CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS PART C SITUATION: In its most basic sense, trauma means

injury to the body. In medicine, the term typically refers to the most severe injuriesthose that threaten life and limb. Unlike most emergency room patients, trauma patients require highly specialized care, including surgery and blood transfusions. Time is a critical factor trauma treatment should be given within the first hour (the so-called "golden hour") following injury. 1. A disaster is defined as: a. Any event or situation that results in multiple casualties and/or deaths b. A catastrophic and/or destructive event that disrupts normal functioning c. An industrial accident or unplanned release of nuclear waste d. An event that results in human casualties that overwhelm the available health care resources ANSWER: B Disastera catastrophic and/or destructive event that disrupts normal functioning; it may include any anticipated or unexpected event whose effects lead to significant destruction and/or adverse consequences. Option A: Mass casualty incident or event (MCI) any event or situation that results in multiple casualties and/or deaths. Option C: Technological disastersindustrial accidents and unplanned release of nuclear waste. Option D: Medical disasters catastrophic events that result in human casualties that overwhelm the available health care resources Reference: Perry Clinical Nursing Skills and Technique. 6th edition. Page 105 : Barbara Blok. First Aid for the Emergency Medicine (2009). 900 2. Which of the following statements is not true regarding the role of nurses in Disaster Response Planst: a. Nurses can perform duties outside of his/her expertise. b. Nurses can serve as a triage officer c. Nurses may participate in crisis intervention and counseling of other staff members d. None of the above ANSWER: D The role of the nurse during a disaster varies. The nurse may be asked to perform outside his or her area of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. For example, a critical care nurse may intubate a patient or even insert chest tubes. Wound dbridement or suturing may be performed by staff registered nurses. A nurse may serve as the triage officer. New settings and atypical roles for nurses arise during a disaster:

the nurse may provide shelter care in a temporary housing area, or bereavement support and assistance with identification of deceased loved ones. Individuals may require crisis intervention, or the nurse may participate in counseling other staff members and in critical incident stress management. Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 2563 3. Which of the following statements best describes prioritization in disaster situations? a. In disaster, decisions are based on the likelihood of survival and consumption of available resources b. In disaster or non-disaster situations, priority is given to those who are most critically ill c. Conditions with high mortality rate would be assigned as a priority in a disaster d. In disaster situations priority is given to those who are most critically ill ANSWER: A In non-disaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. In a disaster, however, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. Decisions are based on the likelihood of survival and consumption of available resources. Therefore, this same patient, and others with conditions associated with a high mortality rate, would be assigned a low triage priority in a disaster situation, even if the person is conscious. Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 2561 4. In performing cardiopulmonary resuscitation, the primary goal of the nurse is to: a. Return the heart to normal rhythm c. Maintain circulation to vital organs b. Maintain acid-base balance d. Avoid fluid volume deficit ANSWER: C The goal of CPR is to maintain circulation to vital organs until more advanced forms of life support can be initiated. Reference: American Heart associations 5. Which of the four phases of emergency management is known as the sustained action that reduces or eliminates long term risk to people and poverty from natural hazards and their effects? a. Mitigation b. Preparedness c. Recovery d. Response ANSWER: A The process of emergency management involves four phases which includes mitigation, preparedness, response and recovery. Mitigation efforts in this phase attempts to prevent hazards from occurring into disasters altogether or to reduce the effects of disasters when they occur. The mitigation phase differs from other phases because it focuses on the longterm measures for eliminating or reducing the risk.

Preparedness in this phase, emergency managers develop plans of action for when the disaster strikes. Common preparedness measures include communication plans, proper maintenance and training of emergency services, response teams, evacuation plans, etc. Response includes the mobilization of necessary emergency services and responders in the disaster area. This includes core emergency services such as fire-fighters, police, ambulance crews and special rescue teams. Recovery the aim of this phase is to restore the affected area to its previous state. It is concerned with the efforts concerned with actions that involve rebuilding destroyed property, rebuilding infrastructure, reemployment and repair of other essential infrastructures. Reference: Veenema. Disaster Nursing and Emergency preparedness. 2nd edition. Page 140 6. Upon arriving at a mass casualty scene, the health care providers will initiate triage by doing which of the following first? a. Assess b. Move c. Sort d. Send ANSWER: B The move phase also allows rescue workers to identify those individuals who can follow commands but may not be able to walk. Option A: The second step of the triage process, assess, allows rescue workers to focus on the remaining victims who are presumed more critically injured. Option C: During the assess triage process personnel actually begin the sort task. Option D: The final step in the MASS triage system is send. Rescue workers evacuate, transport, or release all living clients as soon as possible. Reference: Perry Clinical Nursing Skills and Technique. 6th edition. Page 110 7. During the sort phase of triage, a client with a closed head injury with no altered level of consciousness would be classified using the ID-me system as: a. Green b. Yellow c. Red d. Black ANSWER: B Yellowclosed head injury without altered level of consciousness. Option A: Greenabrasions, contusions, minor lacerations, no apparent injuries. Option C: Redunconscious or unresponsive, altered mental status, severe breathing difficulty. Option D: Blackvictims still alive but so badly injured as to have little chance of survival; victims who have died. Reference: Perry Clinical Nursing Skills and Technique. 6th edition. Page 110-111 : Brunner. Medical Surgical Nursing. 11th edition. Page 2562

8. A 40-year-old male patient who was at the site of a workplace explosion that is considered a disaster area has suffered second- and third-degree burns to 65% of his body, but he is conscious. This person would be triaged as: a. Green b. Yellow c. Red d. Black ANSWER: D A 2nd/3rd degree burns in excess of 60% of body surface area is triaged as black. In black category: Injuries are extensive and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 2562 9. A maintenance man falls from a ladder into the unit hall, striking his head on some equipment. The man is unconscious and not breathing; the Code Team has already been paged and is on its way. The nurse should: a. Wait for the team to start CPR c. Give two rescue breaths after extending the neck b. Open airway with a jaw thrust d. Start chest compressions ANSWER: B The jaw thrust, rather than neck extension, is used when a head or neck injury is suspected. CPR should be initiated and then taken over by the Code Team when they arrive. Reference: Adrian Linton. Introduction to Medical Surgical Nursing. 4th edition. Page 226 10. Nurse Hannah is doing the CPR to an unconscious client. Nurse Hannah can cease CPR when there is: a. Spontaneous breathing and absence of dyspnea c. Heartbeat and spontaneous breathing b. Spontaneous breathing and absence of cyanosis d. Heartbeat and return of consciousness ANSWER: C Cardiopulmonary resuscitation success refers to the lack of need for assisted respiration and assisted blood circulation. These two criteria are met when the heartbeat and spontaneous breathing are restored. Reference: Adrian Linton. Introduction to Medical Surgical Nursing. 4th edition. Page 226 11. A patient enters the emergency department with a gunshot wound to the abdomen. The most common hollow organ injured in this way is the: a. Liver b. Small bowel c. Stomach d. Large bowel ANSWER: B Intra-abdominal injuries are categorized as penetrating or blunt trauma. Penetrating blunt injuries (e.g gunshot wounds, stab wounds) are serious and usually require surgery. Penetrating abdominal trauma results in a high incidence of injury to hollow organs, particularly the small bowel. The liver is the most frequently injured solid organ. Reference: Brunner. Medical and Surgical Nursing. 11th

edition. Page 2529 12. A 45-year-old man is involved in a motor vehicle accident and sustains blunt trauma to his abdomen. The patient must be: a. Ambulated immediately to expel flatus c. Immobilized on a backboard b. Placed in a Fowler's position d. Placed in a left lateral position ANSWER: C Blunt trauma to the abdomen may result form motor vehicle crashes, falls, blows, or explosions. Blunt trauma is commonly associated with extra-abdominal injuries to the chest, head or extremities. Patients with blunt trauma are a challenge because injuries may be difficult to detect. The incidence of delayed and trauma-related complications is greater than penetrating injuries. With blunt trauma, the patient is kept on a stretcher to immobilize the spine. A backboard may be used for transporting the patient. Reference: Brunner. Medical and Surgical Nursing. 11th edition. Page 2531-2532 13. Nurse Isabel is assessing a patient presenting to the emergency department with the potential diagnosis of heat stroke. She is most likely to see which of the following sign/symptom? a. Anhidrosis b. Increased blood pressure c. Warm moist skin d. Decreased heart rate ANSWER: B Heat stroke causes thermal injury at the cellular level, resulting in widespread damage to the heart, liver, kidney, and blood coagulation. Recent patient history reveals exposure to elevated ambient temperature or excessive exercise during extreme heat. When assessing the patient, the nurse notes the following symptoms: profound central nervous system (CNS) dysfunction (manifested by confusion, delirium, bizarre behavior, coma); elevated body temperature (40.6C [105F] or higher); hot, dry skin; and usually anhidrosis (absence of sweating), tachypnea, hypotension, and tachycardia. Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 2534 14. Which laboratory finding is expected of a patient who suffered heat stroke? a. Elevated ALT/AST b. Hot and dry skin c. Normal ECG d. CNS dysfunction ANSWER: A Marked elevation of AST/ALT is expected with peak in 2472 hours. Complete recovery is expected. Options B and D though present, is not a laboratory finding but are symptoms. ECG is monitored for dysrhythmias. Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 2534 : Barbara k. Blok. First Aid for the Emergency Medicine Boards (2009). Page 629

15. Which of the following is the most important step to restore oxygenation and ventilation for the unresponsive, breathless submersion (near drowning) victim? a. Attempt to drain water from breathing passages by performing the Heimlich maneuver b. Begin chest compressions c. Provide cervical spine stabilization because a diving accident may have occurred d. Open the airway and begin rescue breathing as soon as possible even in the water ANSWER: D The first and most important treatment of the near-drowning victim is provision of immediate mouth to mouth ventilation. Prompt initiation of rescue breathing has a positive association with survival. Answer A is incorrect because the drainage of water is unnecessary and will delay provision of rescue breathing. The ACLS guidelines state there is no need to clear the airway of aspirated water. Some victims aspirate nothing At most only a modest amount of water is aspirated by the majority of drowning victims, and it is rapidly absorbed. In addition the abdominal thrusts can cause injuries. Answer B is incorrect because chest compressions should be performed only if there are no signs of circulation after delivery of 2 breaths if the victim is unresponsive and not breathing. Answer C is incorrect because providing cervical spine stabilization will not restore oxygenation and ventilation. 16. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? a. Use a laryngoscope to check for a foreign body lodged in the esophagus. b. Reposition the head to validate that the head is in the proper position to open the airway. c. Turn the client to the side and administer three back blows. d. Perform a finger sweep of the mouth to remove any vomitus. ANSWER: B The most frequent cause of inadequate aeration of the client's lungs during CPR is improper positioning of the head resulting in occlusion of the airway (B). A foreign body can occlude the airway, but this is not common unless choking preceded the cardiac emergency, and (A, C and D) should not be the nurse's first action. 17. The emergency department nurse is performing an assessment on a client who has sustained circumferential burns of both legs. Which assessment would be the priority in caring for this client? a. Assessing peripheral pulses c. Assessing urine output b. Assessing neurological status d. Assessing blood pressure ANSWER: A The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority

assessment would be to check for peripheral pulses to ensure that adequate circulation is present. Although the urine output, neurological status, and BP would also be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses. Reference: Brunner and Suddarths Textbook of Medical Surgical Nursing by Smeltzer and Bare 12th ed. 18. A 35-year-old male presents to the ED with a complaint of abdominal pain, nausea and blurry vision. He has a history of alcohol abuse and reports ingesting something from the copier shop earlier in the day. The nurse will most likely expect the client to receive which initial treatment? a. Administration of ethanol c. Assist in hemodialysis b. Acidifying urine d. Administer oxygen as ordered ANSWER: A This patient has likely ingested methanol; Methanol is found in windshield wiper fluid, antifreeze and photocopier fluid. Initial therapies include administration of fomepizole or ethanol (via drip) to decreased formation of formic acid (the toxic metabolite) and urinary alkalinization to increase its clearance. Consider hemodialysis in cases of severe acidosis, visual changes or a serum level >50 mg/dL. Reference: Barbara k. Blok. First Aid for the Emergency Medicine Boards (2009). Page 322 19. A client presents with circumferential burns to the chest and shortness of breath following an electrical burn injury. The nurse identifies that the priority nursing diagnosis for this injury would be: a. Deficient fluid volume. c. Ineffective breathing pattern. b. Risk for injury. d. Decreased cardiac output ANSWER: C Circumferential burns to the chest wall will decrease chest expansion and ventilation and will compromise breathing. An ineffective breathing pattern is evident as a result of this injury. There is potential for further tissue damage, decreased cardiac output, and fluid volume deficit caused by hypoxia and edema formation for burn with third-spacing of fluids. However, breathing and airway are priorities in this case. SITUATION: Nurses in many types of practice settings encounter patients with altered neurologic function. Disorders of the nervous system can occur at any time during the life span and can vary from mild, self-limiting symptoms to devastating, life-threatening disorders. 20. The nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care? a. Impaired physical mobility related to right-sided 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. ANSWER: B With right-brain damage, a client experience difficulty in judgment and spatial perception and is more likely to be impulsive and move quickly, which placing the client at risk for falls (B). Although clients with right and left hemisphere damage may experience impaired physical mobility, the client with right brain damage will manifest physical impairments on the contralateral side of the body, not the same side (A). The client with a leftbrain injury may manifest right-sided hemiplegia with speech or language deficits (C). A client with left-brain damage is more likely to be aware of the deficits and experience grief related to physical impairment and depression (D). Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 21. Physical examination of a comatose client reveals decorticate posturing. Which statement is accurate regarding this client's status based upon this finding? a. A cerebral infectious process is causing the posturing. c. There is a probable dysfunction of the midbrain. b. Severe dysfunction of the cerebral cortex has occurred. d. The client is exhibiting signs of a brain tumor. ANSWER: B Decorticate posturing (adduction of arms at shoulders, flexion of arms on chest with wrists flexed and hands fisted and extension and adduction of extremities) is seen with severe dysfunction of the cerebral cortex (B). Option A is characteristic of meningitis. Option C is characterized by decerebrate posturing (rigid extension and pronation of arms and legs). A client with (D) may exhibit decorticate posturing, depending on the position of the tumor and the condition of the client. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 22. In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly a. Is to be expected, and progresses with age. c. Is a result of irreversible brain pathology. b. Often follows relocation to new surroundings. d. Can be prevented with adequate sleep. ANSWER: B Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. Option A is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. Reference: Brunner and Suddarths Medical Surgical Nursing 12th

edition 23. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? a. Prone b. Fowler's c. Sims' d. Supine ANSWER: B The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 24. A client with Parkinson's disease is taking carbidopa-levodopa (Sinemet). Which observation by the nurse should indicate that the desired outcome of the medication is being achieved? a. Decreased blood pressure. b. Lessening of tremors. c. Increased salivation. d. Increased attention span. ANSWER: B Sinemet increases the amount of levodopa to the CNS (dopamine to the brain). Increased amounts of dopamine improve the symptoms of Parkinson's, such as involuntary movements, resting tremors (B), shuffling gait, etc. Option A is a side effect of Sinemet. Decreased drooling would be a desired effect, not (C). Sinemet does not affect (D). Reference: Amy Karch. Focus on Nursing Pharmacology 3rd edition 25. A patient with Parkinsons disease would be at risk for falling as a result of: a. Quick movements. b. Unsteady, shuffling gait. c. Hemiparesis. d. Frequent loss of consciousness. ANSWER: B The patient with Parkinsons disease has a very unsteady shuffling gait, as well as a very slow response, which could cause the patient to fall. Reference: Kozier and Erbs Fundamentals of Nursing: Concepts, Process and Practice. 8th edition 26. A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? a. Stay out of direct sunlight. c. Schedule extra rest periods.

b. Restrict intake of high protein foods. d. Go to the emergency room immediately. ANSWER: C Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. Extra rest periods should be scheduled (C) to reduce the symptoms. Options A, B, and D are not necessary. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 27. The Glasgow coma scale measures the level of consciousness. Which of the following is the critical score which is generally accepted as indicating severe head injury? a. 12 b. 9 c. 8 d. 3 ANSWER: C A score of 8 and below is the critical score which is generally accepted as indicating severe head injury. The lowest score is 3 (least responsive) where the client is already in a deep coma. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 28. The physician ordered an MRI for a client . As the nurse taking care of the client, she knows that all of the following are true of MRI, except: a. The client must be placed on NPO four hours prior the test b. All metal objects should be removed from the client c. Sedation may be prescribed in some circumstances d. It uses a powerful magnetic field to obtain images of different areas of the body ANSWER: A The client is not placed NPO prior to an MRI. This is usually done only in tests such as CT-Scan if a contrast agent will be used. All the other options are correct. All metal objects should be removed from the client and the nurse must ensure that no patient care equipment that contains metal or metal parts enters the room where MRI is located. Furthermore, sedation may be prescribed in some circumstances because the MRI is a narrow tube and clients may experience claustrophobia. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 29. A client presents in the emergency room with symptoms of slurred speech, decreased level of consciousness and flaccid paralysis. During assessment, she appears to be drowsy. The attending physician observes that her pupils are fixed and her reflexes are absent. It was determined that she is showing signs of increased ICP. The nurse monitors the client and found his ICP reading to be 60. What is the nurses best action? a. Record the reading c. Notify the physician b. Place the client in a supine position d. Turn the client and recheck the reading ANSWER: C

This is the nurses best action at this time. The normal ICP reading is 10-20mmHg and 60 mmHg is already too high. The physician should be notified immediately. Option A would be the action if the ICP reading was normal. Options B and D are incorrect. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 30. A cleint with ICP exhibits significant changes in mental status and vital signs and continues to deteriorate. The nurse knows that this Cushings triad may happen along with this deterioration and needs immediate intervention. Which of the following is not associated with the Cushings triad? a. HR 50 bpm b. BP 190/98 mmHg c. RR 11 cpm d. TEMP 380C ANSWER: D The Cushings triad includes bradycardia, hypertension and bradypnea and is a grave sign. This requires intermediate intervention. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 31. The nurse is teaching a client recently diagnosed with myasthenia gravis about the disease. Which of the following is true about myasthenia gravis? a. It is a genetic dysfunction c. There is involuntary muscle weakness that escalates with rest b. Men are affected more frequently d. The initial manifestation usually involves the ocular muscles ANSWER: D Myasthenia gravis is an autoimmune (not genetic) disorder affecting the myoneural junctions, affects more women than men, there is voluntary muscle weakness that escalates with activity and the initial manifestation usually involves the ocular muscles (e.g. diplopia and ptosis are common). Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 32. A client is admitted to the hospital for diagnostic testing for possible myasthenia gravis. The nurse prepares for intravenous administration of edrophonium chloride (Tensilon). What is the expected outcome for this client following administration of this pharmacologic agent? a. Progressive difficulty with swallowing. c. Improvement in generalized fatigue. b. Decreased respiratory effort. d. Decreased muscle weakness. ANSWER: D Administration of edrophonium chloride (Tensilon), a cholinergic agent, will temporarily reduce muscle weakness (D), the most common complaint of newly-diagnosed clients with myasthenia gravis. This medication is used to diagnose

myasthenia gravis due to its short duration of action. This drug would temporarily reverse (A and B), not increase these symptoms. (C) is not a typical complaint of clients with myasthenia gravis, but weakness of specific muscles, especially after prolonged use, is a common symptom. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 33. In planning care for a client with advanced Parkinsons disease, which activity is most likely to be effective in alleviating fatigue? a. Getting him to bed on time c. Collaborating with him when scheduling activities b. Avoiding high-carbohydrate foods d. Providing for morning and afternoon naps while he is in the hospital ANSWER: C Scheduling activities in collaboration with the client will allow him to proceed at his own pace and maximize his strength. All activities, including naps, should be planned with the client, as well as providing a highcarbohydrate diet to provide energy. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition Reference: Norman Keltner. Psychiatric Nursing. 5th edition SITUATION: PSYCHE 34. A group of eight psychiatric clients have been together in group therapy for 12 sessions. There has been an expression of warm feelings, self-disclosure, and an awareness of events in the here and now. The group finds it difficult to deal with two members who must now join the group. The nurse recognizes that group members are experiencing which phase of group process? a. Beginning phase b. Transition phase c. Middle phase d. Termination phase ANSWER: C The cohesiveness is apparent in the group. Joining or leaving the group results in strong emotions due to disruption of the sharing group. In the beginning phase, members are getting to know each other, transition phase is not aphase in group process; termination phase may bring various emotions, but not what is described. 35. A female client is hospitalized for depression. One evening after an argument with her husband, she discusses with the evening nurse her intent to cut her wrists. Her husband has threatened to divorce her and retain custody of the children. What is the most appropriate initial action for the nurse to take? a. Attempt to convince the client the need to address her husbands threat instead of using selfdestructive behavior

b. Place the client on suicide precautions, requiring close observation and one-to-one monitoring by nursing staff c. Recognize suicidal remarks as less serious because the client is in a safe environment d. Tell the client that her husband will not divorce her if she wont attempt suicide. ANSWER: C Suicide attempts are more common on evenings, night shift or weekends when the unit structure is lessened. The client feels threatened form her husbands actions and is expressing tunnel vision in regards to her situation. The safety of the client is the first concern and all suicidal remarks and gestures must be taken seriously. Therapeutic sessions will be held at a later time. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 36. The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention bests helps this client deal with his depression? a. Ensure that the client's day is filled with group activities. b. Assist the client in exploring feelings of shame, anger, and guilt. c. Allow the client to initiate and determine activities of daily living. d. Encourage the client to explore the rationale for his depression. ANSWER: B Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings is an important nursing intervention for the depressed client (B). If the client's day is filled with group activities (A) he might not have the opportunity to explore these feelings. Option C is a good intervention for the chronically depressed client who exhibits vegetative signs of depression. Option D is essentially asking the client "why" he is depressed--avoid "whys" disguised as "rationale." Reference: Norman Keltner. Psychiatric Nursing. 5th edition 37. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment? a. Altered thought processes. c. Inadequate social support. b. Moderate levels of anxiety. d. Altered health maintenance. ANSWER: B The nurse should initiate a referral based on anxiety levels (B) and feelings of nervousness that interfere with sleep, appetite, and the inability to solve problems. The client does not report symptoms of (A) or evidence of (C). There is

not enough information to initiate a referral based on (D). Reference: Norman Keltner. Psychiatric Nursing. 5th edition 38. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? a. Let me call and leave a message for your healthcare provider c. How can I help answer your questions? b. The healthcare provider should be here on Monday morning d. What concerns do you have at this time? ANSWER: A It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. The nurse can also implement offer to assist the client (C and D), but the highest priority intervention is contacting the healthcare provider. 39. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis? a. Risk for injury related to suicidal ideation. c. Knowledge deficit related to ineffective coping. b. Risk for injury related to alcohol detoxification. d. Health seeking behaviors related to personal crisis. ANSWER: B The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. Options C and D can be addressed when immediate needs for safety are met. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 40. An adult is experiencing a panic attack. The nurse intervenes by escorting him to his room, using short sentences, and conveying a calm demeanor. Which action by the client indicates the nursing interventions are effective? a. Releases his anxiety by punching his fist on a bedside table

b. States he wants to be alone to deal with his feelings c. Expresses verbally his demands to the nurse d. Makes connections between events and his anxious response ANSWER: D With reduced levels of anxiety, the clients perceptual field broadens, allowing the client to focus on the cause of anxiety and to connect the cause with his anxious response. He is able to learn from the experience. High levels of anxiety, as expressed in other choices, prevent this from occurring. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 41. A young adult is involuntarily admitted to the psychiatric unit in a manic state. Upon arrival on the unit he is unable to sit, he is very difficult to understand because of his rapid rate of speech, and he refuses to eat or drink. What area of disturbance poses the greatest physical danger to this client? a. Activity b. Perceptual c. Sensory d. Social ANSWER: A The clients high activity level poses the most danger because it can lead to absence of food, fluid, and rest with resultant dehydration, electrolyte imbalance, and physical collapse. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 42. A young woman with history of bipolar disorder is admitted to the psychiatric unit. She is talking excitedly and walking rapidly around the unit. What intervention would most likely be initiated during the initial period of hospitalization? a. Encourage the client to participate in group and therapeutic activities b. Observe the client closely until she calms down c. Place the client in four-point restraints for protection of self and others d. Place the client in seclusion but maintain frequent one-to-one contact with her ANSWER: D Manic clients cannot calm down without assistance. Decreasing the level of sensory stimulation is of paramount importance and provides the greatest therapeutic effect until proper medication levels (often lithium) are established. Restraints would further agitate the client. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 43. Which of the following is least likely to influence the potential for a client to comply with lithium therapy after discharge? a. The impact of lithium on the clients energy level and lifestyle b. The need for consistent blood level monitoring

c. The potential side effects of lithium d. What the clients friends think of his need to take medication ANSWER: D While the clients social network can influence the client in terms of compliance, the influence is typically secondary to that of the other factors listed. Side effects of lithium include fine tremor, drowsiness, diarrhea, polyuria, thirst, weight gain, and fatigue, which can be disturbing to the client. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 44. The nurse is caring for an elderly client who has been diagnosed as having sundowners syndrome. The nurse asks the client and his family to list all the medications, prescription and nonprescription, he is currently taking. What is the primary reason for this action? a. Multiple medications can lead to dementia b. The medications can provide clues regarding his medical background c. Ability to recall medications is a good assessment of the clients level of orientation d. Medications taken by a client are part of every nursing assessment ANSWER: A Polypharmacy (concurrent use of several drugs) increases the potential for adverse side effects, one being dementia. Sundowners syndrome involves behavior that are seen in the late afternoon or early evening when the sun sets, which include disorientation, emotional upset, or confusion. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 45. A resident of a long-term care facility is taking lithium carbonate (Eskalith) to treat bipolar disorder. Which instruction should the nurse provide to this client's caregivers? a. Offer the morning dose of the medicine before breakfast. b. Have the client chew the pill if it is difficult to swallow. c. Encourage high energy fluid intake by providing sports drinks or sodas. d. Report symptoms of hypothyroidism such as fatigue and constipation. ANSWER: D Lithium carbonate (Eskalith) causes hypothyroidism in 1 to 4% of those clients receiving the medication, so caregivers should assess for signs of hypothyroidism, including fatigue and constipation (early signs) and myxedema or goiter (late symptoms) (D). Lithium carbonate (Eskalith) should be offered with meals, not before (A), and should not be chewed, crushed, or halved (B). Fluid intake should be encouraged to treat polydipsia caused by this medication, but (C) should be avoided to reduce the occurrence of weight gain and dental caries. 46. When should the nurse introduce information about the end of the nurse-client relationship?

a. During the orientation phase c. At least one or two sessions before the last meeting b. As the goals of the relationship are reached d. When the client can tolerate it ANSWER: A Preparation for ending the nurse-client relationship should begin during the orientation phase, when the limits of the relationship are established. Option B - termination should also be discussed as goals are achieved and the relationship nears an end. Option C - although the nurse should remind the client that only one or two sessions are left, the nurse must not wait until then to prepare the client for termination. Option D - the client's ability to tolerate the end of a relationship shouldn't dictate its timing. Because many clients have had negative experiences when ending relationships, the nurse can use termination of the nurseclient relationship to prepare the client for and work the client through positive termination experiences with others. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 93 47. One tool that is useful in learning more about oneself is the Johari window which creates a word portrait of a person in four areas and indicates how well the person knows himself or herself and communicates with others. Which area evaluated the qualities known only to oneself: a. Quadrant 1 b. Quadrant 2 c. Quadrant 3 d. Quadrant 4 ANSWER: C Quadrant 3: Hidden/ private self portrays to qualities known only to oneself. Option A Open/public self portrays qualities one knows about oneself and others also know. Option B Blind/unaware self portrays qualities known only to otheres. Option D Unknown portrays an empty quadrant to symbolize qualities as yet undiscovered by oneself or others. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 91 48. A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique? a. Restating b. Making observations c. Exploring d. Focusing ANSWER D: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question, ask further questions (exploring), and didn't make an observation. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 111-115 49. Earlier today you said you were concerned that your son was still upset with you. When I stopped by your room about an hour ago, you and your son seemed relaxed and smiling as you spoke to each other. How did things go between the two of you? This is an example of which therapeutic communication technique?

a. Consensual validation b. Encouraging comparison c. Accepting d. General lead ANSWER: A Consensual validation is searching for mutual understanding. For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (all) participants. Sometimes words, phrases, or slang terms, have different meanings and can be easily misunderstood. Option B comparing ideas, experiences, or relationships brings out many recurring themes. The client benefits from making the comparison because she or he might recall past coping strategies that were effective or remember that he or she has survived a similar situation. For example: Have you had similar experiences?, Was it something like.? Option C this response indicates the nurse has heard and followed the train of thought. It does not indicate agreement but is nonjudgmental. For example: Yes., I follow what you said. Nodding. Option D indicates that nurse is listening and following what the client is saying without taking away the initiative for the interaction. Go on, And then? Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 111 50. A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for which of the following lengths of time? a. 5 to 7 days b. 2 to 3 weeks c. 4 to 6 weeks d. 8 to 12 weeks ANSWER: B Generally, 4 to 6 weeks is viewed as the length of time a client can tolerate the severe level of disturbance of a true crisis. In the first week or two, clients usually are still trying to use their normal coping skills and support systems. After 6 weeks of continuous crisis, a client is probably becoming so physically and emotionally drained that he or she has sought or has been brought by others for medical or psychiatric use. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 60 Isaac, A. (2001) Lippincotts Review Series Mental Health and Psychiatric Nursing 3rd Edition. Page 215220 51. The nurse would select which of the following approaches in order to best respond to a client in crisis? a. Behavioral approach c. Problem-solving approach b. Nondirective approach d. Supportive approach ANSWER: C The problem-solving method is used in a systematic manner as part of crisis intervention. Option A and B - the behavioral approach or the nondirective approach would not be selected as part of crisis intervention.

Option D - although a supportive approach (eg. supporting client strengths) is part of crisis intervention, the over-all method guiding the nurse is the problem-solving approach. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 60 Isaac, A. (2001) Lippincotts Review Series Mental Health and Psychiatric Nursing 3rd Edition. Page 215220 52. What nursing intervention should be included prior to electroconvulsive therapy (ECT)? a. Providing an opportunity for the client to ask questions and express concerns about ECT b. Telling the client that it is not helpful to concentrate on the therapy c. Reassuring the client that ECT is no worse than having a venipuncture d. Telling the client she will recover completely as a result of ECT ANSWER: A The opportunity to ask questions helps to reduce anxiety and misinformation while enlisting the client and familys support and cooperation in the treatment. The treatment often results in significant reduction in depression but the results cannot be guaranteed. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 53. The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. How soon will the nurse state the beneficial effects of ECT occur? a. 1 week b. 3 weeks c. 4 weeks d. 6 weeks ANSWER: A Treatments are administered at intervals of 48 hours, with beneficial effects evident after the first several treatments, which is within 1 week. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 54. Nursing assessment before electroconvulsive therapy (ECT) is aimed at establishing parameters that reflect the clients mental and physical status. Which assessment is excluded in the assessment before ECT therapy? a. Activity level b. Bowel habits c. Pain tolerance d. Sleep habit ANSWER: C Pain is not associated with ECT, but activity level, bowel habits, and sleep habits and/or depression provide insight into the clients physical and mental status. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 55. A newly admitted client with conversion disorder says he cannot move his legs. What is the best nursing response? a. The physical tests and examinations state no physiological reason for your paralysis

b. Let me help you out of the bed to the wheelchair. I will show you where the dining room is. Dinner is served at 6:30 pm. Ill be telling you more about the typical routine later c. Ill plan to have your meals served to you in bed. Because of your physical problem you will receive special privileges d. You are here to get an understanding of how your physical symptoms related to the conflicts in your personal life. Maybe you should reflect on this awhile and Ill be back in one hour to discuss it with you ANSWER: B Explanation of normal routine reduces anxiety and decreases secondary gain. It is too early in the relationship to uncover the conflict underlying the conversion. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 56. A client with depression receives a prescription for amitriptyline (Elavil). Which instruction should the nurse include in the client's teaching? a. Do not ingest foods with tyramine. c. Obtain daily blood pressure readings. b. Avoid the consumption of alcohol. d. Take with a glass of orange juice. ANSWER: B Tricyclic antidepressants (TCAs) such as amitriptyline can cause sedation and should not be mixed with agents that depress the central nervous system, so the client should be instructed to avoid alcohol (B). Tyramine rich foods (A) should be avoided when taking mono-amine oxidase inhibitors. Blood pressure (C) should be monitored in a client taking selective-serotonin reuptake inhibitors. Option D does not affect the absorption of amitriptyline. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 57. A young woman is admitted to the psychiatric unit for treatment of bulimia. What is the primary issue for the bulimia client? a. Delusions b. Depersonalization c. Fear and suspicion of others d. Poor impulse control ANSWER: D The bulimic clients awareness of the inappropriateness of the eating pattern coupled with the clients inability to control eating activity indicates lack of impulse control. The other choices describe paranoia or schizophrenia. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 58. The nurse is assessing a client with bulimia. Which characteristic is least likely to be evident in the history? a. Repeated crash dieting c. Rigorous exercise regimens b. Repeated weight fluctuations d. Self-induced vomiting

ANSWER: C This activity is seen in anorexia nervosa. The others are commonly associated with bulimia. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 59. The nurse is assessing a 15-year-old female who's being admitted for treatment of anorexia nervosa. Which symptom is the nurse most likely to find? a. Heat intolerance b. Hypertension c. Hypertrophy of salivary glands d. Not preoccupied with food ANSWER: C Frequent vomiting causes tenderness and swelling of the parotid glands. Symptoms: Preoccupation with thoughts of food, Fear of gaining weight, amenorrhea, cold intolerance, hypotension, hypothermia, bradycardia, hypertrophy of the salivary glands and electrolyte imbalance. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 532-533 60.What should the nurse do when interviewing a child suspected of being sexually abused? a. Ask leading questions c. have a security guard present b. Have the parents present d. Use the childs words to describe body parts ANSWER: D Using words the child uses to describe body parts ensure that the child understands what is being said. The child should be asked to describe things in her own words, and in a private interview so the child will feel free to express her feelings. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 61. What would be a short-term goal (to be met in 1 week following admission) planned by a nurse for a delusional client? a. Reduce the frequency and intensity of the delusional thinking b. Verbalize why he uses delusions to deal with life c. Communicate in only reality-oriented terms d. Recognize his delusions as nonreality-based statements ANSWER: A Within 1 week, there may be minimal to moderate changes in thought process, depending on the clients diagnosed mental illness. An appropriate goal is for the client to feel less threatened and less anxious, lessening the requirement for delusional thought. If the client is compliant with psychotropic medications, the client may respond positively by decreased frequency and intensity of delusions after 1 week of medications. The other choices are longterm goals. Reference: Norman Keltner. Psychiatric Nursing. 5th edition

62. An adult client states, That TV news anchor is talking about me The nurse recognizes the statement as what type of thought process? a. Thought broadcasting b. Delusion of reference c. Thought insertion d. Delusion of persecution ANSWER: B A delusion of reference is a fixed false belief that events or people are directly related to the individual person. The other choices are a disturbance in thought pattern or a belief that others are attempting to harm a person. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 63. In planning care for a client with schizophrenia who has negative symptoms, the nurse would anticipate a problem with: a. Auditory hallucinations b. Bizarre behaviors c. Ideas of reference d. Motivation for activities ANSWER: D In a client demonstrating negative symptoms of schizophrenia, avolition or the lack of motivation for activities is a common problem. Options A, B and C all the other symptoms listed are the positive symptoms of schizophrenia. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 276 Isaac, A. (2001) Lippincotts Review Series Mental Health and Psychiatric Nursing 3rd Edition. Page 132,134 64. A client who has had auditory hallucinations for many years tells the nurse that the voices prevent participation in the social skills training program of the community health center. Which of the following would the nurse teach the client to do? a. Analyze the content of the voices c. Take medication as prescribed b. Participate when the voices cease d. Use thought stopping techniques ANSWER: D Clients with long-lasting auditory hallucinations can learn to use thought-stopping measures to accomplish tasks. Option A analyzing the content of the voices may be indicated when hallucinations first occur to establish whether the voices are threatening to the individual or instructing the client to harm others. Focusing on content at this point would reinforce the symptom. Option B the voices have lasted many years, the client should participate despite the voices. Option C there is no indication that the client is not taking medication as prescribed. Reference: Norman Keltner. Psychiatric Nursing. 5th edition 65. Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance

abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen? a. Signs and symptoms of extrapyramidal effects (EPS). b. Information about substance abuse and schizophrenia. c. The effects of alcohol and drug interaction. d. The availability of support groups for those with dual diagnoses. ANSWER: C Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the halflife of the Prolixin Decanoate IM is 2 to 4 weeks. That means the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM. Options A, B, and D provide valuable information and should be included in the client/family teaching, but they do not have the priority of (C). Reference: Norman Keltner. Psychiatric Nursing. 5th edition 66. A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder? a. Dependent personality c. Avoidant personality disorder b. Passive-aggressive personality d. Obsessive-compulsive disorder ANSWER: B The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. The client with a dependent personality is unable to make everyday decisions and allows others to make important decisions. In addition, the client with a dependent personality often volunteers to do things that are unpleasant so that others will like him. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity. The obsessive-compulsive personality displays a pervasive pattern of perfectionism and inflexibility. Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. 67. Nurse Hannah knows that the client with obsessive-compulsive disorder who constantly does repetitive cleaning is attempting to: a. Decrease her anxiety level c. Control others

b. Focus attention on nonthreatening tasks d. Manipulate others ANSWER: A The primary reason for the compulsive activity is to decrease the anxiety caused by obsessive thoughts. The client is not trying to focus her attention on tasks, control others, or lessen interaction with others. Reference: Vdebeck SL. 2008. Psychiatric Mental Health Nursing. 4th Ed. Wolter Kluwer / Lippincott Williams and Wilkins. p.359. 68. The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment? a. At what age did you begin to exhibit symptoms? c. How often do you drink alcoholic beverages? b. Do you have a family history of borderline disorder? d. Do you frequently have temper tantrums? ANSWER: D Those with a borderline personality disorder demonstrate intense outbursts of anger, so (D) is the most important question to ask. (A, B, and C) provide worthwhile information, but do not have the priority of (D) when assessing a client who is suspected of having a borderline personality disorder. SITUATION: The problems associated with musculoskeletal structures are common and affect all age groups. 69. A woman who has had rheumatoid arthritis for several years is admitted to the hospital. Upon physical examination of the client, what should the nurse expect to find? a. Asymmetric joint involvement b. Heberdens nodes c. Obesity d. Small joint involvement ANSWER: D Small joint involvement is common in rheumatoid arthritis. All of other symptoms are seen in osteoarthritis but not rheumatoid arthritis. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 70. An elderly is admitted to the orthopedic unit with a diagnosis of a right intracapsular hip fracture. Bucks extension traction is employed prior to surgery. She complains of numbness in the right foot. After the nurse notes the tapes are lengthwise on the opposite sides of the limb, what would be the nurses best response? a. How long has your foot been numb? c. Ill call your doctor later b. I can adjust it for your comfort d. There is nothing wrong with the traction ANSWER: A Numbness is symptomatic of circulatory or nerve impairment to the extremity. (Assess) It is important to know the length of time the client has been experiencing this sensation. The physician needs to be notified immediately if neurovascular compromise is suspected. Delay may result in permanent nerve and muscle damage or even necrosis.

The nurse is not allowed to adjust the traction. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 71. The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair which of the following nursing measures will best facilitate the resumption of activities for this client? a. Arranging for wheelchair c. Assisting her to sit out of bed on a chair QID b. Asking her family to visit d. Encouraging the use of an overhead trapeze ANSWER: D Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Use of the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 72. A 90-year old woman is preparing to transfer to continue recovery following repair of a fractured hip. She begins to cry and says, When youre young these things dont happen. Why did I break my hip at this age? Which response by the nurse indicates the best understanding of risk factors for the elderly? a. As you age you become less aware of your surroundings and careless about safety b. Nothing works as well when we are older c. There are no known specific reasons why hip fractures occur more often in your age group d. Your age and sex are factors in the loss of minerals from your bones, making them more likely to break ANSWER: D Elderly females are prone to hip fractures because the cessation of estrogen production after menopause contributes to demineralization of bone. Other options are incorrect. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 73. Mr. Ortega is admitted to the Orthopedic Hospital. X-rays reveal a fractured tibia and a cast is applied. Of the following, which nursing action would be most important after the cast is in place? a. Assessing for capillary refill c. Discussing cast care with the client b. Arranging for physical therapy d. Helping the client to ambulate ANSWER: A Good capillary refill indicates that the cast has not caused a circulatory problem in the extremity. Other options are correct but assessing circulation is a priority action. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition

74. A client attends a class on osteoporosis. Which statement by the client needs further teaching about the relationship between exercise and maintenance of bones? a. I will begin jogging b. I will begin jumping rope c. I will begin swimming d. I will begin walking ANSWER: C Adequate dietary or supplemental calcium and vitamin D, regular weight-bearing exercise, and modification of lifestyle, if necessary (eg, cessation of smoking, reduced use of caffeine and alcohol), help to maintain bone mass. Diet, exercise, and physical activity are the primary keys to developing high-density bones that are resistant to osteoporosis. It is emphasized that all people continue to need sufficient calcium, vitamin D, sunshine, and weightbearing exercise to slow the progression of osteoporosis. Physical compression of weight-bearing joints stimulates osteoblastic deposition of calcium. Swimming does not involve weight bearing and physical compression of joints. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 75. An adult who has had a total hip replacement is learning how to walk with a standard walker. Which description below tells the nurse that he is using the walker correctly? a. One side of the walker is simultaneously advanced with the opposite foot; the process is repeated on the other side b. Each time he steps on his nonaffected side, the client advances the walker; when moving his affected side, he steps into the walker and lifts his nonaffected foot c. The client balances on both feet, most weight on his nonaffected side, and lifts the walker forward; he then balances on the walker and swings both feet forward into the walker d. The client lifts the walker in front while balancing on both feet, then walks into the walker, supporting his body weight on his hands while advancing his affected side ANSWER: D The sequence for using a walker is balance on both feet, lift the walker and place in front of you, walk into the walker (using it for support when standing on affected limb) and then balance on both feet before repeating the sequence. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 76. A man has sprained his knee and the emergency nurse is fitting him with crutches. If the man is measured while he is lying down, how does the nurse ensure correct crutch length? a. Measure the client from anterior axillary fold to sole of the foot and add 2 inches b. Add 6 inches to the length of the clients foot and measure the distance from that point to the clients axilla

c. Measure the clients axilla to his palm to get the length from the top of the crutch to the hand piece. Measure form palm to sole to determine the length of lower part of crutch d. Subtract 24 inches from the clients height to determine length of crutch from top to tip ANSWER: A Although measuring the client while he is lying down is not preferred method of fitting crutches, this formula may used successfully. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition Reference: Kozier and erbs Fundamentals of Nursing 8th edition 77. The nurse is teaching a client with a broken left ankle how to go up stairs when using crutches. Which statement by the nurse is correct? a. Place both crutches on the next step, stand on the right foot and place the left foot on the step next to the crutches b. Place the left crutch and right foot on the next step and push off with both arms then lift the left foot up to the step c. Place the right foot on the next step, then move the crutches and the left foot onto the step d. Place the right crutch and left foot on the next step; move the right crutch up onto the step, then swing the right foot up ANSWER: C The unaffected limb is advanced to the next step, then the crutches and the affected limb move to the next step (weight stays on crutches or foot of unaffected side). A handy mnemonic for clients is, Up with the good leg, down with bad meaning the good leg is used first when going up stairs, and the crutches and bad leg go to the new step first when going down stairs. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition Reference: Kozier and erbs Fundamentals of Nursing 8th edition 78. Which of the following findings would alert the nurse to notify the physician of a serious complication for the client with cast on his leg? a. Itching under the cast c. Ability of client to move toes without difficulty b. Poor capillary refill of the toes d. Pain relieved by application of ice bag to cast ANSWER: B Poor capillary refill ( a pinking up of the toes after the nailbeds are blanched by compression, which takes more than 3 seconds) is indicative of a circulatory compromise. In this situation, the likely cause is compartment syndrome: an

increase of pressure within the cast. Other signs and symptoms include pain unrelieved by usual modalities, disproportional swelling, and inability to move digits. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 79. A client whose left leg is in balanced suspension traction for a femur fracture needs to moved to a new bed. What is the best way to do this safely? a. All weights are removed from the ends of the traction ropes so the leg moves freely before the move is attempted b. The left leg is kept above the level of the heart c. Sufficient time is given to the client to move himself to the new bed at his own rate of tolerance d. The line of pull is maintained on the left leg ANSWER: D A vertical transfer is permitted, as long as manual traction is applied to maintain the line of pull, that is, the direction of the traction, or pull, which balanced suspension device supplied. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 80. Which statement by an adult with osteoarthritis indicates to the nurse that she understands her therapeutic regimen? a. I will wait until my pain is very bad before I take my pain medication, or else further on in my disease, the medication wont help at all b. Jogging for a short distances is better for my arthritis than walking for longer distances c. It would probably be a good idea for me to lose the 30 pounds my doctor recommended I lose d. I should do all my house cleaning on one day, so I can rest for the remainder of the week ANSWER: C Weight reduction can reduce stress on weight-bearing joints; because the clients physician has recommended it, we can believe that she will benefit from weight loss. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 81. In preparing a discharge teaching plan for the client with osteoarthritis, the nurse would include which of the following? a. Application of cold packs to affected joints to decrease swelling b. Client education regarding self-administration of medications c. Progressively increasing activity to point of muscle fatigue to build muscle bulk and improve rate of metabolism d. Teaching client that degenerative changes are progressive and that pain is natural sequela of age ANSWER: B Anti-inflammatory medications including salicylates and NSAID will be taken by the client indefinitely. The client must

understand the regimen; ways to monitor for (and when possible, diminish) adverse effects must also be taught. Option A: Application of heat is used. Option C: It is a degenerative disease with pain as a natural sequela of the disease, not of age. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 82. A 75-year-old male client asks the nurse about the chances of getting osteoporosis like his wife. The nurse responds correctly by stating: a. This is only a problem for women c. You are not at risk because of your small frame b. Exercise is a good way to prevent this problem d. You might think about having bone density test ANSWER: D Osteoporosis is characterized by reduced bony density and a change in bone structure, both of which increase susceptibility to fracture. Osteoporosis is a potential major health problem of all older adults and is not restricted to women Exercise may decrease the occurrence of, but will not prevent, osteoporosis. A regimen including weightbearing exercises is advised. A small frame is a risk factor of osteoporosis. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Pages 2057-2058. 83. The nurse is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first? a. A client with hepatitis A who states, My arms and legs are itching b. A client with osteomyelitis of the spine who states, I am so nauseous that I cant eat c. A client with a cast on the right leg who states, I have a funny feeling in my right leg d. A client with rheumatoid arthritis who states, I am having trouble sleeping ANSWER: C It is important to meet clients needs. In the given situations, physical stability is nurses first concern. The most unstable client should be contacted first. A client with cast that has a funny feeling in his casted leg may indicate neurovascular compromise therefore it requires immediate assessment. Reference: Kozier and Erbs. Fundamentals of Nursing: Concepts, Process and Practice. 8th edition 84. Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? a. Maintain the residual limb on three pillows at all times. c. Apply constant, direct pressure to the residual limb. b. Place a large tourniquet at the client's bedside. d. Do not allow the client to lie in the prone position. ANSWER: B

A large tourniquet should be placed in plain sight at the client's bedside (B). If severe bleeding occurs, the tourniquet should be readily available and applied to the residual limb to control hemorrhage. The residual limb should not be placed on a pillow (option A) because a flexion contracture of the hip may result. Option C should be avoided because it may compromise wound healing. Option D should be encouraged to stretch the flexor muscles and to prevent flexion contracture of the hip. SITUATION: Nurse Hannah is working at the EENT unit of the hospital. 85. A client admitted with glaucoma is being treated with miotic eye drops. Following administration of the eye drops, the nurse will note: a. Dilation of the pupils b. Constriction of the pupils c. Decreased scleral redness d. Decreased corneal edema ANSWER: B Miotic eye drops are given to a client with glaucoma to cause pupillary constriction, thereby lowering intra ocular pressure. Option A refers to the action of mydriatics, which are used for clients with cataracts. Options C and D is also incorrect since miotics do not diminish redness or decrease edema. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 86. After administering pilocarpine, the client complains of blurred vision. Which nursing action is most appropriate? a. Immediately notify the physician c. Suggesting that the client put on his glasses b. Administer antihistamine for allergic reaction d. Explaining that this is an expected side effect ANSWER: D Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after instilling the eyedrops is an expected side effect. The client may also note difficulty adapting to the dark. Option A - Because blurred vision is an expected side effect, the physician does not need to be notified. Option B - Likewise, the client doesn't need to be treated for an allergic reaction. Option C - Wearing glasses won't alter this temporary adverse effect. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 87. The client asks Nurse Hannah when he can stop instilling the eye medication for his chronic openangle glaucoma. The most appropriate response by Nurse Hannah is? a. You can stop using it when your vision improves b. Use the eye medication when you experience the symptoms associated with the disease c. Stop using the medication after 2 consecutive eye examinations

d. You cannot stop using the medication ANSWER: D To control his increased intraocular pressure, the client will need to continue taking eye medications for the rest of his life. Lifelong therapy is almost always necessary because glaucoma cannot be cured. Intraocular pressure will rise once medications are discontinued. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 88. Which of the following is contraindicated for clients with glaucoma? a. Pilocarpine b. Atropine c. Diamox d. Timolol ANSWER: B Options A, C and D are all medications used to treat glaucoma. Atropine is contraindicated for clients with glaucoma because it closes the canal of Schlemm and increases intraocular pressure. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 89. Nurse Hannah assesses a client suspected of having retinal detachment. Signs and symptoms to expect include: a. Painless decrease in vision, veil over the visual field, and flashing lights b. Veil over the visual field, increased intraocular pressure, and yellow-green halos around visual images c. Photophobia, yellow-green halos around visual images and blurred vision d. Unilateral eye inflammation, cloudy cornea, and moderately dilated pupil. ANSWER: A A patient with retinal detachment has a painless decrease in vision and vision that is cloudy or smoky with flashing lights. The patient may also indicate that a curtain or veil is over the visual field. Intraocular pressure is normal or low. Photophobia, yellow-green halos around visual images and blurred vision may occur with digoxin toxicity. Unilateral eye inflammation, cloudy cornea, and a moderately dilated pupil thats not reactive to light may occur with glaucoma. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 90. When Nurse Hannah performs a neurologic assessment on a client, her pupils are dilated and dont respond to light. The client most likely has: a. Glaucoma b. Damage to the third cranial nerve c. Damage to the lumbar spine d. Bells palsy ANSWER: B The third cranial nerve (oculomotor) is responsible for pupil constriction. When there is damage to the nerve, the pupils remain dilated and dont respond to light. Glaucoma, lumber spine injury, and Bells palsy wont affect pupil constriction.

Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 91. When assessing a client's interior eye structures with an ophthalmoscope, which action should the nurse use? a. Use a red-free filter. b. Adjust the diopters. c. Direct a wide-beam light. d. Dilate the client's pupils. ANSWER: B The diopter corresponds to the magnification power of the ophthalmoscope's lens, which is adjusted to bring the retina into focus when a client's error of refraction, such as myopia or hyperopia, causes a change in the eyeball shape. Option A produces a green beam for examination of the optic disc for pallor and recognition of retinal hemorrhages. Option C is used to examine the anterior eye. The application of an ophthalmic mydriatic (option D) should be instilled prior to extended fundoscopic visualization. 92. An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should Nurse Hannah provide to assist the client in adapting to the new hearing aids? a. Begin wearing the aids in quiet environments to experiment with adjustments. b. Wear the hearing aids for an hour a day at first, gradually increasing the time. c. Keep the volume on low until the conditions with noises are audible. d. Use one hearing aid until comfortable, then add the second aid. ANSWER: A Initially, the use of hearing aids should be restricted to quiet situations in the home (A). As adjustments occur, the client should gradually be exposed to conditions with background noise and the outdoors. Time restriction (B) is not necessary. Options C and D do not help the client adjust as well as gradually introducing various sound conditions. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 93. Nurse Hannah is preparing a teaching plan for a client with newly diagnosed glaucoma and a history of allergic rhinitis. Which information is most important for Nurse Hannah to provide the client about using overthe-counter (OTC) medications for allergies? a. Notify your healthcare provider if there is an increase in heart rate. b. Increase fluid intake while taking an antihistamine or decongestant. c. Avoid allergy medications that contain pseudoephedrine or phenylephrine. d. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. ANSWER: C OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side

effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications (C). A client with hypertension should avoid using OTC medications containing ingredients that can increase blood pressure and heart rate (A), but an increase in IOP is most important in a client with glaucoma. (B and D) may provide symptomatic relief for other side effects, such as dry mouth or eye dryness related to common agents used for allergic rhinits. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 94. Nurse Hannah is about to give nutritional teaching to a client with Menieres disease. The most suitable diet for this client is: a. A diet high in protein c. A diet high in vitamins A, D, E and K b. A diet low in sodium d. A diet restricted in carbohydrates/calories ANSWER: B Patients with Menieres disease can control their symptoms by adhering to a low sodium diet (2000mg/day). The amount of sodium is one of the many factors that regulate the balance of fluid within the body. Sodium and fluid retention disrupts the balance between endolymph and perilymph in the inner ear. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 95. With aging, changes occur in the ear that lay lead to hearing loss. Which term is used to describe progressive hearing loss associated with aging? a. Otosclerosis b. Presbycusis c. Presbyopia d. Menieres disease ANSWER: B Presbycusis is the term used to describe progressive hearing loss associated with aging. This type of hearing loss is the result of the damage to the ganglion cells of the cochlea and decreased blood supply to the inner ear. Presbyopia is the term used to describe loss of accommodative power of the lens due to aging. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 96. Which of the following risk factors would Nurse Hannah assess for a client with glaucoma? a. Family history, increased IOP, age of 45-65 c. Female gender, cigarette smoking, age greater than 65 b. History of diabetes and age greater than 55 d. Myopia, history of diabetes, and sudden severe physical exertion ANSWER: A Glaucoma is more prevalent among people older than 45 years of age, and the incidence increases with age. It is also more prevalent among men than women and in the African American and Asian populations. Family history and

increasing IOP is also a risk factor. There is no cure for glaucoma, but research continues. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 97. Nurse Hannah has been planning for home care with the family of a client who will undergo extracapsular lens extraction with an intraocular lens implant. Nurse Hannah takes care to evaluate their understanding. Which behavior by the client and/or family shows progress in understanding post-op home care instructions? a. Using a chart showing various sleeping positions, the client points to a person lying on the affected side b. The family demonstrates that the eye should be cleaned with a washcloth, soap and water c. The client demonstrates medication instillation by carefully dropping the solution on the cornea d. The family shows the nurse the sunglasses they have purchased for the client to wear post-op ANSWER: D To prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks. The nurse instructs the patient and family in applying and caring for the eye shield. Sunglasses should be worn while outdoors during the day because the eye is sensitive to light. Option A: The patient should lie on the unaffected side. Option B: A clean, damp washcloth may be used to remove slight morning eye discharge. Option C: The solution should be dropped on the conjunctiva. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 98. Nurse Hannah cares for a client following surgery for removal of a cataract in her right eye. The client complains of severe eye pain in her right eye. Nurse Hannah knows that this symptom: a. Is expected and should administer analgesic to the client c. Is expected. Hemorrhage is normal after surgery. b. Is expected and should maintain the client on bed rest d. Is unexpected and may signify hemorrhage ANSWER: D Cataract is the change in the transparency of crystalline lens of eye which may be caused by aging, trauma, congenital, systemic disease. Signs and symptoms include blurred vision, decrease in color perception, photophobia. Treated by removal of lens under local anesthesia with sedation. Intraocular lens implantation, eyeglasses, or contact lenses after surgery. Complications of surgery include glaucoma, infection, bleeding, retinal detachment. Ruptured blood vessel or suture causing hemorrhage or increased intraocular pressure; notify physician if restless, increased pulse, drainage on dressing.

Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Pages 1763-1764. 99. Which of the following should be immediately reported to the physician? a. Change in color vision c. Increased lacrimation b. Crusty yellow drainage on eyelashes d. Curtain-like shadow across visual field ANSWER: D A curtain-like shadow is a symptom of retinal detachment, which is an emergency situation. Change in color vision is a symptom of cataract. Crusty drainage is associated with many eye irritants, such as allergies, contact lenses, or foreign bodies. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Pages 1767-1768. 100. Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color? a. Black b. White c. Light green d. Medium yellow ANSWER: D Yellow is the easiest for a person with failing vision to see (D). Option A will be almost impossible to see at night because the shadows of the steps will be too difficult to determine, and would pose a safety hazard. Option B is very hard to see with a glare from the sun and it could hurt the eyes in the daytime to look at them. Option C is a pastel color and is difficult for elderly clients to see.