementation NCLEX: Physiological Integrity
24. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. The
nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum
a. calcium.
b. bilirubin.
c. amylase.
d. potassium.
Correct Answer: C
Rationale: Amylase is elevated early in acute pancreatitis. Changes in bilirubin, calcium, and potassium levels are
not diagnostic for pancreatitis.
Cognitive Level: Comprehension Text Reference: pp. 1120-1121
Nursing Process: Assessment
NCLEX: Physiological Integrity
25. In planning care for a patient with acute pancreatitis, the nurse assigns the highest priority to the patient
outcome of
a. developing no acute complications.
b. maintenance of normal respiratory function.
c. expressing satisfaction with pain control.
d. having adequate fluid and electrolyte balance.
Correct Answer: B
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Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate
respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1122
NCLEX: Physiological Integrity
26. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. The nurse explains to the
patient that the major purpose of this treatment is
a. control of fluid and electrolyte imbalance.
b. relief from nausea and vomiting.
c. reduction of pancreatic enzymes.
d. removal of the precipitating irritants.
Correct Answer: C
Rationale: Pancreatic enzymes are released when the patient eats. NG suction and NPO status decrease the release
of these enzymes. Fluid and electrolyte imbalances will be caused by NG suction and require that the patient receive
IV fluids to prevent this. The patient’s nausea and vomiting may decrease, but this is not the major reason for these
treatments. The pancreatic enzymes that precipitate the pancreatitis are not removed by NG suction.
Cognitive Level: Application
Text Reference: p. 1120
Nursing Process: Implementation NCLEX: Physiological Integrity
27. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with
severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte imbalances associated with
acute pancreatitis include
a. muscle twitching and finger numbness.
b. paralytic ileus and abdominal distention.
c. hypotension.
d. hyperglycemia.
Correct Answer: A
Rationale: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute
pancreatitis. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte
imbalance.
Cognitive Level: Analysis
Nursing Process: Assessment
Text Reference: p. 1122
NCLEX: Physiological Integrity
28. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically
about a history of
a. cigarette smoking.
b. alcohol use.
c. diabetes mellitus.
d. high-protein diet.
Correct Answer: B
Rationale: Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette
smoking, diabetes, and high-protein diets are not risk factors.
Cognitive Level: Comprehension Text Reference: p. 1118
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
29. The health care provider prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The nurse
teaches the patient that the drug is considered effective if the patient experiences
a. normal-appearing stools.
b. decreased jaundice.
c. improved appetite.
d. reduced abdominal pain.
Correct Answer: A
Rationale: The patient’s steatorrhea should improve if the pancreatic enzymes are effective. The pancreatin will not
decrease jaundice, improve appetite, or reduce abdominal pain.
Cognitive Level: Application
Nursing Process: Evaluation
30.
a.
b.
c.
d.
Text Reference: p. 1125
NCLEX: Physiological Integrity
When the nurse is caring for the patient with pancreatic cancer, which nursing diagnosis is a priority?
Chronic pain related to tumor pressure on abdominal structures
Imbalanced nutrition: less than required related to anorexia
Impaired skin integrity related to itching secondary to jaundice
Grieving related to potentially terminal diagnosis
Correct Answer: A
Rationale: All of these nursing diagnoses are appropriate for a patient with pancreatic cancer, but treating the
patient’s pain is the priority because the patient will be unable to meet outcomes for the other nursing diagnoses
unless the pain is controlled.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: pp. 1122, 1126
NCLEX: Physiological Integrity
31. A patient who is admitted to the hospital with a sudden onset of severe right upper-quadrant pain that radiates to
the right shoulder is diagnosed with cholecystitis. Which assessment information will be most important for the
nurse to report to the health care provider?
a. The patient has an increase in pain after eating.
b. The patient needs 4 mg of morphine for pain relief.
c. The patient’s stools are clay colored.
d. The patient’s urine is bright yellow.
Correct Answer: C
Rationale: The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The
other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment
information to the health care provider.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1128
NCLEX: Physiological Integrity
32. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the
highest priority on assisting the patient to
a. turn, cough, and deep breathe every 2 hours.
b. choose low-fat foods from the menu.
c. perform leg exercises hourly while awake.
d. ambulate the evening of the operative day.
Correct Answer: A
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Rationale: Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications
because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing
actions are also important to implement but are not as high a priority as ensuring adequate ventilation.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1131
NCLEX: Physiological Integrity
33. An appropriate collaborative problem for the nurse to include in the care plan for a patient with cholelithiasis
and obstruction of the common bile duct is
a. potential complication: bleeding.
b. potential complication: gastritis.
c. potential complication: thromboembolism.
d. potential complication: biliary cirrhosis.
Correct Answer: D
Rationale: With obstruction of the common bile duct, bile will back up into the liver and damage liver cells.
Bleeding, gastritis, and thromboembolism are not common complications of biliary obstruction.
Cognitive Level: Comprehension Text Reference: pp. 1128-1129
Nursing Process: Planning
NCLEX: Physiological Integrity
34. When providing discharge instructions to a patient following a laparoscopic cholecystectomy at an outpatient
surgical center, the nurse recognizes that teaching has been effective when the patient states,
a. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
b. “I can expect some reddish yellow drainage from the incisions for a few days.”
c. “I can remove the bandages on my incisions tomorrow and take a shower.”
d. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”
Correct Answer: C
Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions;
patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from
the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A
low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.
Cognitive Level: Application
Nursing Process: Evaluation
35.
a.
b.
c.
d.
Text Reference: p. 1132
NCLEX: Physiological Integrity
Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?
The patient’s skin has multiple spider-shaped blood vessels on the abdomen.
The patient has ascites and a 2-kg weight gain from the previous day.
The patient complains of right upper-quadrant pain with abdominal palpation.
The patient’s hands flap back and forth when the arms are extended.
Correct Answer: D
Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The
spider angiomas and right upper-quadrant abdominal pain are not unusual for the patient with cirrhosis and do not
require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as
the changes in neurologic status.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1106
NCLEX: Physiological Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
36. A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will teach the patient
that the medication is ordered to
a. decrease systemic BP.
b. prevent the development of ischemia.
c. lower the risk for bleeding varices.
d. reduce fluid retention and edema.
Correct Answer: C
Rationale: -blockers have been shown to decrease the risk for bleeding in esophageal varices. Although
propranolol will decrease BP and prevent cardiac ischemia, these are not the purposes for this patient. Propranolol
will not decrease fluid retention or edema.
Cognitive Level: Application
Text Reference: p. 1107
Nursing Process: Implementation NCLEX: Physiological Integrity
37. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the
ordered ranitidine (Zantac). Which response by the nurse is most appropriate?
a. The medication will inhibit the development of gastric ulcers.
b. The medication will prevent irritation to the esophageal varices.
c. The medication will decrease nausea and anorexia.
d. The medication will reduce the risk for aspiration.
Correct Answer: B
Rationale: The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation
and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk
for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2
receptor blockade in this patient.
Cognitive Level: Application
Text Reference: p. 1108
Nursing Process: Implementation NCLEX: Physiological Integrity
38. Which of these nursing actions included in the plan of care for a patient with cirrhosis can the nurse delegate to
a nursing assistant?
a. Assessing the patient for jaundice
b. Assisting the patient in choosing the diet
c. Palpating the abdomen for distention
d. Providing oral hygiene before meals
Correct Answer: D
Rationale: Providing oral hygiene is included in the education and scope of practice of nursing assistants.
Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing
education and scope of practice and would be delegated to LPNs/LVNs or RNs.
Cognitive Level: Application
Text Reference: pp. 1110-1115
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment
39. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient’s
hand. Which action should the nurse take next?
a. Notify the health care provider immediately.
b. Retake the patient’s blood pressure.
c. Check the calcium level on the chart.
d. Ask the patient about any arm pain.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Correct Answer: C
Rationale: The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a
positive Trousseau’s sign. The health care provider should be notified after the nurse learns the patient’s calcium
level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.
Cognitive Level: Analysis
Nursing Process: Assessment
Text Reference: p. 1122
NCLEX: Physiological Integrity
40. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information
obtained by the nurse is the best indicator that these therapies have been effective?
a. Bowel sounds are present.
b. Abdominal pain is decreased.
c. Electrolyte levels are normal.
d. Grey Turner sign resolves.
Correct Answer: B
Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and
decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does
not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal
with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually
resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 1120
NCLEX: Physiological Integrity
41. When the nurse is caring for a patient with acute pancreatitis, which of these assessment data should be of most
concern?
a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
d. Palpable abdominal mass
Correct Answer: D
Rationale: A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid
surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are
common in acute pancreatitis and do not require rapid action to prevent further complications.
Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
Test Bank
MULTIPLE CHOICE
1. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient’s illness, the
nurse would expect serologic testing to reveal
a. antibody to hepatitis D (anti-HDV).
b. hepatitis B surface antigen (HBsAg).
c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
ANS: D
Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of
hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would
indicate past infection and lifelong immunity.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1060-1061 | 1064
MSC: NCLEX: Physiological Integrity
2. The nurse determines that administration of hepatitis B vaccine to a patient has been effective when a specimen of
the patient’s blood reveals
a. HBsAg.
b. anti-HBs.
c. anti-HBc IgG.
d. anti-HBc IgM.
ANS: B
The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other
laboratory values indicate current infection with HBV.
DIF:
TOP:
Cognitive Level: Analysis
Nursing Process: Evaluation
REF: 1061-1062 | 1064
MSC: NCLEX: Health Promotion and Maintenance
3. A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is
appropriate?
a. Schedule the patient for HCV genotype testing.
b. Administer immune globulin and the HCV vaccine.
c. Instruct the patient on ribavirin (Rebetol) treatment.
d. Teach that the infection will resolve in a few months.
ANS: A
Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Since
most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the
HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for
chronic HCV infection.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1063-1064
MSC: NCLEX: Physiological Integrity
4. When a patient is diagnosed with acute hepatitis B, the nurse will plan to teach the patient about
a. ways to increase exercise and activity level.
b. self-administration of α-interferon (Intron A).
c. side effects of nucleoside and nucleotide analogs.
d. measures that will be helpful in improving appetite.
ANS: D
Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may
be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Planning
REF: 1064-1065 | 1069-1070
MSC: NCLEX: Physiological Integrity
5. When combination therapy of -interferon and ribavirin (Rebetol) is being used to treat chronic hepatitis C, the
nurse will plan to monitor for
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
a.
b.
c.
d.
leukopenia.
hypokalemia.
polycythemia.
hypoglycemia.
ANS: A
Therapy with ribavirin and -interferon may cause leukopenia. The other problems are not associated with this drug
therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1066
TOP:
Nursing Process: Planning
6. Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis
C should be done?
a. The patient eats frequent meals in fast-food restaurants.
b. The patient recently traveled to an undeveloped country.
c. The patient had a blood transfusion after surgery in 1998.
d. The patient reports a one-time use of IV drugs 20 years ago.
ANS: D
Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when
an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the
oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1062
MSC: NCLEX: Health Promotion and Maintenance
7. A patient is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serologic testing
is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?
a. “Is there any history of IV drug use?”
b. “Are you taking corticosteroids for any reason?”
c. “Do you use any over-the-counter (OTC) drugs?”
d. “Have you recently traveled to a foreign country?”
ANS: C
The patient’s symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis,
which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Travel to a foreign country
and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms
listed.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1070-1071
MSC: NCLEX: Physiological Integrity
8. A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the
nurse to monitor the patient’s
a. hemoglobin.
b. temperature.
c. activity level.
d. albumin level.
ANS: D
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of
edema. The other parameters also should be monitored, but they are not directly associated with the patient’s current
symptoms.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1075 | 1077
MSC: NCLEX: Physiological Integrity
9. A 32-year-old patient is diagnosed with early alcoholic cirrhosis. Which topic is most important to include in patient
teaching?
a. Need to abstain from alcohol
b. Use of vitamin B supplements
c. Maintenance of a nutritious diet
d. Treatment with lactulose (Cephulac)
ANS: A
The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used
when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to
stop the progression of the disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1081 | 1085
TOP:
Nursing Process: Planning
10. A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum
potassium level of 3.2 mEq/L (3.2 mmol/L). Which action should the nurse take?
a. Give both drugs as scheduled.
b. Administer the spironolactone.
c. Administer the furosemide and withhold the spironolactone.
d. Withhold both drugs until talking with the health care provider.
ANS: B
Spironolactone is a potassium-sparing diuretic and will help to increase the patient’s potassium level. The nurse does
not need to talk with the doctor before giving the spironolactone, although the health care provider should be
notified about the low potassium value. The furosemide will further decrease the patient’s potassium level and
should be held until the nurse talks with the health care provider.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1077-1078 | 1080
MSC: NCLEX: Physiological Integrity
11. To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the
nurse take?
a. Request that the patient stand on one foot.
b. Ask the patient to extend both arms to the front.
c. Instruct the patient to perform the Valsalva maneuver.
d. Have the patient walk a few steps with the eyes closed.
ANS: B
Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests
also might be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1076-1077
MSC: NCLEX: Physiological Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
12. A patient who has advanced cirrhosis is receiving lactulose (Cephulac). Which finding by the nurse indicates that
the medication is effective?
a. The patient is alert and oriented.
b. The patient denies nausea or anorexia.
c. The patient’s bilirubin level decreases.
d. The patient has at least one stool daily.
ANS: A
The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy.
Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not
decrease nausea and vomiting or lower bilirubin levels.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1078-1079
TOP:
Nursing Process: Evaluation
13. Which nursing action will be included in the plan of care for a patient who is being treated for bleeding esophageal
varices with balloon tamponade?
a. Monitor the patient for shortness of breath.
b. Encourage the patient to cough every 4 hours.
c. Deflate the gastric balloon every 8 to 12 hours.
d. Verify the position of the balloon every 6 hours.
ANS: A
The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon
ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the
varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further
verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is
deflated, the esophageal balloon may occlude the airway.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1082-1083 | 1084
MSC: NCLEX: Physiological Integrity
14. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of
the bleeding episode, it is most important for the nurse to monitor
a. bilirubin levels.
b. ammonia levels.
c. potassium levels.
d. prothrombin time.
ANS: B
The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia
level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also
should be monitored, but these will not be affected by the bleeding episode.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1076-1077
MSC: NCLEX: Physiological Integrity
15. Which nursing action will be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema
of the feet and legs?
a. Restrict dietary protein intake.
b. Reposition the patient every 4 hours.
c. Use a pressure-relieving mattress.
d. Perform passive range of motion qid.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
ANS: C
The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein
intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will
not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum
that are vulnerable to breakdown.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1082-1083
MSC: NCLEX: Physiological Integrity
16. After a patient has had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates
that the procedure has been effective?
a. Lower indirect bilirubin level
b. Increase in serum albumin level
c. Decrease in episodes of variceal bleeding
d. Improvement in alertness and orientation
ANS: C
TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal
varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase
the risk for hepatic encephalopathy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1078-1080
TOP:
Nursing Process: Evaluation
17. The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient
for the procedure, the nurse
a. places the patient on NPO status.
b. assists the patient to lie flat in bed.
c. asks the patient to empty the bladder.
d. positions the patient on the right side.
ANS: C
The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient
would be positioned in Fowler’s position and would not be able to lie flat without compromising breathing. Since no
sedation is required for paracentesis, the patient does not need to be NPO.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1081 | 1083-1084
MSC: NCLEX: Physiological Integrity
18. When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which
finding is most important to communicate to the health care provider?
a. Dry lips and oral mucosa
b. Crackles at both lung bases
c. Temperature 100.8° F (38.2° C)
d. No bowel movement for 4 days
ANS: C
Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection.
The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for
urgent action.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1088
MSC: NCLEX: Physiological Integrity
19. Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of
therapy for a patient who has acute pancreatitis?
a. Calcium
b. Bilirubin
c. Amylase
d. Potassium
ANS: C
Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be as
useful in evaluating whether the prescribed therapies have been effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1090
TOP:
Nursing Process: Evaluation
20. Which assessment finding in a patient with acute pancreatitis would the nurse need to report most quickly to the
health care provider?
a. Nausea and vomiting
b. Hypotonic bowel sounds
c. Abdominal tenderness and guarding
d. Muscle twitching and finger numbness
ANS: D
Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is
administered. Although the other findings also should be reported to the health care provider, they do not indicate
complications that require rapid action.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1091-1092
MSC: NCLEX: Physiological Integrity
21. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a
history of
a. alcohol use.
b. diabetes mellitus.
c. high-protein diet.
d. cigarette smoking.
ANS: A
Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking,
diabetes, and high-protein diets are not risk factors.
DIF:
TOP:
Cognitive Level: Comprehension
Nursing Process: Assessment
REF: 1088-1089
MSC: NCLEX: Physiological Integrity
22. When educating a patient with chronic pancreatitis about the prescribed pancrelipase (Viokase), the nurse will teach
the patient to take the medication
a. at bedtime.
b. with every meal.
c. upon arising in the morning.
d. as soon as abdominal pain occurs.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
ANS: B
Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1093-1094
MSC: NCLEX: Physiological Integrity
23. After providing discharge instructions to a patient following a laparoscopic cholecystectomy, the nurse recognizes
that teaching has been effective when the patient states,
a. “I can remove the bandages on my incisions tomorrow and take a shower.”
b. “I can expect some yellow-green drainage from the incision for a few days.”
c. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
d. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”
ANS: A
After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are
discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions
would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet
may be recommended for a few weeks after surgery but will not be a life-long requirement.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1100
TOP:
Nursing Process: Evaluation
24. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?
a. The patient’s hands flap back and forth when the arms are extended.
b. The patient has ascites and a 2-kg weight gain from the previous day.
c. The patient’s skin has multiple spider-shaped blood vessels on the abdomen.
d. The patient complains of right upper-quadrant pain with abdominal palpation.
ANS: A
The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider
angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a
change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the
changes in neurologic status.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1072-1074 | 1075-1077
MSC: NCLEX: Physiological Integrity
25. A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which assessment
finding is the best indicator that the medication has been effective?
a. The apical pulse rate is 68 beats/minute.
b. Stools test negative for occult blood.
c. The patient denies complaints of chest pain.
d. Blood pressure is less than 140/90 mm Hg.
ANS: B
Since the purpose of -blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from
esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although
propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease
the risk for bleeding from esophageal varices.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1077-1078
TOP:
Nursing Process: Evaluation
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
26. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered
ranitidine (Zantac). Which response by the nurse is most appropriate?
a. The medication will reduce the risk for aspiration.
b. The medication will decrease nausea and anorexia.
c. The medication will inhibit the development of gastric ulcers.
d. The medication will prevent irritation to the esophageal varices.
ANS: D
The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and
bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for
peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2
receptor blockade in this patient.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1080
MSC: NCLEX: Physiological Integrity
27. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient’s hand.
Which action should the nurse take next?
a. Ask the patient about any arm pain.
b. Retake the patient’s blood pressure.
c. Check the calcium level on the chart.
d. Notify the health care provider immediately.
ANS: C
The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive
Trousseau’s sign. The health care provider should be notified after the nurse checks the patient’s calcium level.
There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1091-1092
MSC: NCLEX: Physiological Integrity
28. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by
the nurse indicates that these therapies have been effective?
a. Bowel sounds are present.
b. Grey Turner sign resolves.
c. Electrolyte levels are normal.
d. Abdominal pain is decreased.
ANS: D
NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain.
Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate
that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG
suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it
would not be appropriate to wait for this occur to determine whether treatment was effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1091
TOP:
Nursing Process: Evaluation
29. When the nurse is caring for a patient with acute pancreatitis, which assessment finding is of most concern?
a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
d.
Palpable abdominal mass
ANS: D
A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical
drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in
acute pancreatitis and do not require rapid action to prevent further complications.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1089-1090
MSC: NCLEX: Physiological Integrity
30. Which nursing action will be included in the plan of care for a patient who has recently been diagnosed with
asymptomatic nonalcoholic fatty liver disease (NAFLD)?
a. Teach symptoms of variceal bleeding.
b. Discuss the need to increase caloric intake.
c. Review the patient’s current medication list.
d. Draw blood for hepatitis serology testing.
ANS: C
Some medications can increase the risk for NAFLD and these should be eliminated. NAFLD is not associated with
hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with
asymptomatic NAFLD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1071-1072
TOP:
Nursing Process: Planning
31. The nurse is caring for a patient with chronic hepatitis C infection who has these medications prescribed. Which
medication requires further discussion with the health care provider prior to administration?
a. ribavirin (Rebetol, Copegus) 600 mg PO bid
b. pegylated α-interferon (PEG-Intron, Pegasys) SQ daily
c. diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching
d. dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea
ANS: B
Pegylated α-interferon is administered weekly. The other medications are appropriate for a patient with chronic
hepatitis C infection.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1064-1066
MSC: NCLEX: Physiological Integrity
32. During change-of-shift report, the nurse learns about the following four patients. Which patient requires the most
rapid assessment?
a. 50-year-old with chronic pancreatitis who has gnawing abdominal pain
b. 48-year-old who has compensated cirrhosis and is complaining of anorexia
c. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 102° F (38.8° C)
d. 56-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain
ANS: C
This patient’s history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and
interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their
diagnoses and do not indicate complications are occurring.
DIF:
Cognitive Level: Analysis
REF:
1075-1076
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
OBJ:
TOP:
Special Questions: Multiple Patients
Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
33. A homeless patient with severe anorexia and fatigue is admitted to the hospital with viral hepatitis. Which patient
goal has the highest priority when the nurse is developing the plan of care?
a. Increase activity level.
b. Maintain adequate nutrition.
c. Establish a stable home environment.
d. Identify the source of exposure to hepatitis.
ANS: B
The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte
regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate
activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient’s activity level
will be gradually increased, rest is indicated during the acute phase of hepatitis.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1066
Nursing Process: Planning
34. A patient with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action
should the nurse take first?
a. Insert a large-gauge IV catheter.
b. Draw blood for coagulation studies.
c. Check BP, heart rate, and respirations.
d. Place the patient in the supine position.
ANS: C
The nurse’s first action should be to determine the patient’s hemodynamic status by assessing vital signs. Drawing
blood for coagulation studies and inserting an IV catheter also are appropriate. However, the vital signs may indicate
the need for more urgent actions. Since aspiration is a concern for this patient, the nurse will need to assess the
patient’s vital signs and neurologic status before placing the patient in the supine position.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1084
Nursing Process: Implementation
35. In planning care for a patient with acute severe pancreatitis, the nurse assigns the highest priority to the patient
outcome of
a. expressing satisfaction with pain control.
b. developing no ongoing pancreatic problems.
c. maintenance of normal respiratory function.
d. having adequate fluid and electrolyte balance.
ANS: C
Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory
function is the priority goal. The other outcomes also would be appropriate for the patient.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1091-1092
Nursing Process: Planning
36. Which nursing action is a priority when the nurse is caring for a patient with pancreatic cancer?
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
a.
b.
c.
d.
Offer high-calorie, high-protein dietary choices.
Offer psychologic support for anxiety or depression.
Educate about the need to avoid scratching pruritic areas.
Administer prescribed opioids to relieve pain as needed.
ANS: D
Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education,
or manage anxiety or depression.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1094-1096
Nursing Process: Planning
37. A patient is admitted to the hospital with acute cholecystitis. Which assessment information will be most important
for the nurse to report to the health care provider?
a. The patient’s urine is bright yellow.
b. The patient’s stools are clay colored.
c. The patient complains of chronic heartburn.
d. The patient has an increase in pain after eating.
ANS: B
The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are
not unusual for a patient with this diagnosis, although the nurse also would report the other assessment information
to the health care provider.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1096 | 1099
Nursing Process: Assessment
38. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest
priority on assisting the patient to
a. choose low-fat foods from the menu.
b. perform leg exercises hourly while awake.
c. ambulate the evening of the operative day.
d. turn, cough, and deep breathe every 2 hours.
ANS: D
Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the
surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are
important to implement but are not as high a priority as ensuring adequate ventilation.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1099-1100
Nursing Process: Planning
39. Which of the following nursing actions included in the plan of care for a patient with cirrhosis can the RN delegate
to nursing assistive personnel?
a. Assessing the patient for jaundice
b. Providing oral hygiene before meals
c. Palpating the abdomen for distention
d. Assisting the patient in choosing the diet
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
ANS: B
Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and
assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and
scope of practice and would be delegated to LPNs/LVNs or RNs.
DIF: Cognitive Level: Application
REF: 1080-1085
OBJ: Special Questions: Delegation
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the
nurse plan to take (select all that apply)?
a. Administer hepatitis B vaccine.
b. Test for antibodies to hepatitis B.
c. Teach about α-interferon therapy.
d. Give hepatitis B immune globulin.
e. Educate about oral antiviral therapy.
ANS: A, B, D
The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In
addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for
hepatitis B prophylaxis.
Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 6 th Edition
Test Bank
Chapter 55: Nursing Management: Acute Intracranial Problems
1.
A patient has a systemic blood pressure of 120/60 and an intracranial pressure of 24 mm Hg. The nurse
determines that the cerebral perfusion pressure of this patient indicates
1. high blood flow to the brain.
2. normal intracranial pressure.
3. impaired blood flow to the brain.
4. adequate autoregulation of cerebral blood flow.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1492
2.
Intracranial pressure monitoring is instituted for a patient with a head injury. The patient’s arterial blood
pressure is 92/50 mm Hg, and her intracranial pressure is 18 mm Hg. Using these values to calculate the
patient’s cerebral perfusion pressure (CPP), the nurse determines
1. the CPP is adequate for normal cerebral blood flow.
2. the CPP is so low that ischemia and neuronal death are imminent.
3. to prevent cerebral hypoxia, the patient’s blood pressure should be increased.
4. lowering the patient’s blood pressure will reduce the intracranial pressure, increasing cerebral blood flow.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Analysis
NCLEX: Physiologic Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Text Reference: p. 1492
3.
Unconsciousness without response to painful stimuli is assessed in a patient with a head injury who has been
admitted to the emergency department. To promote cerebral blood flow in the patient, initially it is most
important for the nurse to monitor the patient’s
1. respiratory rate.
2. arterial blood pressure.
3. level of consciousness.
4. arterial blood gas results.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1492
4.
A patient with a serum sodium level of 115 mEq/L (115 mmol/L) has a decreasing level of consciousness and
complains of a headache. The nurse knows the patient is at risk for cerebral edema caused by
1. cerebral hypoxia.
2. shift of fluid into brain cells.
3. accumulation of CO2 in brain cells.
4. a defect in the permeability of the blood-brain barrier.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1494
5.
The wife of a patient who is in a coma is optimistic about her husband’s recovery because he opens his eyes and
appears to be awake. The most appropriate response by the nurse to the wife’s comment is
1. “Your husband’s behavior is only a reflex and does not really show improvement in his condition.”
2. “Sleep-wake cycles are encouraging signs of recovery, and you should be optimistic about your husband’s
condition.”
3. “You are right to be optimistic. When patients begin to recover from a coma, the first behaviors seen are
those of wakefulness.”
4. “Your husband may show sleep-wake patterns if the part of the brain responsible for arousal is not injured,
but these patterns don’t reflect activity of the higher brain centers.”
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1495
6.
When assessing a patient with a head injury, the nurse recognizes that an early indication of increased
intracranial pressure is
1. vomiting.
2. headache.
3. change in orientation.
4. sluggish pupillary response to light.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Text Reference: p. 1495
7.
A patient is admitted to the hospital with a head injury resulting from an automobile accident. On admission the
patient’s vital signs are temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. One
hour after admission, the nurse notes the presence of the Cushing’s triad when the patient’s vital signs are
1. blood pressure 140/60, pulse 80, respirations 16.
2. blood pressure 130/72, pulse 90, respirations 24.
3. blood pressure 148/78, pulse 112, respirations 28.
4. blood pressure 110/70, pulse 120, respirations 30.
Answer: 1
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1495
8.
The nurse suspects possible supratentorial herniation and compression of the brainstem when assessment of the
oculomotor nerve reveals
1. absent corneal reflexes.
2. the development of nystagmus.
3. decreasing pupillary response to light.
4. enlargement of the pupil on the contralateral side.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1495
9.
When the nurse applies a painful stimuli to an unconscious patient, the patient responds by stiffly extending and
abducting the arms and hyperpronating the wrists. The nurse interprets this finding as
1. decorticate posturing indicating an interruption of voluntary motor tracts.
2. decerebrate posturing indicating an interruption of voluntary motor tracts.
3. decorticate posturing indicating a disruption of motor fibers in the midbrain and brainstem.
4. decerebrate posturing indicating a disruption of motor fibers in the midbrain and brainstem.
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1495-1496
10. When a patient’s intracranial pressure is being monitored with an intraventricular catheter, a priority nursing
intervention is
1. strict aseptic technique to prevent infection.
2. maintaining the patient’s head in a fixed position.
3. continuous monitoring of the intracranial pressure waveform.
4. removal of cerebral spinal fluid to keep pressure at normal levels.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1497
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
11. The nurse monitors the intracranial pressure waveform of a patient with a ventricular catheter intracranial
pressure monitor system. The waveform the nurse recognizes as a possible precursor of severe cerebral
ischemia is one that has
1. tall, plateau waves with sustained pressures of 50 to 100 mm Hg.
2. triple-notched waves that range in pressure from 4 to 15 mm Hg.
3. jagged, saw-toothed spikes with unsustained pressures up to 50 mm Hg.
4. small, rapid waves that correspond to changes in arterial pressure and respirations.
Answer: 1
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1497
12. A patient is brought to the emergency department by ambulance after she was found unconscious on the
bathroom floor by her husband. In admitting the patient, it is most important for the nurse to first assess the
patient’s
1. heath history.
2. airway patency.
3. neurologic status.
4. status of bodily functions.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1498
13. Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with
marked increased intracranial pressure. The nurse knows that the rationale for this therapy is to
1. prevent cerebral alkalosis.
2. decrease cerebral metabolism.
3. promote cerebral vasoconstriction.
4. prevent tissue hypoxia to the brain.
Answer: 3
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1499
14. The physician prescribes intravenous mannitol for an unconscious patient. The nurse would expect the
therapeutic effect of this drug to result in decreased
1. seizure activity.
2. cerebral edema.
3. cerebral metabolism.
4. cerebral inflammation.
Answer: 2
Nursing Process: Evaluation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1499
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
15. A patient with a severe head injury has been maintained on intravenous fluids of 5% dextrose in water for 3
days. The nurse consults with the physician about starting enteral feedings for the patient, based on the
knowledge that
1. malnutrition promotes continued cerebral edema.
2. free water should be avoided to prevent overhydration.
3. a state of dehydration can best be met with enteral feedings.
4. sodium restrictions can best be managed with enteral or parenteral feedings.
Answer: 1
Nursing Process: Evaluation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1499
16. When assessing a patient with a neurologic disorder using the Glasgow Coma Scale, the nurse is obtaining
information related to the
1. level of consciousness.
2. presence of cerebral edema.
3. presence of corneal and pupillary reflexes.
4. integrated functions of the cerebral cortex.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1500
17. A patient with a head injury opens his eyes when his name is called, curses when he is stimulated, and does not
respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the
patient’s Glasgow Coma Scale score as
1. 9.
2. 11.
3. 13.
4. 15.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1501
18. The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system
integrative function for a patient who has posttraumatic brain swelling, based on the finding of
1. apneustic breathing.
2. crackles on inspiration.
3. Glasgow Coma Scale score <8.
4. central perfusion pressure <60 mm Hg.
Answer: 1
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1502
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
19. A woman is admitted unconscious to the emergency department after striking her head on a boulder while
hiking. Her husband and three teenaged children will not leave her side and constantly ask about the treatment
being given. The nurse’s best approach to the patient’s family is to
1. call the family’s pastor or spiritual advisor to support them while initial care is given.
2. refer the family members to the hospital counseling service to deal with their anxiety.
3. allow the family to stay with the patient and explain all procedures thoroughly to them.
4. ask the family to wait in the waiting room until the initial assessment can be completed and care can be
started.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Psychosocial Integrity
Text Reference: p. 1504
20. An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral
tissue swelling. An appropriate nursing intervention for this problem is to
1. elevate the head of the bed 30 degrees.
2. provide a position of comfort with the knees and hips flexed.
3. cluster nursing interventions to provide uninterrupted periods of rest.
4. teach the patient to cough and deep breathe to prevent the necessity for suctioning.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 1503, 1505
21. The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action
for this finding is to
1. obtain a specimen of the fluid for culture and sensitivity.
2. check the nasal drainage for glucose with a Dextrostik or Testape.
3. take the patient’s temperature to determine whether a fever is present.
4. instruct the patient to blow his nose and then check the nares for inflammation.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1506-1507
22. A patient is brought to the emergency department after he became faint and disoriented after being hit in the
head with a baseball bat during a company picnic. On admission he has a headache and cannot remember being
hit, but he has no other signs of neurologic deficit. The nurse expects treatment for the patient to include
1. diagnostic testing with MRI.
2. hospitalization for observation for 24 hours.
3. discharge with observation and monitoring instructions.
4. administration of a narcotic for the headache, followed by observation for several hours.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1507
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
23. A victim of an automobile accident was found unconscious at the scene of the accident but regained
consciousness during transport to the hospital. Shortly after admission, her Glasgow Coma Scale score is 8, and
an acute epidural hematoma is suspected. The nurse plans care for the patient, based on the expectation that
treatment will include
1. immediate craniotomy.
2. administration of IV furosemide.
3. administration of IV corticosteroids.
4. endotracheal intubation with mechanical ventilation.
Answer: 1
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1508
24. The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and recognizes an
intervention that is absolutely contraindicated for this patient is
1. lying the patient flat in bed.
2. feeding the patient solid food.
3. performing nasopharyngeal suctioning.
4. application of a dressing under the nose.
Answer: 3
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1511
25. In planning long-term care for the patient following brain trauma, the nurse includes teaching and support for
the family primarily because
1. patients will always have some residual deficits of the brain damage.
2. most patients experience seizure disorders in the weeks or even years following head injury.
3. families become dysfunctional and unable to cope with the role reversals required during convalescence.
4. patients with head injuries with unconsciousness often have changes in personality with loss of
concentration and memory processing.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Psychosocial Integrity
Text Reference: p. 1511
26. During the assessment of a patient who has a tumor of the left frontal lobe, the nurse would expect to find
1. speech disturbances.
2. ataxic gait and vertigo.
3. personality and judgment changes.
4. papilledema and vision disturbances.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1513-1514
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
27. A patient seeks care for an increasing headache and nausea and vomiting. When diagnostic testing for a brain
tumor is performed, the patient asks the nurse what will happen to him if he has a brain tumor. The nurse’s
response to the patient is based on the knowledge that
1. benign brain tumors are readily treatable and have a favorable prognosis.
2. brain tumors increase cerebral mass, resulting in increased intracranial pressure.
3. most brain tumors cause death by metastasizing to vital organs, such as the liver or lungs.
4. malignant brain tumors are usually untreatable surgically and are managed with chemotherapy.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1512
28. Four days after a patient has undergone a craniotomy to remove an astrocytoma of the temporal lobe, the
dressing is removed and the nurse finds the patient crying. She tells the nurse she looks and feels awful. The
nurse recognizes that this behavior is related to
1. mental and emotional residual effects of the surgery.
2. disturbed body image due to the change in her appearance.
3. effects of surgical trauma and swelling in the temporal lobe.
4. an improvement in the patient’s condition with increased awareness of her situation.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Psychosocial Integrity
Text Reference: p. 1517
29. Because the risk of increased ICP restricts the implementation of some usual nursing interventions that are used
to prevent postoperative complications, the nurse should be especially careful to monitor the patient with a
craniotomy for
1. meningitis.
2. CSF leakage.
3. adventitious lung sounds.
4. signs and symptoms of wound infection.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1502
30. Following a craniotomy with a craniectomy and left anterior fossae incision, the patient has a nursing diagnosis
of ineffective protection related to decreased LOC and weakness. An appropriate nursing intervention for the
patient includes
1. assessing for changes in motor ability daily.
2. performing range-of-motion exercises q4hr.
3. turning and repositioning the patient side to side q4hr.
4. eliminating extraneous noise to prevent sensory overload.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1517
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
31. The nurse identifies a nursing diagnosis of disturbed sensory perception related to decreased level of
consciousness for a patient with bacterial meningitis who is exhibiting disorientation and anxiety. An
appropriate nursing intervention to decrease the patient’s disorientation is to
1. apply restraints to protect the patient from injuring herself.
2. avoid touching or speaking to the patient to decrease sensory input.
3. allow a family member to remain at the bedside as much as possible.
4. maintain a well-lighted room with frequent stimulation to prevent misinterpretation of the environment.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1520
32. When aspirin does not relieve a temperature of 102.4° F (39.1° C) in a patient with meningitis, the physician
orders a hypothermia blanket to be applied. During the use of the hypothermia blanket, the nurse should
1. administer sedatives to prevent muscle spasms and shivering.
2. wrap the patient’s extremities in sheepskins or towels to prevent tissue damage.
3. moisten the patient’s skin with tepid water to increase the heat loss through evaporation.
4. reduce the patient’s temperature to normal as quickly as possible to prevent increased intracranial pressure
and seizures.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1521
33. A patient with suspected viral encephalitis has an analysis of cerebral spinal fluid (CSF) performed. A result of
CSF analysis that the nurse would expect in the patient with viral encephalitis includes
1. red blood cells.
2. increased glucose.
3. decreased protein.
4. clear appearance of fluid.
Answer: 4
Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 6 th Edition
Test Bank
Chapter 56: Nursing Management: Stroke
1.
The daughter of a patient admitted unconscious to the emergency room with a possible stroke reports her
mother has a history of hypertension that she does not manage well. She has been using estrogen replacement
therapy for the past 6 years, and estrogen and her antihypertensive medication are the only drugs she uses. Her
only activity is managing her home, and she appears overweight. The finding that the nurse recognizes as the
most significant risk factor for a stroke in the patient is
1. obesity.
2. hypertension.
3. sedentary lifestyle.
4. estrogen replacement therapy.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1526
2.
A patient is hospitalized with a stroke manifested by hemiplegia and impaired speech. When obtaining a health
history from the patient’s family, the nurse recognizes that the effects of the stroke are most likely to be
complicated by the patient’s history of
1. hypertension.
2. diabetes mellitus.
3. moderate alcohol consumption.
4. chronic obstructive pulmonary disease.
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Analysis
NCLEX: Physiologic Integrity
Text Reference: p. 1526
3.
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and
dysarthria with no residual effects will include
1. oral administration of ticlopidine (Ticlid).
2. heparin via continuous intravenous infusion.
3. prophylactic clipping of cerebral aneurysms.
4. therapy with tissue plasminogen activator (TPA).
Answer: 1
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 1527-1528
4.
When a patient is hospitalized with a possible stroke, the nurse recognizes that the stroke most likely resulted
from a subarachnoid hemorrhage when the patient’s family reports that the patient
1. has a history of atrial fibrillation.
2. was unable to be aroused in the morning.
3. had been complaining of a headache before losing consciousness.
4. has had several brief episodes of mental confusion and right arm and leg weakness.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1528-1529
5.
A patient with a stroke caused by thrombosis of the middle cerebral artery experiences right-sided paralysis of
the upper and lower extremities and facial drooping on the right side. Based on the location of the patient’s
stroke, an additional assessment finding that the nurse would expect to be present is
1. apraxia.
2. aphasia.
3. atonic bladder.
4. central vision loss.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1530
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
6.
A patient has an occlusion of the left posterior cerebral artery. The nurse recognizes that manifestations most
likely to occur indicate damage to the
1. cerebellum.
2. frontal lobe.
3. parietal lobe.
4. occipital and inferior temporal lobes.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1530
7.
The physician prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. The nurse teaches the
patient that an expected outcome of this drug includes
1. regulation of his blood pressure.
2. breakdown of clots that have formed in his cerebral arteries.
3. prevention of platelet clumps around atherosclerotic plaques.
4. healing of sites where blood is leaking out of his cerebral arteries.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1533, 1535
8.
The physician recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of
transient ischemic attacks. The patient asks the nurse whether this procedure involves brain surgery. In
responding to the patient, the nurse includes the information that
1. an endarterectomy involves brain surgery because plaques in arteries at the base of the brain are removed.
2. this surgery involves resection of a diseased portion of the artery in the brain and replacing it with a
synthetic graft.
3. a carotid endarterectomy involves removal of plaques in an artery in the neck and does not involve surgery
in the brain.
4. in this surgery a burr hole is drilled in the skull to connect an artery outside the skull to one inside the brain,
bypassing a blockage.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1533
9.
On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient’s blood pressure to
be 180/90. The nurse anticipates that
1. IV fluids will be withheld until the blood pressure is within normal range.
2. unless the blood pressure is lowered, the patient is at risk for another stroke.
3. IV fluids will be administered to promote hydration to maintain cerebral perfusion.
4. IV antihypertensive agents will be administered to maintain a mean arterial pressure (MAP) of 140 mm Hg.
Answer: 3
Nursing Process: Planning
Cognitive Level: Analysis
NCLEX: Physiologic Integrity
Text Reference: p. 1534
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
10. A 68-year-old man has had several transient ischemic attacks with temporary hemiparesis and dysarthria that
have lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance for any
symptoms that last longer than an hour, explaining that permanent disability from a stroke may be reduced if
therapy is initiated within 3 hours with the use of
1. intravenous heparin.
2. transluminal angioplasty.
3. a surgical endarterectomy.
4. tissue plasminogen activator (TPA).
Answer: 4
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1535
11. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive
aphasia. An appropriate nursing intervention to help the patient communicate is to
1. ask simple questions that can be answered with “yes” or “no.”
2. develop a list of simple words that she can read and practice reciting.
3. have her practice facial and tongue exercises to improve motor control necessary for speech.
4. prevent embarrassing her by changing the subject if she does not respond in a timely manner.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1542
12. Twenty-four hours after admission, a patient with a stroke has progressive development of neurologic deficits
with increasing weakness and decreased level of consciousness. The primary goal of nursing management of the
patient at this time is
1. protecting the skin from breakdown.
2. monitoring for changes in neurologic status.
3. maintaining the patient’s respiratory function.
4. preventing joint contractures and muscle atrophy.
Answer: 3
Nursing Process: Planning
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1539
13. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right
brain damage, the nurse establishes a nursing diagnosis of
1. impaired physical mobility related to right hemiplegia.
2. risk for injury related to denial of deficits and impulsiveness.
3. impaired verbal communication related to speech-language deficits.
4. ineffective coping related to depression and distress about disability.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1531
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
14. A patient with homonymous hemianopia resulting from a stroke has a nursing diagnosis of disturbed sensory
perception related to hemianopia. An appropriate nursing intervention that will help the patient learn to
compensate for the deficit during the rehabilitation period is to
1. apply an eye patch to the affected eye.
2. approach the patient on the unaffected side.
3. place objects necessary for activities of daily living on the affected side.
4. teach the patient to exercise the eye muscles with full range of motion at least twice a day.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1542
15. During the acute phase of a patient with an ischemic stroke, the nurse monitors the patient’s neurologic status
closely with the knowledge that following a stroke, increased intracranial pressure from cerebral edema is most
likely to peak in
1. 12 hours.
2. 24 hours.
3. 48 hours.
4. 72 hours.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1534
16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to
inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention to help
improve the patient’s nutrition is to
1. assist the patient to eat with her left hand.
2. provide a pureed diet that is easy for the patient to swallow.
3. stroke the patient’s throat while feeding her to stimulate swallowing of food.
4. provide a wide variety of food choices on the meal tray to stimulate her appetite.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1544
17. After 3 days, a patient with an ischemic stroke has stable symptoms and she is taught to balance herself sitting
on the edge of the bed. To teach the patient to transfer from the bed to the wheelchair, the nurse
1. places the wheelchair next to the bed on the patient’s affected side.
2. places the wheelchair parallel to the bed on the patient’s unaffected side.
3. places the wheelchair directly in front of the patient while she is sitting on the side of the bed.
4. places a wheelchair with a removable arm against the bed where the patient is lying and has her slide from
the bed to the chair.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: pp. 1543-1544
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
18. A 32-year-old patient has a stroke resulting from a ruptured aneurysm with a subarachnoid hemorrhage. In
planning initial care for the patient, the nurse recognizes a patient outcome appropriate for patients with
ischemic strokes that would be contraindicated for this patient is
1. tolerates food and fluids without choking.
2. demonstrates ability to communicate needs.
3. performs active range of motion of the extremities.
4. transfers and ambulates at maximal level of activity.
Answer: 4
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1541
19. When initiating oral feedings for a patient with a stroke, the nurse determines that the patient has an intact gag
reflex and then
1. assesses the patient’s ability to move the tongue.
2. offers semisolid food that is easiest for the patient to swallow.
3. suctions the patient’s oral cavity to prevent aspiration of secretions.
4. places the patient in a high-Fowler’s position with the head flexed forward.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1539, 1541
20. A patient has right-sided paresis and aphasia as a result of a stroke but is attempting to use his left hand for
feeding and other activities. When his wife visits, she insists on doing everything for him. A nursing diagnosis
that is most appropriate in this situation is
1. situational low self-esteem related to increasing dependence on others.
2. interrupted family processes related to effects of illness of a family member.
3. disabled family coping related to inadequate understanding by primary person.
4. risk for ineffective therapeutic regimen management related to functional and communication limitations.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Psychosocial Integrity
Text Reference: p. 1543
21. Following a stroke, a patient has urinary incontinence with an impaired impulse to void. A bladder retraining
program for the patient should include
1. limiting fluid intake to 1000 ml/day to reduce urine volume.
2. assisting the patient onto the bed pan or the bedside commode every 2 hours.
3. performing intermittent catheterization after each voiding to check for residual urine.
4. inserting an indwelling catheter, clamping and draining the catheter every 4 hours to reestablish bladder
tone.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 1541-1542
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
22. A 72-year-old man is being discharged home following a stroke. He is able to walk with assistance but needs
help with hygiene, dressing, and eating. The patient’s 70-year-old wife has received instruction and practice in
necessary areas of care. A statement by the patient’s wife indicating to the nurse that the outcomes for discharge
planning have been met includes
1. “I can handle all of my husband’s needs with the instruction provided.”
2. “I have arranged for a home health aide to provide all the care my husband will need.”
3. “I can provide the care my husband needs if I use the support and resources available in the community.”
4. “Because my husband will have continuous improvement in his condition, I won’t need outside assistance
in his care for very long.”
Answer: 3
Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 6th Edition
Test Bank
Chapter 59: Nursing Management: Peripheral Nerve and Spinal Cord Problems
1.
The most prominent clinical manifestation the nurse would expect the patient with trigeminal neuralgia to report
during assessment is
1. a loss of taste.
2. inability to close the eye.
3. numbness of the forehead and eyelids.
4. brief periods of excruciating facial pain.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Knowledge
NCLEX: Physiologic Integrity
Text Reference: p. 1601
2.
During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should
1. examine the oral cavity for the state of hygiene.
2. observe the extent of facial weakness and eye closure.
3. identify trigger zones by lightly tickling the affected side of the face.
4. gently palpate the affected side of the face for warmth and swelling.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1603-1604
3.
A patient with a long history of trigeminal neuralgia recently had a glycerol rhizotomy for control of symptoms.
During a follow-up visit after the rhizotomy, a finding indicating to the nurse that the patient has made a
successful adjustment to the surgical intervention is the patient
1. uses an eye shield to protect the cornea from injury.
2. develops and implements a daily routine of facial exercises.
3. is careful to chew foods on the unaffected side of the mouth.
4. has positive interpersonal and social relationships with family and friends.
Answer: 4
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1604
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
4.
When the nurse is planning care for a patient during an acute episode of trigeminal neuralgia, an appropriate
intervention to include is
1. evaluation of hydration and nutrition status.
2. exercise of the muscles of the face and jaw.
3. application of ice packs to the affected area.
4. regular oral hygiene with tooth brushing and flossing.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1604
5.
The nurse teaches patients prone to herpes simplex infections to seek health care if pain occurs around the ear,
primarily because
1. full recovery from Bell’s palsy is likely if corticosteroids are started immediately.
2. prophylactic analgesics will prevent the clustering of painful episodes of Bell’s palsy.
3. administration of herpes simplex vaccine can prevent the development of Bell’s palsy.
4. treatment of a herpes outbreak with antiviral agents can prevent development of Bell’s palsy.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1605
6.
A patient with Bell’s palsy refuses to eat while others are present. The best response by the nurse to the
patient’s behavior is to
1. respect her desire for privacy and leave her alone while she eats.
2. provide a liquid diet high in protein and calories, which she can easily swallow.
3. assure the patient that it does not bother others to observe her while she eats.
4. teach the patient to chew her food on the unaffected side of the mouth for better control.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 1606
7.
A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient,
the nurse explains that Guillain-Barré syndrome
1. is an infection of the peripheral nerves spread from a bacterial infection of the respiratory tract.
2. is most likely caused by some immune system stimulation that results in abnormal immune destruction of
myelin.
3. is caused by an exposure to viruses in a vaccine or during an infection, which then causes destruction of
nerve fibers.
4. results from degeneration of the myelin covering of nerve fibers, caused by vasospasms and lack of blood
supply.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1606
8.
A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the
patient’s illness, the most essential assessment for the nurse to carry out is
1. monitoring the vital signs q2hr.
2. determining the patient’s level of consciousness q2hr.
3. performing constant evaluation of respiratory function.
4. evaluating sensory and motor function of the extremities.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1607
9.
A patient with acute Guillain-Barré syndrome is very alarmed by the progression of neurologic impairment and
asks several times whether he is going to die if the disease affects his head. The most appropriate response by
the nurse is
1. “I know you are frightened, but you are not going to die.”
2. “Many patients who survive Guillain-Barré syndrome have had involvement of the head and face.”
3. “Don’t worry. We will maintain all of your vital functions until your body systems recover from the
disease.”
4. “You may notice face and neck symptoms, but these are not fatal, and we are doing everything possible to
maintain normal functions.”
Answer: 4
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Psychosocial Integrity
Text Reference: p. 1608
10. A 45-year-old woman is hospitalized with Guillain-Barré syndrome. The nurse explains that during the first 2
weeks of her illness, treatment most likely will include
1. hemodialysis.
2. mechanical ventilation.
3. administration of immunoglobulin (Sandoglobulin).
4. administration of methylprednisolone (Solu-Medrol).
Answer: 3
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1607
11. A patient admitted to the emergency room is diagnosed with botulism poisoning, and botulinum antitoxin is to
be administered. Prior to administration of the antitoxin, the nurse should
1. obtain baseline vital signs.
2. administer an intradermal test dose.
3. ask the patient about a history of allergies.
4. document the presence of neurologic symptoms.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1608
12. A patient arrives at an urgent care center after stepping on a nail that was embedded in some old lumber in a
field. The patient reports having had a tetanus booster 7 years ago. The most appropriate nursing action is to
1. administer a tetanus booster.
2. clean the wound with soap and water.
3. initiate the series of tetanus immunizations.
4. administer an intradermal test dose of antiserum.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1609
13. A patient with a cervical neck fracture at the C5 level is admitted to the ICU following initial treatment in the
emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock
upon finding
1. hypotension, bradycardia, and warm extremities.
2. involuntary, spastic movements of the arms and legs.
3. flaccid paralysis and lack of sensation below the level of the injury.
4. loss of voluntary motor control but presence of reflex activity below the level of the injury.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1611
14. Initial x-ray and MRI results indicate that a patient has an incomplete spinal cord lesion at C8. During the first
72 hours after injury, the nurse plans care for the patient, with the knowledge that the complete cord damage
will result from
1. secondary injury to the cord.
2. unstable ligament support of the vertebrae.
3. loss of vasomotor control in the damaged area.
4. mechanical pressure of vertebral bone fragments.
Answer: 1
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1611
15. A patient with a spinal cord transection at T1 is in spinal shock. While monitoring the patient, the nurse
recognizes that alterations in sympathetic nervous system function may cause
1. tachycardia.
2. bladder hyperirritability.
3. fluctuating body temperature.
4. hypermotility of the GI system.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1614
16. As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting
in Brown-Séquard syndrome. In planning care for the patient, the nurse recognizes that the patient experiences
1.
2.
3.
4.
total motor and sensory loss in the right leg.
loss of proprioception in both legs but intact pain, temperature, and motor function.
loss of motor function and position and vibratory sense in the right leg and loss of pain and temperature in
the left leg.
motor paralysis with decreased pain sensations and loss of temperature control in both legs but retained
sense of touch, position, vibration, and motion.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1612
17. The nurse expects that a patient with spinal cord trauma would be able to have full upper extremity function
when the lesion is at the level of
1. C8.
2. T1.
3. T6.
4. L1.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 1612, 1615
18. During the initial phase of care for a patient with spinal cord trauma at C5, the nurse gives high priority to
maintaining respiratory function because
1. at the C5 level there is total loss of diaphragmatic and intercostal muscle function.
2. extension of edema above the site of the injury may affect phrenic nerve function.
3. immobilization of the patient’s spine promotes pooling of respiratory secretions.
4. without abdominal muscle control, the patient cannot adequately cough to clear the lungs.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1614
19. The physician orders administration of intravenous methylprednisolone for the first 24 hours to a patient who
experienced a spinal cord injury 3 hours ago. The nurse explains to the patient that this drug
1. maintains blood pressure and heart rate during spinal shock.
2. prevents complications resulting from decreased GI motility.
3. reduces spinal cord edema and improves nerve impulse conduction.
4. counteracts the effects of uninhibited parasympathetic nervous system stimulation.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 1617
20. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. The nurse
consults with the physician regarding bladder management, recommending that initial treatment should include
1. intermittent catheterization q4hr.
2. limiting fluid intake to 1000 ml/day.
3.
4.
clamping a Foley catheter and draining it q2hr.
catheterization for residual urine after each voiding.
Answer: 1
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1626
21. A patient with a T2 spinal cord injury is beginning intensive rehabilitation. One morning as the nurse prepares
to assist her to transfer to the wheelchair, the patient tells the nurse that she does not feel like getting up, that she
has a throbbing headache, and that she is slightly nauseated. It is most important that the nurse
1. notify the physician.
2. check the patient’s blood pressure.
3. tell her she will feel better if she sits upright in her wheelchair.
4. do a digital rectal examination for the presence of an impaction.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1625
22. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient
outcome for the patient is
1. transfers independently to a wheelchair.
2. drives a car with powered hand controls.
3. feeds himself with powered hand splints.
4. pushes a wheelchair on flat, smooth surfaces.
Answer: 4
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 1615
23. A patient with a T1 spinal cord injury had been optimistic about regaining normal function, but 10 days after the
injury, his physician informs him that there is a complete spinal cord injury and there will be little or no
improvement in his function. The patient then refuses to discuss his condition and becomes verbally abusive to
the nurses and other staff. He demands to be transferred to another hospital, where “they know what they are
doing.” The best response by the nurse to the patient’s behavior is to
1. ignore his anger but insist on performing necessary care.
2. allow his outbursts and ask for his input into his plan of care.
3. sympathize with his feelings and expect him to be dependent during this phase.
4. inform him that his anger is destructive and will only delay his rehabilitation efforts.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Psychosocial Integrity
Text Reference: p. 1621
24. A 26-year-old patient with a C8 spinal cord injury tells the nurse that sexual activity has always been very
important to him and his wife and he worries she may leave him if he cannot function sexually. The most
appropriate response by the nurse to the patient’s comment is to
1. advise the patient to talk to his wife about his concerns.
2.
3.
4.
tell the patient that alternative methods of obtaining sexual satisfaction could be used.
inform the patient that most patients with upper motor neuron injuries have reflex erections.
suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Psychosocial Integrity
Text Reference: p. 1629
25. A young married woman has returned home following extensive rehabilitation for a C8 spinal cord injury. The
home care nurse visits and notices that the patient’s mother and husband are performing many of the activities
of daily living that the patient was managing during rehabilitation. The most appropriate action by the nurse at
this time is to
1. encourage the patient to perform her own care as she has been taught.
2. tell the mother and husband to stop performing care that the patient can do herself.
3. recognize that it is important for the patient’s family to be involved in her care and support their activities.
4. include the husband and the mother in developing a plan of care to increase the patient’s independence.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 1626
26. Following a CT scan to identify the cause of back pain and sensory and motor deficits in the lower extremities,
a patient is diagnosed with an intradural extramedullary spinal cord tumor. When the patient asks the nurse if
she will be paralyzed as a result of treatment, the nurse explains that
1. her prognosis is good for complete functional return when the tumor is surgically removed.
2. the tumors in this area are very aggressive and the surgery required to remove them will result in permanent
cord damage.
3. tumors in this area are most often spread from another site and more testing needs to be done before a
prognosis can be determined
4. because the tumor is within the spinal cord, radiation may be used to shrink it but treatment won’t restore
function that has already been lost.
Answer: 1
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 57: Nursing Management: Acute Intracranial Problems
MULTIPLE CHOICE
1. A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The
nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates
a. high blood flow to the brain.
b. normal intracranial pressure (ICP).
c. impaired brain blood flow.
d. adequate cerebral perfusion.
Correct Answer: C
Rationale: The patient’s CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia
and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1468
NCLEX: Physiological Integrity
2. A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18
mm Hg. Which action by the nurse is appropriate?
a. Document and continue to monitor the parameters.
b. Elevate the head of the patient’s bed.
c. Notify the health care provider about the assessments.
d. Check the patient’s pupillary response to light.
Correct Answer: C
Rationale: The patient’s cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia
and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP. Documentation and
monitoring are inadequate responses to the patient’s problem. Elevating the head of the bed will lower the ICP but
may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of
increased ICP, so the nurse will only take more time doing this without adding any useful information.
Cognitive Level: Analysis
Text Reference: pp. 1468-1469
Nursing Process: Implementation NCLEX: Physiological Integrity
3. Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN
who has floated from the medical unit?
a. A 23-year-old patient who had a skull fracture and craniotomy the previous day
b. A 30-year-old patient who has an ICP monitor in place after a head injury a week ago
c. A 44-year-old patient receiving IV antibiotics for meningococcal meningitis
d. A 61-year-old patient who has increased ICP and is receiving hyperventilation therapy
Correct Answer: C
Rationale: An RN who works on a medical unit will be familiar with administration of IV antibiotics and with
meningitis. The post-craniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be
assigned to an RN familiar with the care of critically ill patients.
Cognitive Level: Application
Text Reference: pp. 1495-1497
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
4. A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing
level of consciousness (LOC) and complains of a headache. All of the following orders have been received.
Which one should the nurse accomplish first?
a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send patient to radiology for computed tomography (CT) of the head.
Correct Answer: B
Rationale: The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and the
nurse’s first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on
the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan
may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
Cognitive Level: Application
Text Reference: p. 1470
Nursing Process: Implementation NCLEX: Physiological Integrity
5. Family members are optimistic about a comatose patient’s recovery because the patient’s eyes open and the
patient appears to be awake at times. Which statement by the nurse to the family is appropriate?
a. “The behavior is only a reflex and does not indicate improvement in the comatose condition.”
b. “Sleep-wake cycles are indicators of recovery and a sign that the brain function is improving.”
c. “When patients begin to recover from a coma, the first behaviors seen are those of wakefulness and
opening the eyes.”
d. “The part of the brain responsible for arousal is not injured, but the wakefulness does not indicate
improvement in higher brain centers.”
Correct Answer: D
Rationale: Arousal is controlled by the reticular activating system in the brainstem and will allow the patient to
maintain wakefulness even though the damage to the cerebral cortex is severe. The patient’s behavior is not a reflex
action. The behaviors of eye opening and wakefulness are not indicators of improvement in the comatose condition.
Cognitive Level: Application
Text Reference: p. 1470
Nursing Process: Implementation NCLEX: Physiological Integrity
6. When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased
intracranial pressure (ICP) is
a. vomiting.
b. headache.
c. change in level of consciousness (LOC).
d. sluggish pupil response to light.
Correct Answer: C
Rationale: LOC is the most sensitive indicator of the patient’s neurologic status and possible changes in ICP.
Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by
compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.
Cognitive Level: Comprehension Text Reference: p. 1470
Nursing Process: Assessment
NCLEX: Physiological Integrity
7. A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure
128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of
most concern to the nurse?
a. Blood pressure 130/72, pulse 90, respirations 32
b. Blood pressure 148/78, pulse 112, respirations 28
c. Blood pressure 156/60, pulse 60, respirations 14
d. Blood pressure 110/70, pulse 120, respirations 30
Correct Answer: C
Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent
Cushing’s triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate
action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1469
NCLEX: Physiological Integrity
8. When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial
herniation and compression of the brainstem when the
a.
b.
c.
d.
corneal reflexes are absent.
patient develops nystagmus.
right pupil does not react to light.
left pupil is 10 mm in size.
Correct Answer: C
Rationale: A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation. Absent
corneal reflexes and nystagmus are not symptoms of herniation. A nonreactive left pupil would be consistent with
left-sided damage.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1471
NCLEX: Physiological Integrity
9. When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with
internal rotation, adduction, and flexion of the arms. The nurse documents this as
a. decorticate posturing.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal.
Correct Answer: A
Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as
decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does
not indicate localization of pain or flexion withdrawal.
Cognitive Level: Comprehension Text Reference: p. 1472
Nursing Process: Assessment
NCLEX: Physiological Integrity
10. When a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these
data obtained during the assessment is most important to communicate to the health care provider?
a. Oral temperature 101.6° F
b. Intracranial pressure 15 mm Hg
c. Mean arterial pressure 70 mm Hg
d. Apical pulse 106 beats/min
Correct Answer: A
Rationale: Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; the
temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse
are all borderline high but require only ongoing monitoring at this time.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1473
NCLEX: Physiological Integrity
11. The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy
for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
a. The staff nurse has the patient deep-breathe and cough.
b. The staff nurse assesses neurologic status every hour.
c. The staff nurse elevates the head of the bed to 30 degrees.
d. The staff nurse administers an analgesic before turning the patient.
Correct Answer: A
Rationale: Coughing can increase ICP and is generally discouraged in patients at risk for increased ICP. The other
actions by the staff nurse are appropriate.
Cognitive Level: Application
Text Reference: pp. 1478, 1480
Nursing Process: Implementation NCLEX: Physiological Integrity
12. A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the
bathroom floor by the spouse. In admitting the patient, the nurse will first assess
a. medication history.
b. oxygen saturation.
c. Glasgow Coma Scale (GCS).
d. pupil reaction to light.
Correct Answer: B
Rationale: Airway patency and breathing are the most vital functions and should be assessed first. The neurologic
assessments should be accomplished next and the health and medication history last.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1476
NCLEX: Physiological Integrity
13. Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a
head injury. To evaluate the effectiveness of the therapy, the nurse should
a. monitor oxygen saturation.
b. check arterial blood gases (ABGs).
c. monitor intracranial pressure (ICP).
d. assess patient breath sounds.
Correct Answer: C
Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be
monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in
patient’s receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing
ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 1475
NCLEX: Physiological Integrity
14. The health care provider prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine
that the medication is effective if
a. seizure behavior is reduced.
b. intracranial pressure (ICP) is lower.
c. abnormal electroencephalographic (EEG) activity decreases.
d. Glasgow Coma score (GCS) is lower.
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP. It will not directly affect seizure
activity or abnormal EEG activity. A decreased GCS would indicate worsening of the patient’s neurologic status.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 1474
NCLEX: Physiological Integrity
15. A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D 5W) at 50 ml/hr
for 3 days. The nurse will anticipate the need to
a. continue the D5W to provide the needed glucose for brain function.
b. decrease the rate of IV infusion to avoid increasing cerebral edema.
c.
d.
insert an enteral feeding tube to provide nutritional replacement.
administer IV 5% albumin to increase serum protein levels.
Correct Answer: C
Rationale: The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients
for brain function and also for healing and immune function. 5% dextrose does not provide adequate nutrition to
meet patient needs and can lead to lower serum osmolarity and cerebral edema. A total fluid intake of 1200 ml for
24 hours will not cause cerebral edema. Albumin administration will temporarily increase serum protein, but the
patient also requires lipids, carbohydrate, and other nutrients that will be supplied through enteral feeding.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1475
NCLEX: Physiological Integrity
16. When caring for a patient who has had a head injury, which assessment information is of most concern to the
nurse?
a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient’s apical pulse is slightly irregular.
Correct Answer: B
Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by
the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need
for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical
pulse is not unusual.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1470
NCLEX: Physiological Integrity
17. A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond
to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient’s
Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
Correct Answer: B
Rationale: The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1477
NCLEX: Physiological Integrity
18. The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system
(CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of
a. apneustic breathing.
b. crackles on inspiration.
c. Glasgow Coma Scale score of 7.
d. cerebral perfusion pressure of 56 mm Hg.
Correct Answer: A
Rationale: Apneustic breathing is caused by loss of CNS integration in the pons and is not effective in maximizing
gas exchange. Crackles on inspiration are abnormal, but they are not an indication of an abnormal breathing pattern.
The Glasgow Coma Scale and cerebral perfusion pressure P are not useful in determining or documenting a patient’s
respiratory patterns.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 1478
NCLEX: Physiological Integrity
19. A patient is admitted unconscious to the emergency department (ED) after falling and hitting the head on a rock
while hiking. The patient’s spouse and children stay at the patient’s side and constantly ask about the treatment
being given. The nurse’s best approach to the patient’s family is to
a. call the family’s pastor or spiritual advisor to support them while initial care is given.
b. refer the family members to the hospital counseling service to deal with their anxiety.
c. allow the family to stay with the patient and explain all procedures thoroughly to them.
d. ask the family to stay in the waiting room while the initial assessment and care are done.
Correct Answer: C
Rationale: The need for information about the diagnosis and care is very high in family members of acutely ill
patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling
service can offer some support, but research supports information as being more effective. Asking the family to stay
in the waiting room will increase their anxiety.
Cognitive Level: Application
Text Reference: p. 1486
Nursing Process: Implementation NCLEX: Psychosocial Integrity
20. An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral
tissue swelling. An appropriate nursing intervention for this problem is to
a. maintain the patient in a head-up position.
b. position the patient with the knees and hips flexed.
c. cluster nursing interventions to provide uninterrupted periods of rest.
d. encourage coughing and deep-breathing to improve oxygenation.
Correct Answer: A
Rationale: The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to
help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the
stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate
ICP. Coughing increases intrathoracic pressure and ICP.
Cognitive Level: Application
Text Reference: p. 1480
Nursing Process: Implementation NCLEX: Physiological Integrity
21. The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action
for this finding is to
a. obtain a specimen of the fluid and send for culture and sensitivity.
b. take the patient’s temperature to determine whether a fever is present.
c. check the nasal drainage for glucose with a Dextrostik or Testape.
d. have the patient to blow the nose and then check the nares for redness.
Correct Answer: C
Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid
leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does
increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is
CSF. Blowing the nose is avoided to prevent CSF leakage.
Cognitive Level: Application
Text Reference: p. 1481
Nursing Process: Implementation NCLEX: Physiological Integrity
22. A patient is brought to the emergency department (ED) after being hit in the head with a baseball during a
company picnic. On admission, the patient has a headache and cannot remember being hit but has no other signs
of neurologic deficit. The nurse will plan to
a. send the patient for diagnostic testing with MRI.
b. admit the patient for observation for 24 hours.
c. discharge the patient with monitoring instructions.
d. observe the patient in the ED for several hours.
Correct Answer: C
Rationale: A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring
and the need to return if neurologic status deteriorates. MRI, hospital admission, and continued observation in the
ED are not indicated in a patient who only briefly lost consciousness and has no neurologic deficits.
Cognitive Level: Application
Text Reference: p. 1482
Nursing Process: Implementation NCLEX: Physiological Integrity
23. A victim of an automobile accident was found unconscious at the scene of the accident but briefly regained
consciousness during transport to the hospital. On admission, the Glasgow Coma Scale score is 8, and an acute
epidural hematoma is suspected. The nurse will anticipate the need to
a. prepare the patient for immediate craniotomy.
b. administer IV furosemide (Lasix).
c. type and crossmatch for blood transfusion.
d. initiate high-dose barbiturate therapy.
Correct Answer: A
Rationale: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent
herniation. If ICP is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these
will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and
transfusion is usually not necessary.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 1483, 1485
NCLEX: Physiological Integrity
24. While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient’s nose.
Which of these admission orders should the nurse question?
a. Insert nasogastric tube.
b. Turn patient every 2 hours.
c. Keep head of bed elevated.
d. Cold packs for facial bruising.
Correct Answer: A
Rationale: Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a
nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevation of the head,
and cold pack applications are appropriate orders.
Cognitive Level: Application
Text Reference: p. 1486
Nursing Process: Implementation NCLEX: Physiological Integrity
25. In planning discharge for the patient following brain trauma, the nurse includes teaching and support for the
family, primarily because
a. the residual deficits of the brain damage are unlikely to improve in the months after discharge.
b. families become dysfunctional and unable to cope with the role reversals required during
convalescence.
c. patients with severe head injuries often have changes in personality with loss of concentration and
memory processing.
d. most patients experience seizure disorders in the weeks or even years following head injury.
Correct Answer: C
Rationale: Changes in personality, concentration, and memory are common after severe head injury and require
anticipatory guidance for the patient and family. Recovery continues for up to 6 months after the injury. Most
families are able to cope with the changes in role during the convalescence. Seizure disorders are more common
soon after brain injury, and most patients do not develop seizures.
Cognitive Level: Application
Text Reference: p. 1487
Nursing Process: Implementation NCLEX: Psychosocial Integrity
26.
a.
b.
c.
d.
When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find
expressive aphasia.
right-sided weakness.
judgment changes.
difficulty swallowing.
Correct Answer: C
Rationale: The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal
lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the
brainstem.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 1488-1489
NCLEX: Physiological Integrity
27. A patient with increasing headaches who is having diagnostic testing for a brain tumor asks the nurse what type
of treatment will be used if a tumor is discovered. Which response by the nurse is most appropriate?
a. “If the tumor is benign, treatment may not be necessary.”
b. “Therapy to remove or reduce the tumor size will be recommended.”
c. “Surgery will initially be used to reduce or remove the tumor.”
d. “Chemotherapy is used to shrink the tumor, followed by craniotomy.”
Correct Answer: B
Rationale: Treatment is designed to reduce tumor size or remove the tumor. Benign brain tumors place pressure on
intracranial structures and need to be treated. Surgery is the preferred initial therapy but may not be possible for
tumors located deep in the brain. The usefulness of chemotherapy is limited in brain tumors; chemotherapy is
usually not the initial treatment.
Cognitive Level: Application
Text Reference: p. 1489
Nursing Process: Implementation NCLEX: Physiological Integrity
28. Four days after a patient has undergone a craniotomy to remove an astrocytoma of the temporal lobe, the
dressing is removed and the nurse finds the patient crying. The patient tells the nurse, “I look awful and feel
even worse.” The most appropriate nursing diagnosis for the patient is
a. grieving related to the patient’s ongoing fear of dying.
b. disturbed body image related to postoperative change in appearance.
c.
d.
ineffective denial related to unrealistic expectations about surgery.
hopelessness related to emotional lability secondary to cerebral edema.
Correct Answer: B
Rationale: The patient’s statement about looking and feeling awful supports the diagnosis of disturbed body image,
which is common after surgery because of shaving of the scalp, incisions, and dressings, etc. There is no indication
that the patient’s immediate concern is with dying. The patient does not have indications of denial. The assessment
data do not indicate that the patient feels hopeless or that cerebral edema is contributing to the patient’s emotional
status.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 1493
NCLEX: Psychosocial Integrity
29. A patient with a brain tumor is receiving radiation after having had a craniotomy. The nurse will explain that the
purpose of the ordered methylprednisolone (Solu-Medrol) is to
a. eliminate the remaining tumor cells.
b. prevent an increase in intracranial pressure (ICP).
c. promote wound healing after the craniotomy.
d. decrease the risk of metastasis of the cancer.
Correct Answer: B
Rationale: Radiation can lead to cerebral edema and rapid ICP increases and corticosteroids are administered to
prevent this. Corticosteroids do not damage tumor cells, promote wound healing, or decrease risk for metastasis.
Cognitive Level: Application
Text Reference: p. 1489
Nursing Process: Implementation NCLEX: Physiological Integrity
30. Following a craniotomy with a craniectomy and left anterior fossae incision, the patient has a nursing diagnosis
of impaired physical mobility related to decreased level of consciousness (LOC) and weakness. An appropriate
nursing intervention is to
a. position the bed flat and log roll the patient.
b. perform range-of-motion (ROM) exercises every 4 hours.
c. turn and reposition the patient side to side every 2 hours.
d. cluster nursing activities to allow longer rest periods.
Correct Answer: B
Rationale: ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies
are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side.
When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
Cognitive Level: Application
Text Reference: pp. 1480, 1493
Nursing Process: Implementation NCLEX: Physiological Integrity
31. A patient who has bacterial meningitis and is disoriented and anxious has a nursing diagnosis of disturbed
sensory perception related to decreased level of consciousness. An appropriate nursing intervention is to
a. apply soft restraints to protect the patient from injury.
b. minimize contact with the patient to decrease sensory input.
c. encourage family members to remain at the bedside.
d. keep the room well-lighted to improve patient orientation.
Correct Answer: C
Rationale: Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the
bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent
assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The
patient will have photophobia, so the light should be dim.
Cognitive Level: Application
Text Reference: p. 1495
Nursing Process: Implementation NCLEX: Physiological Integrity
32. When assessing a patient with bacterial meningitis, the nurse obtains all of the following information. Which
should be reported immediately to the health care provider?
a. The patient complains of having a stiff neck.
b. The patient has a positive Kernig’s sign.
c. The patient’s blood pressure is 86/42 mm Hg.
d. The patient’s temperature is 102° F.
Correct Answer: C
Rationale: Shock is a serious complication of meningitis, and the patient’s low blood pressure indicates the need for
interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig’s sign are expected with bacterial
meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the
hypotension.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1494
NCLEX: Physiological Integrity
33. A patient admitted with bacterial meningitis and a temperature of 102° F has orders for all of these collaborative
interventions. Which one should the nurse accomplish first?
a. IV ceftizoxime (Cefizox) 1 g now and every 6 hours
b. IV dexamethasone (Decadron) 4 mg now
c. Hypothermia blanket to keep temperature less than 101.6° F
d. Nasopharyngeal swab for culture and sensitivity
Correct Answer: D
Rationale: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before
antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Administration of
dexamethasone and initiation of hypothermia therapy should be done as quickly as possible once cultures and
antibiotics are initiated.
Cognitive Level: Application
Text Reference: p. 1495
Nursing Process: Implementation NCLEX: Physiological Integrity
34. The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and
young adults. Which nursing action is most important?
a. Emphasize the importance of hand washing to prevent spread of infection.
b. Immunize adolescents and college freshman against Neisseria meningitides.
c. Vaccinate 11 and 12 year-old children against Haemophilus influenzae.
d. Encourage adolescents and young adults to avoid crowded areas in the winter.
Correct Answer: B
Rationale: The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens
entering high school, and college freshmen. Hand washing may help to decrease the spread of bacteria, but it is not
as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because
adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
Cognitive Level: Application
Text Reference: p. 1495
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
35. While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of
the following. Which one requires action by the RN?
a. The nursing assistant goes into the patient’s room without a mask.
b. The bedrails at the head and foot of the bed are both elevated.
c. The lights in the patient’s room are turned off and the blinds are shut.
d. The patient receives a regular diet from the dietary department.
Correct Answer: A
Rationale: Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory
isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated
at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is
an important aspect of care in a patient with meningitis.
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 58: Nursing Management: Stroke
MULTIPLE CHOICE
1. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a
plan to decrease stroke risk, which risk factor is most important for the nurse to address?
a. The patient smokes a pack of cigarettes daily.
b. The patient’s blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg.
c. The patient works at a desk and relaxes by watching television.
d. The patient is 25 pounds above the ideal weight.
Correct Answer: B
Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all
contribute to stroke risk but not so much as hypertension.
Cognitive Level: Application
Text Reference: p. 1503
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
2. A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all
these diagnostic tests are ordered. Which order should the nurse act on first?
a. Noncontrast computed tomography (CT) scan
b. Chest radiograph
c. Complete blood count (CBC)
d. Electrocardiogram (ECG)
Correct Answer: A
Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen
activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner
the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible
causes of the stroke and do not need to be completed as urgently as the CT scan.
Cognitive Level: Application
Text Reference: pp. 1509, 1511-1512
Nursing Process: Implementation NCLEX: Physiological Integrity
3. The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and
dysarthria with no residual effects will include
a. heparin via continuous intravenous infusion.
b. prophylactic clipping of cerebral aneurysms.
c. therapy with tissue plasminogen activator (tPA).
d. oral administration of ticlopidine (Ticlid).
Correct Answer: D
Rationale: The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit
platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used
after TIA or with acute ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is
used only for acute ischemic stroke, but not for TIA.
Cognitive Level: Application
Text Reference: p. 1505
Nursing Process: Implementation NCLEX: Physiological Integrity
4. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the
admission assessment indicates that the nurse should consult with the health care provider before giving the
aspirin?
a. The patient has atrial fibrillation.
b. The patient has dysphasia.
c. The patient states, “I suddenly developed a terrible headache.”
d. The patient has a history of brief episodes of right hemiplegia.
Correct Answer: C
Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial
fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can
administer the aspirin.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1507
NCLEX: Physiological Integrity
5. A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side.
When obtaining admission assessment data about the patient’s clinical manifestations, it is most important the
nurse assess the patient’s
a. ability to follow commands.
b. visual fields.
c. right-sided reflexes.
d. emotional state.
Correct Answer: A
Rationale: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use
of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on
patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about
reflexes and emotional state will be collected but is not as high a priority as information about language abilities.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1508
NCLEX: Physiological Integrity
6. The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has
an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will
anticipate that the patient may have
a. visual deficits.
b. dysphasia.
c. confusion.
d. poor judgment.
Correct Answer: A
Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle
cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery
occlusion.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1507
NCLEX: Physiological Integrity
7. The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When
teaching about the new medication, the nurse will tell the patient
a. that Plavix will reduce cerebral artery plaque formation.
b. to monitor and record the blood pressure daily.
c. to call the health care provider if stools are tarry.
d. that Plavix will dissolve clots in the cerebral arteries.
Correct Answer: C
Rationale: Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be
advised to notify the health care provider about any signs of bleeding. The medication does not lower blood
pressure, decrease plaque formation, or dissolve clots.
Cognitive Level: Application
Text Reference: p. 1510
Nursing Process: Implementation NCLEX: Physiological Integrity
8. The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a
history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which
response by the nurse is appropriate?
a. “The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.”
b. “The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.”
c. “A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to
flatten the plaque.”
d. “A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are
removed.”
Correct Answer: B
Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response
beginning, “The diseased portion of the artery in the brain is removed” describes an arterial graft procedure. The
answer beginning, “A catheter with a deflated balloon is positioned at the narrow area” describes an angioplasty.
The final response (beginning, “A wire is threaded through the artery”) describes the Merci procedure.
Cognitive Level: Application
Text Reference: p. 1510
Nursing Process: Implementation NCLEX: Physiological Integrity
9. On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient’s blood pressure to
be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question?
a. Infuse normal saline at 75 ml/hr.
b.
c.
d.
Keep head of bed elevated at least 30 degrees.
Administer tissue plasminogen activator (tPA) per protocol.
Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.
Correct Answer: D
Rationale: Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy
is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to
2000 ml daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless
the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for
tPA use.
Cognitive Level: Application
Text Reference: p. 1511
Nursing Process: Implementation NCLEX: Physiological Integrity
10. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with
hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient
for
a. intravenous heparin administration.
b. transluminal angioplasty.
c. surgical endarterectomy.
d. tissue plasminogen activator (tPA) infusion.
Correct Answer: D
Rationale: The patient’s history and clinical manifestations suggest an acute ischemic stroke and a patient who is
seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration
in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not
indicated for the patient who is having an acute ischemic stroke.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1512
NCLEX: Physiological Integrity
11. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive
aphasia. An appropriate nursing intervention to help the patient communicate is to
a. ask simple questions that the patient can answer with “yes” or “no.”
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice facial and tongue exercises to improve motor control necessary for speech.
d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely
manner.
Correct Answer: A
Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a “yes”
or “no” response are used. When the language areas of the brain are injured, the patient might not be able to read or
recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by
damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse
should allow time for the patient to respond.
Cognitive Level: Application
Text Reference: p. 1520
Nursing Process: Implementation NCLEX: Physiological Integrity
12. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and
decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is
a. risk for impaired skin integrity related to immobility.
b. disturbed sensory perception related to brain injury.
c.
d.
risk for aspiration related to inability to protect airway.
impaired physical mobility related to weakness.
Correct Answer: C
Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other
diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 1515
NCLEX: Physiological Integrity
13. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right
brain damage, the nurse establishes a nursing diagnosis of
a. impaired physical mobility related to right hemiplegia.
b. impaired verbal communication related to speech-language deficits.
c. risk for injury related to denial of deficits and impulsiveness.
d. ineffective coping related to depression and distress about disability.
Correct Answer: C
Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk
for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage
causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is
associated with depression and distress about the disability.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 1508
NCLEX: Physiological Integrity
14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory
perception related to hemianopsia. To help the patient learn to compensate for the deficit during the
rehabilitation period, the nurse should
a. apply an eye patch to the affected eye.
b. approach the patient on the unaffected side.
c. place objects necessary for activities of daily living on the patient’s affected side.
d. have the patient use the eye muscles to move the eyes through the entire visual field.
Correct Answer: C
Rationale: During the rehabilitation period, placing objects on the affected side will encourage the patient to use the
scanning technique to visualize the affected side. Because homonymous hemianopsia affects half the visual field in
each eye, use of an eye patch is not appropriate. Approaching the patient on the affected side is appropriate during
the acute period but does not help the patient learn skills needed to compensate for the visual defect. The problem is
with the visual field, not with the eye muscles, so practice moving the eyes through the visual field will not be
effective.
Cognitive Level: Application
Text Reference: p. 1517
Nursing Process: Implementation NCLEX: Physiological Integrity
15. A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which
information about the patient is most important to communicate to the health care provider?
a. The patient complains of an ongoing severe headache.
b. The patient’s blood pressure is 90/50 mm Hg.
c. The cerebrospinal fluid (CFS) report shows red blood cells (RBCs).
d. The patient complains about having a stiff neck.
Correct Answer: B
Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained
at a high level after a subarachnoid hemorrhage. A low or drop in BP indicates a need to administer fluids and/or
vasopressors to increase the BP An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical
manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care
provider.
Cognitive Level: Analysis
Nursing Process: Assessment
Text Reference: p. 1515
NCLEX: Physiological Integrity
16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to
inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to
a. assist the patient to eat with the left hand.
b. provide oral care before and after meals.
c. teach the patient the “chin-tuck” technique.
d. provide a wide variety of food choices.
Correct Answer: A
Rationale: Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the rightsided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for selffeeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
Cognitive Level: Application
Text Reference: p. 1522
Nursing Process: Implementation NCLEX: Physiological Integrity
17. The nurse is assisting the patient who is recovering from an acute stroke and has right-side hemiplegia to
transfer from the bed to the wheelchair. Which action by the nurse is appropriate?
a. Positioning the wheelchair next to the bed on the patient’s right side
b. Placing the wheelchair parallel to the bed on the patient’s left side
c. Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed
d. Moving the wheelchair a few steps from the bed and having the patient walk to the chair
Correct Answer: B
Rationale: Placing the wheelchair on the patient’s left side will allow the patient to use the left hand to grasp the left
arm of the chair to transfer. If the chair is placed on the patient’s right side or in front of the patient, it will be
awkward to use the strong arm, and the patient will be at increased risk for a fall. Because the patient has
hemiplegia, it is not appropriate to place the chair where the patient will need to walk to it.
Cognitive Level: Application
Text Reference: p. 1522
Nursing Process: Implementation NCLEX: Physiological Integrity
18. A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which
intervention will be included in the care plan?
a. Encouraging patient to cough and deep breath every 4 hours
b. Inserting an oropharyngeal airway to prevent airway obstruction
c. Assisting to dangle on edge of bed and assess for dizziness
d. Applying intermittent pneumatic compression stockings
Correct Answer: D
Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm
or further bleeding and is at risk for deep vein thrombosis (DVT). Activities (such as coughing and sitting up) that
might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no
indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1518
NCLEX: Physiological Integrity
19. A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex
and then
a. offer the patient a sip of juice.
b. order a varied pureed diet.
c. assess the patient’s appetite.
d. assist the patient into a chair.
Correct Answer: D
Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and
decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient.
Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the
oral feeding should be attempted regardless.
Cognitive Level: Application
Text Reference: pp. 1518-1519
Nursing Process: Implementation NCLEX: Physiological Integrity
20. A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for
feeding and other activities. The patient’s wife insists on feeding and dressing him, telling the nurse, “I just
don’t like to see him struggle.” A nursing diagnosis that is most appropriate in this situation is
a. situational low self-esteem related to increasing dependence on others.
b. interrupted family processes related to effects of illness of a family member.
c. disabled family coping related to inadequate understanding by patient’s spouse.
d. ineffective therapeutic regimen management related to hemiplegia and aphasia.
Correct Answer: C
Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand
the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting
independence. The data do not support an interruption in family processes because this may be a typical pattern for
the couple. The patient’s attempts to use the left hand indicate that he is managing the therapeutic regimen
appropriately.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 1523
NCLEX: Psychosocial Integrity
21. Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder
fullness. A bladder retraining program for the patient should include
a. limiting fluid intake to 1000 ml daily to reduce urine volume.
b. assisting the patient onto the bedside commode every 2 hours.
c. performing intermittent catheterization after each voiding to check for residual urine.
d. using an external “condom” catheter to protect the skin and prevent embarrassment.
Correct Answer: B
Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of
a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and
use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for
long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1523
NCLEX: Physiological Integrity
22. A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but
needs help with hygiene, dressing, and eating. Which statement by the patient’s wife indicates that discharge
planning goals have been met?
a. “I can provide the care my husband needs if I use the support and resources available in the
community.”
b. “Because my husband will have continuous improvement in his condition, I won’t need outside
assistance in his care for very long.”
c. “I can handle all of my husband’s needs thanks to the instructions you’ve given me.”
d. “I have arranged for a home health aide to provide all the care my husband will need.”
Correct Answer: A
Rationale: The statement that community resources will be used indicates a realistic outcome. The patient is
unlikely to continue to improve to the point of needing no assistance. The wife is likely to be overwhelmed by the
patient’s needs if she attempts to manage without assistance. There is no indication that the patient will need a home
health aide to meet all of his care needs.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 1524
NCLEX: Physiological Integrity
23. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the
nurse is administering the medications, the patient says, “I don’t need the aspirin today. I don’t have any aches
or pains.” Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Call the health care provider to clarify the medication order.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Tell the patient that the aspirin is used to prevent aches.
Correct Answer: C
Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the
patient’s refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order
with the health care provider. The aspirin is not ordered to prevent aches and pains.
Cognitive Level: Application
Text Reference: pp. 1505, 1510
Nursing Process: Implementation NCLEX: Physiological Integrity
24. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The
nurse will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop).
Correct Answer: B
Rationale: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function
and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial
fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 1505, 1510
NCLEX: Physiological Integrity
25. The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid
artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
a.
b.
c.
d.
The pulse rate is 104 beats/min.
There are fine crackles at the lung bases.
The patient has difficulty talking.
The blood pressure is 142/88 mm Hg.
Correct Answer: C
Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a
possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual as a result of
anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility
during the procedure; the nurse should have the patient take some deep breaths.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1510
NCLEX: Physiological Integrity
26. A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should
the nurse take first?
a. Obtain the Glasgow Coma Scale score.
b. Check the respiratory rate.
c. Monitor the blood pressure.
d. Send the patient for a CT scan.
Correct Answer: B
Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent
airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
Cognitive Level: Application
Text Reference: p. 1511
Nursing Process: Implementation NCLEX: Physiological Integrity
27. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral
hemorrhage. Which information about the patient is most important to communicate to the health care provider?
a. The patient has atrial fibrillation and takes warfarin (Coumadin).
b. The patient takes a diuretic because of a history of hypertension.
c. The patient’s blood pressure is 144/90 mm Hg.
d. The patient’s speech is difficult to understand.
Correct Answer: A
Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for
further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the
patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has
no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing monitoring but not for
any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is
indicated.
Cognitive Level: Application
Nursing Process: Assessment
28.
a.
b.
c.
d.
Text Reference: p. 1512
NCLEX: Physiological Integrity
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should
explain to the family that depression is normal following a stroke.
have the family members leave the patient alone for a few minutes.
teach the family that emotional outbursts are common after strokes.
use a calm voice to ask the patient to stop the crying behavior.
Correct Answer: C
Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily
related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s
outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The
crying is not within the patient’s control and asking the patient to stop will lead to embarrassment.
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 61: Nursing Management: Peripheral Nerve and Spinal Cord
Problems
MULTIPLE CHOICE
1.
a.
b.
c.
d.
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about
triggers that lead to facial pain.
visual problems caused by ptosis.
poor appetite caused by a loss of taste.
decreased sensation on the affected side.
Correct Answer: D
Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by
cutaneous stimulation of the nerve. Ptosis, loss of taste, and numbness are not characteristics of trigeminal neuralgia,
although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by
eating.
Cognitive Level: Application
Nursing Process: Assessment
2.
a.
b.
c.
d.
Text Reference: p. 1581
NCLEX: Physiological Integrity
During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should
examine the mouth and teeth thoroughly.
have the patient clench and relax the jaw and eyes.
identify trigger zones by lightly touching the affected side.
gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench
the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia.
Light touch and palpation may be triggers for pain and should be avoided.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1583
NCLEX: Physiological Integrity
3. A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the
nurse will evaluate that the patient has had a successful outcome for the surgery if the patient
a. uses an eye shield at night to protect the cornea from injury.
b. develops and implements a daily routine of facial exercises.
c. is careful to chew foods on the unaffected side of the mouth.
d. talks about enjoying social activities with family and friends.
Correct Answer: D
Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment
of social activities indicates successful reduction of symptoms. Glycerol rhizotomy does not damage the corneal
reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take
precautions with chewing.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: pp. 1583-1584
NCLEX: Physiological Integrity
4. When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal
neuralgia, an appropriate action to include is
a. teach facial and jaw relaxation techniques.
b. assess intake and output and dietary intake.
c. apply ice packs for no more than 20 minutes.
d. spend time at the bedside talking with the patient.
Correct Answer: B
Rationale: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment
of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain,
relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The
patient will not want to engage in conversation, which may precipitate attacks.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1583
NCLEX: Physiological Integrity
5. When teaching patients who are at risk for Bell’s palsy because of previous herpes simplex infection, which
information should the nurse include?
a. “You should call the doctor if pain or herpes lesions occur near the ear.”
b. “Treatment of herpes with antiviral agents will prevent development of Bell’s palsy.”
c. “Medications to treat Bell’s palsy work only if started before paralysis onset.”
d. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
Correct Answer: A
Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell’s palsy and rapid corticosteroid
treatment may reduce the duration of Bell’s palsy symptoms. Antiviral therapy for herpes simplex does not reduce
the risk for Bell’s palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before
paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell’s
palsy.
Cognitive Level: Application
Text Reference: p. 1585
Nursing Process: Implementation NCLEX: Physiological Integrity
6. A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. The
best response by the nurse to the patient’s behavior is to
a. respect the patient’s desire and arrange for privacy at mealtimes.
b. offer the patient liquid nutritional supplements at frequent intervals.
c. discuss the patient’s concerns with visitors who arrive at mealtimes.
d. teach the patient to chew food on the unaffected side of the mouth.
Correct Answer: A
Rationale: The patient’s desire for privacy should be respected to encourage adequate nutrition and reduce patient
embarrassment. Liquid supplements will reduce the patient’s enjoyment of the taste of food. It would be
inappropriate for the nurse to discuss the patient’s embarrassment with visitors unless the patient wishes to share this
information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not
decrease the drooling.
Cognitive Level: Application
Text Reference: p. 1585
Nursing Process: Implementation NCLEX: Psychosocial Integrity
7. A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient,
the nurse explains that Guillain-Barré syndrome
a. results from an acute infection and inflammation of the peripheral nerves.
b. is due to an immune reaction that attacks the covering of the peripheral nerves.
c. is caused by destruction of the peripheral nerves after exposure to a viral infection.
d. results from degeneration of the peripheral nerve caused by viral attacks.
Correct Answer: B
Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin
sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves
are not destroyed and do not degenerate.
Cognitive Level: Comprehension Text Reference: pp. 1585-1586
Nursing Process: Implementation NCLEX: Physiological Integrity
8. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the
patient’s illness, the most essential assessment for the nurse to carry out is
a. monitoring the cardiac rhythm continuously.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities.
d. performing constant evaluation of respiratory function.
Correct Answer: D
Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should
monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are
not as important as respiratory assessment.
Cognitive Level: Comprehension Text Reference: p. 1586
Nursing Process: Assessment
NCLEX: Physiological Integrity
9. When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will
require the most immediate action?
a. The patient complains of severe tingling pain in the feet.
b. The patient has continuous drooling of saliva.
c. The patient’s blood pressure (BP) is 106/50 mm Hg.
d. The patient’s quadriceps and triceps reflexes are absent.
Correct Answer: B
Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and
requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot
pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not
as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is
a common finding in Guillain-Barré syndrome.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 1586-1587
NCLEX: Physiological Integrity
10. A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse
will anticipate that collaborative interventions at this time will include
a. intubation and mechanical ventilation.
b. insertion of a nasogastric (NG) feeding tube.
c.
d.
administration of methylprednisolone (Solu-Medrol).
IV infusion of immunoglobulin (Sandoglobulin).
Correct Answer: D
Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of
high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and
tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not
helpful in reducing the duration or symptoms of the syndrome.
Cognitive Level: Application
Text Reference: p. 1586
Nursing Process: Implementation NCLEX: Physiological Integrity
11. A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum
antitoxin is received. Before administering the antitoxin, it is most important for the nurse to
a. obtain baseline vital signs.
b. administer an intradermal test dose.
c. ask the patient about a history of allergies.
d. document the presence of neurologic symptoms.
Correct Answer: B
Rationale: To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although
baseline vital signs, allergy history, and symptom assessment and documentation are appropriate, these assessments
will not impact on the decision to administer the antitoxin.
Cognitive Level: Application
Text Reference: pp. 1587-1588
Nursing Process: Implementation NCLEX: Physiological Integrity
12. A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was
embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. The nurse
will anticipate
a. IV infusion of tetanus immune globulin (TIG).
b. initiation of the tetanus-diphtheria immunization series.
c. intradermal injection of an immune globulin test dose.
d. administration of the tetanus-diphtheria (Td) toxoid booster.
Correct Answer: D
Rationale: If the patient has not been immunized within 5 years, administration of the Td booster is indicated
because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous
immunization. Administration of a series of immunization is not indicated. A test dose is not needed for immune
globulin, and TIG is not indicated for the patient.
Cognitive Level: Application
Text Reference: p. 1589
Nursing Process: Implementation NCLEX: Physiological Integrity
13. A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial
treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of
spinal shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. the presence of hyperactive reflex activity below the level of the injury.
d. flaccid paralysis and lack of sensation below the level of the injury.
Correct Answer: D
Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid
paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic
shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord
injury.
Cognitive Level: Comprehension Text Reference: p. 1590
Nursing Process: Assessment
NCLEX: Physiological Integrity
14. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar
crackles, and decreased breath sounds, the initial intervention by the nurse should be to
a. administer oxygen at 7 to 9 L/min with a face mask.
b. place the hands on the epigastric area and push upward when the patient coughs.
c. encourage the patient to use an incentive spirometer every 2 hours during the day.
d. suction the patient’s oral and pharyngeal airway.
Correct Answer: B
Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted
coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve
oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use
of the spirometer may improve respiratory status, but the patient’s ability to take deep breaths is limited by the loss
of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but
should not be the nurse’s first action.
Cognitive Level: Application
Text Reference: p. 1602
Nursing Process: Implementation NCLEX: Physiological Integrity
15. As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting
in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
a. Assessment of the patient for left leg pain
b. Assessment of the patient for left arm weakness
c. Positioning the patient’s right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position
Correct Answer: C
Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will
require the nurse to move the right leg. Pain sensation will be lost on the patient’s left leg. Left arm weakness will
not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
Cognitive Level: Application
Text Reference: pp. 1591-1592
Nursing Process: Implementation NCLEX: Physiological Integrity
16. A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the
patient and family that
a. use of the shoulders will be preserved.
b. full function of the patient’s arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of injury.
Correct Answer: B
Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only
the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above
the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
Cognitive Level: Application
Text Reference: p. 1594
Nursing Process: Implementation NCLEX: Physiological Integrity
17. The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to
a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness
of the medication the nurse will assess
a. blood pressure and heart rate.
b. respiratory effort and O2 saturation.
c. motor and sensory function of the legs.
d. bowel sounds and abdominal distension.
Correct Answer: C
Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the
nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with
injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the
medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will
not provide information about whether the medication is effective.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 1596
NCLEX: Physiological Integrity
18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the
nurse develops a plan of care for this problem, which nursing action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding
Correct Answer: A
Rationale: Because the patient’s bladder is spastic and will empty in response to overstretching of the bladder wall,
the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through
intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty.
The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic
bladder. Catheterization after voiding will not resolve the patient’s incontinence.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1605
NCLEX: Physiological Integrity
19. A patient with a history of a T2 spinal cord tells the nurse, “I feel awful today. My head is throbbing, and I feel
sick to my stomach.” Which action should the nurse take first?
a. Notify the patient’s health care provider.
b. Check the blood pressure (BP).
c. Give the ordered antiemetic.
d. Assess for a fecal impaction.
Correct Answer: B
Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who
complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including
hypertension. Notification of the patient’s health care provider is appropriate after the BP is obtained.
Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The
nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be
used to prevent further increases in the BP.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1603
NCLEX: Physiological Integrity
20. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient
outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently when in bed.
d. pushes a manual wheelchair on flat, smooth surfaces.
Correct Answer: D
Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces.
Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during
transfer, drive a car with powered hand controls, or turn independently in bed.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 1594
NCLEX: Physiological Integrity
21. A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally
abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where “they
know what they are doing.” The best response by the nurse to the patient’s behavior is to
a. ask for the patient’s input into the plan for care.
b. clarify that abusive behavior will not be tolerated.
c. reassure the patient that the anger will pass and rehabilitation will then progress.
d. ignore the patient’s anger and continue to perform needed assessments and care.
Correct Answer: A
Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the
nurse should allow expression of anger and seek the patient’s input into care. Expression of anger is appropriate at
this stage and should be tolerated by the nurse. Refusal to acknowledge the patient’s anger by telling the patient that
the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the
nurse should seek the patient’s input into what care is needed.
Cognitive Level: Application
Text Reference: p. 1608
Nursing Process: Implementation NCLEX: Psychosocial Integrity
22. A 26-year-old patient with a C8 spinal cord injury tells the nurse, “My wife and I have always had a very active
sex life, and I am worried that she may leave me if I cannot function sexually.” The most appropriate response
by the nurse to the patient’s comment is to
a. advise the patient to talk to his wife to determine how she feels about his sexual function.
b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal
cord injury.
c. inform the patient that most patients with upper motor neuron injuries have reflex erections.
d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
Correct Answer: D
Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be
handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his
wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does
assist with erectile dysfunction after spinal cord injury, but the patient’s sexuality is not determined solely by the
ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are
uncontrolled and cannot be maintained during coitus.
Cognitive Level: Application
Text Reference: p. 1608
Nursing Process: Implementation NCLEX: Psychosocial Integrity
23. A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The
home care nurse visits and notices that the patient’s spouse and parents are performing many of the activities of
daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by
the nurse at this time is to
a. tell the family members that the patient can perform ADLs independently.
b. remind the patient about the importance of independence in daily activities.
c. recognize that it is important for the patient’s family to be involved in the patient’s care and support
their activities.
d. develop a plan to increase the patient’s independence in consultation with the with the patient,
spouse, and parents.
Correct Answer: D
Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care.
Because family members who will be assisting with the patient’s ongoing care need to feel that their input is
important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the
patient about the importance of independence may not change the behaviors of the family members. Supporting the
activities of the spouse and parents will lead to ongoing dependency by the patient.
Cognitive Level: Application
Text Reference: p. 1609
Nursing Process: Implementation NCLEX: Psychosocial Integrity
24. The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of
these data obtained when assessing the patient requires most immediate action by the nurse?
a. The patient has new onset weakness of both legs.
b. The patient complains of chronic level 6 pain on a 10-point scale.
c. The patient starts to cry and says, “I feel hopeless.”
d. The patient expresses anxiety about having surgery.
Correct Answer: A
Rationale: The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to
avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not
require intervention as rapidly as the new onset weakness.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1610
NCLEX: Physiological Integrity
25. Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to
delegate to an experienced nursing assistant?
a. Nasogastric tube feeding q4hr
b. Artificial tear administration q2hr
c. Assessment for bladder distension q2hr
d. Passive range of motion to extremities q8hr
Correct Answer: D
Rationale: Assisting a patient with movement is included in nursing assistant education and scope of practice.
Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more
education and scope of practice, and the RN should perform these skills.
Cognitive Level: Application
Text Reference: pp. 1586-1587
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
26. A patient with possible botulism poisoning is admitted for observation and administration of botulinum
antitoxin. Which of the following health care provider orders should the nurse question?
a. Maintain NPO status.
b. Obtain lumbar puncture tray.
c. Give magnesium citrate 8 oz now.
d. Administer 1500-ml tapwater enema.
Correct Answer: C
Rationale: Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are
appropriate for the patient.
Cognitive Level: Application
Text Reference: p. 1588
Nursing Process: Implementation NCLEX: Physiological Integrity
27. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing
action has the highest priority?
a. Continuous cardiac monitoring for bradycardia
b. Administration of methylprednisolone (Solu-Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression devices to both legs
Correct Answer: C
Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is
assessment of the patient’s respiratory function. The other actions are also appropriate but are not as important as
assessment of respiratory effort.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 1602
NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and
nursing actions will the nurse include in the plan of care? (Select all that apply.)
a. Endotracheal suctioning
b. Continuous cardiac monitoring
c. Avoidance of cool room temperature
d. Nasogastric tube feeding
e. Retention catheter care
f. Administration of H2 receptor blockers
Correct Answer: B, C, E, F
Rationale: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system
dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room
temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder
distension, a retention catheter is used during this acute phase. Stress ulcers are a common complication but can be
avoided through the use of the H2 receptor blockers such as famotidine.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 1594-1595, 1597, 1603
NCLEX: Physiological Integrity
OTHER
1. In which order will the nurse perform the following actions when caring for a patient with possible cervical
spinal cord trauma who is admitted to the emergency department?
a. Administer O2 using a non-rebreathing mask.
b. Monitor cardiac rhythm and blood pressure.
c. Immobilize the patient’s head, neck, and spine.
d. Transfer the patient to radiology for spinal CT.
Correct Answer: C, A, B, D
Rationale: The first action should be to prevent further injury by stabilizing the patient’s spinal cord. Maintenance
of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible
complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level
of injury is needed once initial assessment and stabilization is accomplished.
Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 57: Nursing Management: Acute Intracranial Problems
Test Bank
MULTIPLE CHOICE
1. When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial
pressure monitoring for a patient, which response by the nurse is best?
a. “This type of monitoring system is complex and highly skilled staff are needed.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of cerebrospinal fluid
drainage.”
ANS: B
Short and simple explanations should be given to patients and family members. The other explanations are either too
complicated to be easily understood or may increase the family member’s anxiety.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1438
MSC: NCLEX: Psychosocial Integrity
2. A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26.
Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad
and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless
immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but
they are not indicative of an immediately life-threatening process.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1429-1430
MSC: NCLEX: Physiological Integrity
3. When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with
internal rotation, adduction, and flexion of the arms. The nurse documents this as
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.
ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate
posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not
indicate localization of pain or flexion withdrawal.
DIF:
TOP:
Cognitive Level: Comprehension
Nursing Process: Assessment
REF: 1429-1430
MSC: NCLEX: Physiological Integrity
4. Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has
been effective for an unconscious patient?
a. Hematocrit
b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure
ANS: D
Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce
hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of
the drug. Oxygen saturation will not directly improve as a result of mannitol administration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1432-1433
TOP:
Nursing Process: Evaluation
5. A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a
verbal command to move but attempts to remove a painful stimulus. The nurse records the patient’s Glasgow Coma
Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1434
MSC: NCLEX: Physiological Integrity
6. Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The
patient’s spouse and children stay at the patient’s side and constantly ask about the treatment being given. What
action is best for the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the patient and briefly explain all procedures to them.
c. Call the family’s pastor or spiritual advisor to support them while initial care is given.
d. Refer the family members to the hospital counseling service to deal with their anxiety.
ANS: B
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the
nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer
some support, but research supports information as being more effective. Asking the family to stay in the waiting
room will increase their anxiety.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1438
MSC: NCLEX: Psychosocial Integrity
7. An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue
swelling. Which nursing intervention will be included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANS: A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce
ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation
associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP.
Coughing increases intrathoracic pressure and ICP.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1436-1437
MSC: NCLEX: Physiological Integrity
8. After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take?
a. Have the patient blow the nose.
b. Check the nasal drainage for glucose.
c. Assure the patient that rhinorrhea is normal after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.
ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If
the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so
culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1438-1439
MSC: NCLEX: Physiological Integrity
9. A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?
a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.
ANS: B
A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need
to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a
concussion.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1440
TOP:
Nursing Process: Planning
10. A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action
will the nurse plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANS: D
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If
intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but
these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and
transfusion is usually not necessary.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1440-1441
TOP:
Nursing Process: Planning
11. While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient’s nose. Which
of these admission orders should the nurse question?
a. Insert nasogastric tube.
b. Turn patient every 2 hours.
c. Keep the head of bed elevated.
d. Apply cold packs for facial bruising.
ANS: A
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will
increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack
are appropriate orders.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1440
MSC: NCLEX: Physiological Integrity
12. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion
syndrome?
a. Muscle resistance
b. Short-term memory
c. Glasgow coma scale
d. Pupil reaction to light
ANS: B
Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are
not indications of postconcussion syndrome.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1440
MSC: NCLEX: Physiological Integrity
13. When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find
a. judgment changes.
b. expressive aphasia.
c. right-sided weakness.
d. difficulty swallowing.
ANS: A
The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness
and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1447 | 1448
MSC: NCLEX: Physiological Integrity
14. Which statement by a patient who is being discharged from the emergency department (ED) after a head injury
indicates a need for intervention by the nurse?
a. “I will return if I feel dizzy or nauseated.”
b. “I am going to drive home and go to bed.”
c. “I do not even remember being in an accident.”
d. “I can take acetaminophen (Tylenol) for my headache.”
ANS: B
Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a
concussion. The patient can take acetaminophen for headache and should return if symptoms of increased
intracranial pressure such as dizziness or nausea occur.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1444
MSC: NCLEX: Physiological Integrity
15. After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical
mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to
a. position the bed flat and log roll the patient.
b. cluster nursing activities to allow longer rest periods.
c. turn and reposition the patient side to side every 2 hours.
d. perform range-of-motion (ROM) exercises every 4 hours.
ANS: D
ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are
positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When
the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1450-1451
MSC: NCLEX: Physiological Integrity
16. A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan
of care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well-lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input.
ANS: A
Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside.
Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment
for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will
have photophobia, so the light should be dim.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1453-1455
TOP:
Nursing Process: Planning
17. The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and
young adults. Which nursing action is most important?
a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
b. Emphasize the importance of hand washing to prevent spread of infection.
c. Immunize adolescents and college freshman against Neisseria meningitides.
d. Encourage adolescents and young adults to avoid crowded areas in the winter.
ANS: C
The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering
high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective
as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and
young adults are in school or the workplace, avoiding crowds is not realistic.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1453-1455
MSC: NCLEX: Health Promotion and Maintenance
18. While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the
following. Which one requires action by the RN?
a. The bedrails at the head and foot of the bed are both elevated.
b. The patient receives a regular diet from the dietary department.
c. The nursing assistant goes into the patient’s room without a mask.
d. The lights in the patient’s room are turned off and the blinds are shut.
ANS: C
Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as
well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the
food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an
important aspect of care in a patient with meningitis.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1453-1455
MSC: NCLEX: Safe and Effective Care Environment
19. When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be
reported immediately to the health care provider?
a. The patient has a positive Kernig’s sign.
b. The patient complains of having a stiff neck.
c. The patient’s temperature is 101° F (38.3° C).
d. The patient’s blood pressure is 86/42 mm Hg.
ANS: D
Shock is a serious complication of meningitis, and the patient’s low blood pressure indicates the need for
interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig’s sign are expected with bacterial
meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the
hypotension.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1452-1453
Nursing Process: Assessment
20. A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should
the nurse take first?
a. Elevate the head of the patient’s bed to 60 degrees.
b. Document the BP and ICP in the patient’s record.
c.
d.
Report the BP and ICP to the health care provider.
Continue to monitor the patient’s vital signs and ICP.
ANS: C
The patient’s cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the
level of ischemia and neuronal death. Immediate changes in the patient’s therapy such as fluid infusion or
vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation
should only be done after consulting with the health care provider. Continued monitoring and documentation also
will be done, but they are not the first actions that the nurse should take.
DIF: Cognitive Level: Analysis
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1426
Nursing Process: Implementation
21. After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has
increased from 14 to 16 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Assure that the patient’s neck is not in a flexed position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprovan) infusion.
ANS: B
Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other
factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is
needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction
to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has
contributed to the increase in intracranial pressure.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1426 | 1435-1437 | 1436-1437
Nursing Process: Implementation
22. Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who
has floated from the medical unit?
a. A 44-year-old receiving IV antibiotics for meningococcal meningitis
b. A 23-year-old who had a skull fracture and craniotomy the previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week
ago
d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy
ANS: A
An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The
postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN
familiar with the care of critically ill patients.
DIF: Cognitive Level: Application
REF: 1435-1438
OBJ: Special Questions: Multiple Patients
MSC: NCLEX: Safe and Effective Care Environment
TOP:
Nursing Process: Planning
23. A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level
of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse
implement first?
a. Draw blood for arterial blood gases (ABGs).
b.
c.
d.
Administer 5% hypertonic saline intravenously.
Administer acetaminophen (Tylenol) 650 mg orally.
Send patient for computed tomography (CT) of the head.
ANS: B
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse’s first
action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the
headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and
obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is
addressed quickly.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1452-1455
Nursing Process: Implementation
24. After the emergency department nurse has received a status report on the following patients who have been admitted
with head injuries, which patient should the nurse assess first?
a. A patient whose cranial x-ray shows a linear skull fracture
b. A patient who has an initial Glasgow Coma Scale score of 13
c. A patient who lost consciousness for a few seconds after a fall
d. A patient whose right pupil is 10 mm and unresponsive to light
ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure.
The other patients are not at immediate risk for complications such as herniation.
DIF: Cognitive Level: Analysis
REF: 1432-1433 | 1437-1438
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
25. Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most
important to report to the health care provider?
a. Bruising under both eyes
b. Complaint of severe headache
c. Large ecchymosis behind one ear
d. Temperature of 101.5° F (38.6° C)
ANS: D
Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to
the health care provider. The other findings are typical of a patient with a basilar skull fracture.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1440
Nursing Process: Assessment
26. When a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information
obtained by the nurse is most important to communicate to the health care provider?
a. Oral temperature 101.6° F
b. Apical pulse 102 beats/min
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg
ANS: A
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature
indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all
borderline high but require only ongoing monitoring at this time.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1438-1440
Nursing Process: Assessment
27. The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a
brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
a. The staff nurse suctions the patient every 2 hours.
b. The staff nurse assesses neurologic status every hour.
c. The staff nurse elevates the head of the bed to 30 degrees.
d. The staff nurse administers a mild analgesic before turning the patient.
ANS: A
Suctioning increases intracranial pressure and is done only when the patient’s respiratory condition indicates it is
needed. The other actions by the staff nurse are appropriate.
DIF: Cognitive Level: Application
REF: 1430-1431
OBJ: Special Questions: Delegation
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
28. A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the
bathroom floor by the spouse. Which action will the nurse take first?
a. Obtain oxygen saturation.
b. Check pupil reaction to light.
c. Palpate the head for hematoma.
d. Assess Glasgow Coma Scale (GCS).
ANS: A
Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments
should be accomplished next and the health and medication history last.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1435-1437
Nursing Process: Assessment
29. The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following
nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the
intensive care unit?
a. Monitor cerebrospinal fluid color hourly.
b. Document intracranial pressure every hour.
c. Turn and reposition the patient every 2 hours.
d. Check capillary blood glucose level every 6 hours.
ANS: D
Experienced NAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill.
Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level
education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a
patient with a ventriculostomy is complex and should be done by the RN.
DIF: Cognitive Level: Application
REF: 1442
OBJ: Special Questions: Delegation
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
30. Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action
by the nurse?
a. Intracranial pressure of 15 mm Hg
b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min
ANS: C
The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15
mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus
tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1430-1432
Nursing Process: Assessment
31. When caring for a patient who has had a head injury, which assessment information requires the most rapid action
by the nurse?
a. The patient is more difficult to arouse.
b. The patient’s pulse is slightly irregular.
c. The patient’s blood pressure increases from 120/54 to 136/62 mm Hg.
d. The patient complains of a headache at pain level 5 of a 10-point scale.
ANS: A
The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that
action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator
of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular
apical pulse is not unusual.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1431-1433
Nursing Process: Assessment
32. The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported
rapidly to the health care provider?
a. Urine output of 800 mL in the last hour
b. Intracranial pressure of 16 mm Hg when patient is turned
c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour
d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg
ANS: A
The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration
need to be rapidly implemented. The other data do not indicate a need for any change in therapy.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1434-1435
Nursing Process: Assessment
33. When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department,
the nurse obtains the following information. Which finding is most important to report to the health care provider?
a. The patient takes warfarin (Coumadin) daily.
b. The patient’s blood pressure is 162/94 mm Hg.
c. The patient is unable to remember the accident.
d. The patient complains of a severe dull headache.
ANS: A
The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The
other information would not be unusual in a patient with a head injury who had just arrived to the ED.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1437-1438
Nursing Process: Assessment
34. A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these
collaborative interventions. Which action should the nurse take first?
a. Administer ceftizoxime (Cefizox) 1 g IV.
b. Use a cooling blanket to lower temperature.
c. Swap the nasopharyngeal mucosa for cultures.
d. Give acetaminophen (Tylenol) 650 mg PO.
ANS: C
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics
are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and
acetaminophen administration are appropriate but can be started after the other actions are implemented.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1440-1441
Nursing Process: Implementation
COMPLETION
1. An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial
pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.
ANS:
72 mm Hg
The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure  2)/3] =
intracranial pressure.
Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 58: Nursing Management: Stroke
Test Bank
MULTIPLE CHOICE
1. The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and
dysarthria with no residual effects will include
a. prophylactic clipping of cerebral aneurysms.
b. heparin via continuous intravenous infusion.
c. oral administration of low dose aspirin therapy.
d.
therapy with tissue plasminogen activator (tPA).
ANS: C
The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet
aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA
or with acute ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is used only
for acute ischemic stroke, not for TIA.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1468-1469
TOP:
Nursing Process: Planning
2. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the
admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient states, “My symptoms started with a terrible headache.”
d. The patient has a history of brief episodes of right-sided hemiplegia.
ANS: C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation,
dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer
the aspirin.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1466
MSC: NCLEX: Physiological Integrity
3. A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When
admitting the patient, which clinical manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided reflexes
d. Difficulty in understanding commands
ANS: D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of
language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a rightside stroke.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1466-1468
MSC: NCLEX: Physiological Integrity
4. The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will
anticipate that the patient may have
a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment.
ANS: C
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral
artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery
occlusion.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1466
MSC: NCLEX: Physiological Integrity
5. The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching
about the new medication, the nurse will tell the patient
a. to monitor and record the blood pressure daily.
b. to call the health care provider if stools are tarry.
c. that Plavix will dissolve clots in the cerebral arteries.
d. that Plavix will reduce cerebral artery plaque formation.
ANS: B
Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to
notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease
plaque formation, or dissolve clots.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1468-1469
MSC: NCLEX: Physiological Integrity
6. The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a
history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by
the nurse is appropriate?
a. “The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.”
b. “The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.”
c. “A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are
removed.”
d. “A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to
flatten the plaque.”
ANS: A
In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, “The
diseased portion of the artery in the brain is removed” describes an arterial graft procedure. The answer beginning,
“A catheter with a deflated balloon is positioned at the narrow area” describes an angioplasty. The final response
beginning, “A wire is threaded through the artery” describes the MERCI procedure.
DIF:
TOP:
Cognitive Level: Comprehension
Nursing Process: Implementation
REF: 1469-1471
MSC: NCLEX: Physiological Integrity
7. When assessing a patient with a possible stroke, the nurse finds that the patient’s aphasia started 3.5 hours
previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the
nurse question?
a. Infuse normal saline at 75 mL/hr.
b. Keep head of bed elevated at least 30 degrees.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.
ANS: D
Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is
recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid
intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to
at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient
meets the other criteria for tPA use.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1469-1471
MSC: NCLEX: Physiological Integrity
8. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with
hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.
+
ANS: D
The patient’s history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within
4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the
emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for
the patient who is having an acute ischemic stroke.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1471-1472
TOP:
Nursing Process: Planning
9. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia.
An appropriate nursing intervention to help the patient communicate is to
a. have the patient practice facial and tongue exercises.
b. ask simple questions that the patient can answer with “yes” or “no.”
c. develop a list of words that the patient can read and practice reciting.
d. prevent embarrassing the patient by changing the subject if the patient does not respond.
ANS: B
Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no”
response are used. When the language areas of the brain are injured, the patient might not be able to read or recite
words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage
to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow
time for the patient to respond.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1470 | 1480
MSC: NCLEX: Physiological Integrity
10. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain
damage, the nurse establishes a nursing diagnosis of
a. impaired physical mobility related to right hemiplegia.
b. risk for injury related to denial of deficits and impulsiveness.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability.
ANS: B
Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury
when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left
hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with
depression and distress about the disability.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1482-1484
TOP:
Nursing Process: Diagnosis
11. When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention
should the nurse include in the plan of care during the acute period of the stroke?
a. Apply an eye patch to the left eye.
b. Approach the patient from the left side.
c. Place objects needed for activities of daily living on the patient’s right side.
d. Reassure the patient that the visual deficit will resolve as the stroke progresses.
ANS: C
During the acute period, the nurse should place objects on the patient’s unaffected side. Since there is a visual defect
in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side.
The visual deficit may not resolve, although the patient can learn to compensate for the defect.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1470-1471
TOP:
Nursing Process: Planning
12. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired
self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of
care?
a. Provide a wide variety of food choices.
b. Provide oral care before and after meals.
c. Assist the patient to eat with the left hand.
d. Teach the patient the “chin-tuck” technique.
ANS: C
Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the right-sided
hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The
other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1482-1483
TOP:
Nursing Process: Planning
13. A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which
intervention will be included in the care plan?
a. Applying intermittent pneumatic compression stockings
b. Assisting to dangle on edge of bed and assess for dizziness
c. Encouraging patient to cough and deep breathe every 4 hours
d. Inserting an oropharyngeal airway to prevent airway obstruction
ANS: A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further
bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might
increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that
the patient is unconscious, an oropharyngeal airway is inappropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1477-1479
TOP:
Nursing Process: Planning
14. A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and
then
a. order a varied pureed diet.
b. assess the patient’s appetite.
c. assist the patient into a chair.
d. offer the patient a sip of juice.
ANS: C
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease
aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets
are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding
should be attempted regardless.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1470
MSC: NCLEX: Physiological Integrity
15. A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other
activities. The patient’s wife insists on feeding and dressing him, telling the nurse, “I just don’t like to see him
struggle.” Which nursing diagnosis is most appropriate for the patient?
a. Situational low self-esteem related to increasing dependence on others
b. Interrupted family processes related to effects of illness of a family member
c. Disabled family coping related to inadequate understanding by patient’s spouse
d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
ANS: C
The information supports the diagnosis of disabled family coping because the wife does not understand the
rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence.
The data do not support an interruption in family processes because this may be a typical pattern for the couple.
There is no indication that the patient has impaired nutrition.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Diagnosis
REF: 1480-1482 | 1483-1484
MSC: NCLEX: Psychosocial Integrity
16. Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder
fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of
care?
a. Limit fluid intake to 1200 mL daily to reduce urine volume.
b. Assist the patient onto the bedside commode every 2 hours.
c. Perform intermittent catheterization after each voiding to check for residual urine.
d. Use an external “condom” catheter to protect the skin and prevent embarrassment.
ANS: B
Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full
bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom
catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term
management because of the risks for urinary tract infection (UTI) and skin breakdown.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1482-1483
TOP:
Nursing Process: Planning
17. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the
nurse is administering the medications, the patient says, “I don’t need the aspirin today. I don’t have any aches or
pains.” Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Tell the patient that the aspirin is used to prevent aches.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order.
ANS: C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient’s refusal
to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health
care provider. The aspirin is not ordered to prevent aches and pains.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1468-1469
MSC: NCLEX: Physiological Integrity
18. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse
will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop).
ANS: B
Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and
decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial
fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1468-1469
TOP:
Nursing Process: Planning
19. A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should
a. use a calm voice to ask the patient to stop the crying behavior.
b. explain to the family that depression is normal following a stroke.
c. have the family members leave the patient alone for a few minutes.
d. teach the family that emotional outbursts are common after strokes.
ANS: D
Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the
emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s outburst
suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying
is not within the patient’s control and asking the patient to stop will lead to embarrassment.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1483-1484
MSC: NCLEX: Psychosocial Integrity
20. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan
to decrease stroke risk, which risk factor is most important for the nurse to address?
a. The patient has a daily glass of wine to relax.
b. The patient is 25 pounds above the ideal weight.
c. The patient works at a desk and relaxes by watching television.
d. The patient’s blood pressure (BP) is usually about 180/90 mm Hg.
ANS: D
Hypertension is the single most important modifiable risk factor and this patient’s hypertension is at the stage 2
level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for
hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
DIF: Cognitive Level: Application
REF:
OBJ: Special Questions: Prioritization
TOP:
MSC: NCLEX: Health Promotion and Maintenance
1463-1466
Nursing Process: Assessment
21. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage.
Which information about the patient is most important to communicate to the health care provider?
a. The patient’s speech is difficult to understand.
b. The patient’s blood pressure is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of hypertension.
d. The patient has atrial fibrillation and takes warfarin (Coumadin).
ANS: D
The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding.
Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have
surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate
effect on the patient’s care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate
change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1465-1466
Nursing Process: Assessment
22. A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all
these diagnostic tests are ordered. Which test should be done first?
a. Electrocardiogram (ECG)
b. Complete blood count (CBC)
c. Chest radiograph (Chest x-ray)
d. Noncontrast computed tomography (CT) scan
ANS: D
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA),
which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is
given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the
stroke and do not need to be completed as urgently as the CT scan.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1469 | 1471
Nursing Process: Implementation
23. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased
level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient?
a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
ANS: D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also
are appropriate, but interventions to prevent aspiration are the priority at this time.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1477-1479
Nursing Process: Diagnosis
24. A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information
about the patient is most important to communicate to the health care provider?
a.
b.
c.
d.
The patient’s blood pressure is 90/50 mm Hg.
The patient complains about having a stiff neck.
The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
The patient complains of an ongoing severe headache.
ANS: A
To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level
higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to
administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck
are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to
the health care provider.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1472-1473
Nursing Process: Assessment
25. Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60
minutes can the nurse delegate to an LPN/LVN?
a. Assess the patient’s gag and cough reflexes.
b. Determine when the stroke symptoms began.
c. Administer the prescribed clopidogrel (Plavix).
d. Infuse the prescribed IV metoprolol (Lopressor).
ANS: C
Administration of oral medications is included in LPN education and scope of practice. The other actions require
more education and scope of practice and should be done by the RN.
DIF: Cognitive Level: Application
REF: 1473
OBJ: Special Questions: Delegation
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
26. After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
a. A patient with right-sided weakness who has an infusion of tPA prescribed
b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin)
c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
ANS: A
tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing
brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not
as critical.
DIF:
OBJ:
TOP:
Cognitive Level: Application
Special Questions: Multiple Patients
Nursing Process: Implementation
REF:
1471
MSC: NCLEX: Safe and Effective Care Environment
27. The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery
angioplasty and stenting. Which assessment information is of most concern to the nurse?
a. The pulse rate is 104 beats/min.
b. The patient has difficulty talking.
c. The blood pressure is 142/88 mm Hg.
d. There are fine crackles at the lung bases.
ANS: B
Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke
during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated
with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the
procedure; the nurse should have the patient take some deep breaths.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1469-1471
Nursing Process: Assessment
28. A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the
nurse take first?
a. Check the respiratory rate.
b. Monitor the blood pressure.
c. Send the patient for a CT scan.
d. Obtain the Glasgow Coma Scale score.
ANS: A
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The
other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1469-1471
Nursing Process: Implementation
COMPLETION
1. A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency
department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and
space between each answer choice (a, b, c, d, etc.) ____________________
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
ANS:
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments
should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems
Test Bank
MULTIPLE CHOICE
1. When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about
a. triggers that lead to facial pain.
b. visual problems caused by ptosis.
c. poor appetite caused by a loss of taste.
d. weakness on the affected side of the face.
ANS: A
The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous
stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1541-1543
MSC: NCLEX: Physiological Integrity
2. Which action should the nurse take when assessing a patient with trigeminal neuralgia?
a. Examine the mouth and teeth thoroughly.
b. Have the patient clench and relax the jaw and eyes.
c. Identify trigger zones by lightly touching the affected side.
d. Gently palpate the face to compare skin temperature bilaterally.
ANS: A
Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial
muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light
touch and palpation may be triggers for pain and should be avoided.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1542-1543
MSC: NCLEX: Physiological Integrity
3. When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will
a. ask whether the patient is using an eye shield at night.
b. determine whether the patient is doing daily facial exercises.
c. question the patient about social activities with family and friends.
d. remind the patient to chew food on the unaffected side of the mouth.
ANS: C
Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social
activities will help in evaluating whether the patient’s symptoms have improved. Glycerol rhizotomy does not
damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do
facial exercises, or take precautions with chewing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1542
TOP:
Nursing Process: Evaluation
4. Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal
neuralgia?
a. Teach facial and jaw relaxation techniques.
b. Assess intake and output and dietary intake.
c. Apply ice packs for no more than 20 minutes.
d. Spend time at the bedside talking with the patient.
ANS: B
The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of
nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain,
relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The
patient will not want to engage in conversation, which may precipitate attacks.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1542-1543
TOP:
Nursing Process: Planning
5. When teaching patients who are at risk for Bell’s palsy because of previous herpes simplex infection, which
information should the nurse include?
a. “Call the doctor if pain or herpes lesions occur near the ear.”
b. “Treatment of herpes with antiviral agents prevents Bell’s palsy.”
c. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
d. “Medications to treat Bell’s palsy work only if started before paralysis onset.”
ANS: A
Pain or herpes lesions near the ear may indicate the onset of Bell’s palsy and rapid corticosteroid treatment may
reduce the duration of Bell’s palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for
Bell’s palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is
complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell’s palsy.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1543-1544
MSC: NCLEX: Physiological Integrity
6. A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. The
best response by the nurse to the patient’s behavior is to
a. respect the patient’s desire 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 patient’s concerns with visitors who arrive at mealtimes.
ANS: A
The patient’s desire for privacy should be respected to encourage adequate nutrition and reduce patient
embarrassment. Liquid supplements will reduce the patient’s enjoyment of the taste of food. It would be
inappropriate for the nurse to discuss the patient’s embarrassment with visitors unless the patient wishes to share this
information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not
decrease the drooling.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1543-1545
MSC: NCLEX: Psychosocial Integrity
7. Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to
prevent autonomic dysreflexia?
a. Assist with selection of a high protein diet.
b. Use quad coughing to assist cough effort.
c. Discuss options for sexuality and fertility.
d. Teach the purpose of a prescribed bowel program.
ANS: D
Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of
care but will not reduce the risk for autonomic dysreflexia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1560-1561
TOP:
Nursing Process: Planning
8. When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will
require the most immediate action?
a. The patient has continuous drooling of saliva.
b. The patient’s blood pressure (BP) is 106/50 mm Hg.
c. The patient’s quadriceps and triceps reflexes are absent.
d. The patient complains of severe tingling pain in the feet.
ANS: A
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid
nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be
treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently
needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common
finding in Guillain-Barré syndrome.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Assessment
REF: 1545-1546
MSC: NCLEX: Physiological Integrity
9. A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will
anticipate the need to teach the patient about
a. intubation and mechanical ventilation.
b. administration of IV corticosteroid drugs.
c. insertion of a nasogastric (NG) feeding tube.
d. IV infusion of immunoglobulin (Sandoglobulin).
ANS: D
Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose
immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube
feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not
helpful in reducing the duration or symptoms of the syndrome.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1545
MSC: NCLEX: Physiological Integrity
10. A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was lying on the
ground. The patient reports having had a tetanus booster 7 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
If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the
wound is deep. Immune globulin administration is given by the IM route if the patient has no previous
immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and
a test dose is not needed for immune globulin.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1547
MSC: NCLEX: Physiological Integrity
11. A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the
patient, the nurse recognizes the presence of neurogenic shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. hyperactive reflex activity below the level of the injury.
d. lack of movement or sensation below the level of the injury.
ANS: A
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature.
Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation
indicate spinal cord injury, but not neurogenic shock.
DIF:
TOP:
Cognitive Level: Comprehension
Nursing Process: Assessment
REF: 1549-1550
MSC: NCLEX: Physiological Integrity
12. A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which
nursing action should be included in the plan of care?
a. Assessment of the patient for left leg pain
b. Assessment of the patient for left arm weakness
c. Positioning the patient’s right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position
ANS: C
The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the
nurse to move the right leg. Pain sensation will be lost on the patient’s left leg. Left arm weakness will not be a
problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1550-1551
MSC: NCLEX: Physiological Integrity
13. A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and
family that
a. use of the shoulders will be preserved.
b. full function of the patient’s arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of injury.
ANS: B
The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the
shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries.
Bradycardia is associated with injuries above the T6 level.
DIF:
TOP:
Cognitive Level: Comprehension
Nursing Process: Implementation
REF: 1549-1550
MSC: NCLEX: Physiological Integrity
14. A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will
the nurse include in the plan of care?
a. Educate on the use of the Credé method.
b. Teach 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
Because the patient’s bladder is spastic and will empty in response to overstretching of the bladder wall, the most
appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent
catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé
method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder.
Catheterization after voiding will not resolve the patient’s incontinence.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1561-1562
TOP:
Nursing Process: Planning
15. When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient
goal is that the patient will be able to
a. transfer independently to a wheelchair.
b. drive a car with powered hand controls.
c. turn and reposition independently when in bed.
d. push a manual wheelchair on flat, smooth surfaces.
ANS: D
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because
flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a
car with powered hand controls, or turn independently in bed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
REF:
1552
TOP:
Nursing Process: Planning
16. A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse “I want to be transferred to
a hospital where the nurses know what they are doing!” Which reaction by the nurse is best?
a. Ask for the patient’s input into the plan for care.
b. Clarify that abusive behavior will not be tolerated.
c. Reassure the patient about the competence of the nursing staff.
d. Continue to perform care without responding to the patient’s comments.
ANS: A
The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse
should allow expression of anger and seek the patient’s input into care. Expression of anger is appropriate at this
stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in
responding to the patient’s anger. Ignoring the patient’s comments will increase the patient’s anger and sense of
helplessness.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1565
MSC: NCLEX: Psychosocial Integrity
17. After a 25-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 during rehabilitation.
The most appropriate action by the nurse at this time is to
a. tell the spouse that the patient can perform activities independently.
b. remind the patient about the importance of independence in daily activities.
c. develop a plan to increase the patient’s independence in consultation with the patient and the
spouse.
d. recognize that it is important for the spouse to be involved in the patient’s care and support the
spouse’s participation.
ANS: C
The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family
members who will be assisting with the patient’s ongoing care need to feel that their input is important, telling the
spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the
importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will
lead to ongoing dependency by the patient.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1565
MSC: NCLEX: Psychosocial Integrity
18. The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which one
will the nurse question?
a. Maintain NPO status.
b. Obtain lumbar puncture tray.
c. Give magnesium citrate 8 oz now.
d. Administer 1500-mL tap water enema.
ANS: C
Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate
for the patient.
DIF:
TOP:
Cognitive Level: Application
Nursing Process: Implementation
REF: 1546-1547
MSC: NCLEX: Physiological Integrity
19. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action
has the highest priority?
a. Assessment of respiratory rate and depth
b. Continuous cardiac monitoring for bradycardia
c. Application of pneumatic compression devices to both legs
d. Administration of methylprednisolone (Solu-Medrol) infusion
ANS: A
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the
patient’s respiratory function. The other actions also are appropriate but are not as important as assessment of
respiratory effort.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1550-1551 | 1556-1557 | 1558-1559
Nursing Process: Assessment
20. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient’s
illness, the most essential assessment for the nurse to carry out is
a. monitoring the cardiac rhythm.
b. determining level of consciousness.
c. checking strength of the extremities.
d. observing respiratory rate and effort.
ANS: D
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor
respiratory function continuously. The other assessments also will be included in nursing care, but they are not as
important as respiratory assessment.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1545
Nursing Process: Assessment
21. A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is
received. Before administering the antitoxin, it is most important for the nurse to
a. obtain the patient’s temperature.
b. administer an intradermal test dose.
c. ask the patient about a history of egg allergies.
d. document the presence of neurologic symptoms.
ANS: B
To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although
temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will
not affect the decision to administer the antitoxin.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1546-1547
Nursing Process: Implementation
22. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loosesounding secretions, the initial intervention by the nurse should be to
a. suction the patient’s oral and pharyngeal airway.
b. administer oxygen at 7 to 9 L/min with a face mask.
c. place the hands on the epigastric area and push upward when the patient coughs.
d. encourage the patient to use an incentive spirometer every 2 hours during the day.
ANS: C
Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability
to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia.
The use of the spirometer may improve respiratory status, but the patient’s ability to take deep breaths is limited by
the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by
coughing but should not be the nurse’s first action.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1559
Nursing Process: Implementation
23. To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord
injury, which information is most important for the nurse to obtain?
a. Leg strength and sensation
b. Skin temperature and color
c. Blood pressure and apical heart rate
d. Respiratory effort and O2 saturation
ANS: A
The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the
nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but
they do not reflect the effectiveness of the methylprednisolone.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1554-1555
Nursing Process: Evaluation
24. A patient with a history of a T2 spinal cord injury tells the nurse, “I feel awful today. My head is throbbing, and I
feel sick to my stomach.” Which action should the nurse take first?
a. Assess for a fecal impaction.
b. Give the prescribed antiemetic.
c. Check the blood pressure (BP).
d. Notify the health care provider.
ANS: C
The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a
headache to determine whether autonomic dysreflexia is occurring. Notification of the patient’s health care provider
is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is
ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after
checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1556-1557 | 1560-1561
Nursing Process: Implementation
25. The nurse is assessing a patient who 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
The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid
permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require
intervention as rapidly as the new onset weakness.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
REF:
TOP:
1566-1567
Nursing Process: Assessment
26. Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to
delegate to an experienced nursing assistant?
a. Nasogastric tube feeding q4hr
b. Artificial tear administration q2hr
c. Assessment for bladder distention q2hr
d. Passive range of motion to extremities q8hr
ANS: D
Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration
of tube feedings, administration of ordered medications, and assessment are skills requiring more education and
scope of practice, and the RN should perform these skills.
DIF: Cognitive Level: Application
REF: 1545-1546
OBJ: Special Questions: Delegation
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
27. A 26-year-old patient with a T3 spinal cord injury asks the nurse about 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
Although sexuality will be changed by the patient’s spinal cord injury, there are options for expression of sexuality
and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the
patient’s individual feelings about sexuality.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Psychosocial Integrity
REF:
TOP:
1563-1564
Nursing Process: Implementation
MULTIPLE RESPONSE
1. When caring for a patient who experienced a T1 spinal cord transsection 2 days 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. Avoidance of cool room temperature
e. Administration of H2 receptor blockers
ANS: A, C, D, E
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and
should have continuous cardiac monitoring and maintenance of a relatively warm room temperature.
Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a
urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be
avoided through the use of the H2 receptor blockers such as famotidine.
DIF: Cognitive Level: Application
REF:
OBJ: Special Questions: Alternate Item Format
MSC: NCLEX: Physiological Integrity
1555 | 1558-1561
TOP:
Nursing Process: Planning
COMPLETION
1. In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord
trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c,
d, etc.) ____________________
a. Infuse normal saline at 150 mL/hr.
b. Monitor cardiac rhythm and blood pressure.
c. Administer O2 using a non-rebreather mask.
d. Transfer the patient to radiology for spinal computed tomography (CT).
e. Immobilize the patient’s head, neck, and spine.
ANS:
E, C, B, A, D
The first action should be to prevent further injury by stabilizing the patient’s spinal cord. Maintenance of
oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible
complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume
replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and
stabilization are accomplished.