JUNE, 2007 NLE NP5

Situation 1- The nurse is caring for an adult admitted with diagnosis of brain tumor. He was scheduled for craniotomy. 1. A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Post operatively, the position that would be most appropriate for this client would be: A. High fowlers with knee gatch raised B. Head of the bed elevated 45 degrees with a large pillow under the head and shoulders C. Flat with small pillow under the nape of the neck D. Head of the bed elevated 20 degrees with the head turned to the operative side 2. A client is regaining consciousness after a craniotomy becomes restless and attempts to pull out her intravenous line. Which nursing intervention protects the client without increasing her ICP? A. Place her in a jacket restraint B. Tuck her arms and hands under the draw sheet C. Apply a wrist restraint to each arm D. Wrap her hands in soft mitten restraints 3. Following 3 months of rehabilitation after craniotomy, a female client is still having some motor speech difficulty. To promote the clients use of speech the nurse should: A. Respond to her crude efforts of speaking B. Correct her mistakes immediately C. Re-explain why she is having difficulty of speaking D. Speak to her in simple words and short sentences 4. A client undergoes a craniotomy for removal of her brain tumor. The nurse notes that her dressing is saturated with blood. Which of the following interventions is most appropriate? A. Replacing the dressing B. Marking the area of drainage on the dressing C. Reinforcing the dressing and notifying the doctor immediately D. Doing nothing because this is normal occurrence 5. After craniotomy, what is your primary goal? A. Prevent infection B. Prevent secondary surgery C. Prevent increased ICP D. Prevent hemorrhage Situation 2- Technique of therapeutic communication should be utilized and incorporated into nursing practice. 6. When a nurse establishes a therapeutic relationship with a client, which of the following is the primary focus of the clients care? A. The medical diagnosis B. The nursing diagnosis C. The clients social interaction D. The clients needs and problems 7. Which of the following is the overall purpose of therapeutic communication? A. To provide emotional support B. To elicit cooperation C. To facilitate a helping relationship D. To analyze clients problems Rationale: Although other choices are appropriate, Option C is the answer- it is encompassing. Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when working with clients. Communication is the means by which a therapeutic relationship is initiated, maintained, and terminated. To have an effective therapeutic communication the nurse must consider privacy and respect of boundaries, use of touch, and active listening and observation (Videbeck, 107). 8. In which of the following situations would communications be LEAST likely hindered? A. Mrs. D, 45 years old, is admitted to the hospital for Stage IV cervical cancer. B. Mr. T, 70 years old, is admitted for fractured tibia. He speaks Khmer only. C. Mrs. L. 30 years old is admitted to the hospital for the first time for acute appendicitis. D. Mrs. R, 50 years old, diabetic, is admitted to the hospital after a stroke. She is right hemiplegia. Rationale: There are 2 factors that may affect communication namely, Personal and Environmental Factors. Personal factors that can impede accurate transmission or interpretation of messages include emotional factors (e.g., mood, knowledge levels, language use) and social factors (e.g., previous experience, differences in culture, language). Patients with right sided hemiplegia has difficulty in speaking. Differences in language in Option B and difficulty in speaking in Option D are factors that make it impossible to have an effective communication since the message cannot be understood. Options A and C both deals with the pain which affects the mood of the patient. The pain

of cervical cancer is worst compared to an acute pain suffered by the patient with AP. Although pain may affect the mood of the sender/ receiver, the messages can still be understood and among the choices C is the least to hinder communication. Source: Varcarolis, 248 http://www.healthopedia.com/hemiplegia/symptoms.html 9. Which of the following communication technique is MOST effective in dealing with covert communication? A. Validation B. Evaluation C. Listening D. Clarification 10. Which of the following is MOST important in fostering a positive relationship? A. The nurse must fully share the patients feelings before she can develop her goal for her nursing care. B. The nurse recognizes that some patients regress when confronted with illness C. The nurse functions as a positive role model to encourage health oriented patient behavior. D. Needs to understand that patients may test her before he can accept and trust her. Situation 3- The following questions pertain to Musculoskeletal System of aging persons. 11. Which of the following behaviors contribute to osteoporosis? A. Knee bends, shopping, and weight lifting B. Physical activity, dancing and swimming C. Smoking and lack of exercise D. Drinking tea, deep breathing and losing weight 12. As people get older, they lose height (Become shorter). This sis due to A. The fact that they dont stand up straight B. Loss of bone mass in the vertebral discs C. Inaccurate measurement D. The rest of the population has grown taller 13. As one ages, muscle mass (that is muscle size): A. Increases B. Decreases C. Stays about the same D. Can go either way 14. As a result of changes in long bones and spinal column, the gait of older people: A. Becomes like a dancer B. Is more steady C. Is less stable and balanced when walking D. Hardly changes at all 15. Changes in the bone of older people make which of the following a major danger? A. Allergy B. Fractures C. Infection D. Contagion Situation 4 - Stress can bring about various human reactions that may result to illness or enhance ones coping mechanism. Stress also triggers local and general adaptation syndrome. 16. Which of the following BEST describes the general adaptation syndrome? A. It is a Psychological response to stress B. It is a Behavioral response to stress C. It is a Physiologic response to stress D. It is a Sociocultural response to stress 17. Which of the following levels of anxiety is BEST for clients learning? A. No anxiety B. Moderate C. Mild D. Severe Rationale: Levels of anxiety Anxiety Level Mild

Responses Sharpened senses Increased motivation Effective problem solving INCREASED LEARNING ABILITY

Moderate

Severe

Panic

Narrowed perceptual field Selectively attentive Increased use of automatism Cannot complete task Cannot solve problem Feels awe, dread, or horror Ritualistic behavior Perceptual field reduced to focus on self Cannot process environmental stimuli Distorted perception Loss of rational thought May be suicidal

Source: Videbeck, 251 18. Which of the following defense mechanism is consciously used in coping mechanism with stress? A. Regression B. Suppression C. Repression D. Projection Rationale: Suppression is the answer. Suppression is consciously done while repression is unconsciously done. Suppression is replacing the desired gratification with one that is more readily available (Videbeck, 52). Repression is excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness (Videbeck, 51). Regression is moving back to the previous developmental stage to feel safe or have needs met (Videbeck, 51). Projection is the unconscious blaming of unacceptable inclinations or thoughts on an external object (Videbeck, 51). 19. Which of the following models identifies ability to cope with stress, practice and norms of the peer group, effect of social environment and the resources used to deal with stress as determinants to stress and stress reactions? A. Stimulus based model B. Transaction based model C. Adaptation based model D. Response based model 20. The purpose of the first stage of the General Adaptation Syndrome is which of the following? A. Determine the causes of danger B. Alert the individual to danger C. Present the individual from having an unpleasant experience D. Mobilize energy needed for adaptation Situation 5 - Sensory deprivation is experienced by most people in any setting whether they are patients confined in hospitals, workers assigned in mining industries or a family member assigned in far place. 21. Which of the following will LEAST likely result to sensory deprivation? A. Reduced sensory input in the case of patients who have just been operated on glaucoma B. Elimination of order or meaning form input in the case of ICU patients or was in reverse isolation C. Increased sensory input brought about by unlimited visitors from families and friends D. Restriction of the environment in patients who are absolute on bedrest 22. Which of the following are observed in sensorially deprived adult and elderly people because of deafness? A. They show greater interdependence than hearing adult B. They become more flexible in daily routine C. They prefer interaction with hearing adults D. They show poor social judgment 23. Which nursing intervention would be appropriate for client with hyperthesia? A. Minimal use of direct touch B. Firm pressure when touching body parts C. Vigorous hair brushing D. Frequent back rubs 24. A post-operative blind patient needs to be assisted for ambulation. Which of the following should the nurse do in ambulating a client with visual impairment? A. Stand on the clients dominant side and grasp the clients arm B. Stand on the clients dominant side slightly in front of the client, allowing the client to grasp the nurses arm C. Stand on the clients nondominant side, approximately one step behind the client, grasping the clients arm. D. Stand slightly in front of the clients nondominant side allowing the client to grasp the nurse arm 25. Which of the following is an appropriate communication n method for clients with hearing impairment? A. Restrict use of the clients hands B. Talk side by side with the client C. Use visual aide and gestures to enhance the spoken word D. Speak loud enough or shout if you may so that the client will be able to hear you

Situation 6 - As a nurse generalist you should be familiar with the Defense Mechanisms used by patients. 26. Kris is admitted to the ICU with chest pain, an abnormal ECG and elevated enzymes. When the significance of this is explained to her, she says, I cant be having a heart attack. No way. You must be mistaken. The nurse suspects the client is using which defense mechanism? A. Denial B. Projection C. Rationalization D. Compensation Rationale: Kris manifested denial. Denial is the failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue (Videbeck, 51). Other options are inappropriate. Projection is the unconscious blaming of unacceptable inclinations or thoughts on an external object (Videbeck, 51). Rationalization is excusing own behavior to avoid guilt, responsibility, conflict, anxiety or loss of self-respect (Videbeck, 51). Compensation is overachievement in one area to offset real or perceived deficiencies in another area (Videbeck, 51). 27. Robin was released from prison for selling narcotics, has been rehabilitated and now works for youth drug prevention agency. Robin is reflecting which of the following defense mechanism? A. Denial B. Sublimation C. Displacement D. Identification Rationale: Option B is the answer. Sublimation is exhibiting acceptable behavior to make up for or negate unacceptable behavior (Videbeck, 52). Denial is the failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue (Videbeck, 51). Displacement is the ventilation of intense feelings towards persons less threatening than the one who aroused those feelings (Videbeck, 51). Identification is modeling actions and opinions of influential others while searching for identity or aspiring to reach a personal, social or occupational goal (Videbeck, 51). 28. After initial assessment Luke suddenly urinated on his pants A. Sublimation B. Denial C. Dissociation D. Regression Rationale: Urinating on the pants can be seen in toddlers (toilet training), therefore Mr. Pascual regress to its previous developmental stage. Regression is moving back to the previous developmental stage to feel safe or have needs met (Videbeck, 51). Sublimation is exhibiting acceptable behavior to make up for or negate unacceptable behavior (Videbeck, 52). Denial is the failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue (Videbeck, 51). Dissociation is dealing with emotional conflict by a temporary alteration in consciousness or identity (Videbeck, 51). 29. In patients with dissociative disorders, the defense mechanism most often used to block traumatic experiences is: A. Fixation B. Denial C. Reaction Formation D. Repression Rationale: According to Freud - Repression, an unconscious action that exhibits a forgotten history is one of the defense mechanisms used in patients with personality disorder (Varcarolis, 377). Repression is excluding emotionally painful or anxiety provoking thoughts and feelings from conscious awareness (Videbeck, 51). Fixation is immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage (Videbeck, 51). Denial is the failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue (Videbeck, 51). Reaction formation is acting the opposite of what one thinks or feels (Videbeck, 51). 30. The defense mechanism utilized by manic patients to cover up depression is: A. Displacement B. Denial C. Reaction formation

D. Compensation Rationale: Reaction formation is acting the opposite of what one thinks or feels (Videbeck, 51). Depressed patient act in opposite by acting like there mood is elevated (mania) although they are actually depressed. Displacement is ventilation of intense feelings toward persons less threatening than the one who aroused those feelings (Videbeck, 51). Denial is the failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue (Videbeck, 51). Compensation is overachievement in one area to offset real or perceived deficiencies in another area (Videbeck, 51). Situation 7 - Nurse Djohn is caring for a client who is experiencing panic attack. Anxiety is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response and a feeling of apprehension caused by anticipation of danger (Schultz, 56). 31. Which intervention would be most appropriate? A. Tell the client hes all right and there is no need to panic B. Explain to the client that theres no need to worry because hes safe C. Give the client a detailed explanation of his panic reaction D. Speak to client in short, simple sentences Rationale: Options A and B are false reassurance and advising, therefore untherapeutic. Giving a detailed explanation is inappropriate since patient in panic state lack the ability to concentrate (Doenges, 85). Speaking in brief statement using simple words is the most appropriate intervention for the client experiencing panic anxiety (Doenges, 86). Option D is the answer. 32. KC reports that she often feels a choking sensation in her throat, a racing heart, dizziness and fearfulness. All of these symptoms have occurred almost daily for the past 3 months. Suspecting a psychological component to these symptoms, what would Nurse Djohn anticipate administering? A. Benzodiazepines B. Tofranil C. Clozapine D. Lithium carbonate Rationale: The answer is Benzodiazepines (Anxiolytic). Benzodiazepines have proved to be the most effective in relieving anxiety and are the drugs most frequently prescribed. Benzodiazepines produce their effect by binding to a specific site on GABA receptor (Videbeck, 37). Imipramine (Tofranil)- a cyclic compound antidepressant. The cyclic compounds became available in the 1950s and for years become the treatment of choice for depression although they cause varying degrees of sedation, orthostatic hypotension and anticholinergic side effects (Videbeck, 33). Clozapine (Clozaril) is an antipsychotic. Major actions of all antipsychotics in the nervous system is to block receptors for the neurotransmitter dopamine (Videbeck, 28-29). Lithium is the most established mood stabilizing agents. Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the clients mood, preventing or minimizing the highs and lows that characterized bipolar illness, and treating acute episodes of mania (Videbeck, 35). 33. Edwin has generalized anxiety disorder. Which statement is true about this client? A. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder B. Generalized anxiety disorder is characterized by anxiety that last longer than 6 months C. The client has regular obsessions D. Relaxation techniques and psychotherapy are necessary for care Rationale: Option B is the answer. Generalized anxiety disorder is characterized by at least 6 months of persistent and excessive worry and anxiety (Videbeck, 255). Option A is Posttraumatic stress disorder (PTSD). PTSD is characterized by re-experiencing of an extremely traumatic event, avoidance of stimuli associated with the event, numbing of responsiveness, and persistent increased arousal; it begins within 3 months to years after the event and may last a few months or years (Videbeck, 255). Option C is a characteristic of Obsessive-compulsive disorder (OCD). OCD involves obsessions (thought, impulses, or images) that cause marked anxiety and/or compulsions (repeated behaviors or mental acts) that attempt to neutralize anxiety (Videbeck, 255). Option D is too general and may be applicable to anxious patients. Therefore not the answer. 34. The client is pacing and complains of racing thoughts. The nurse asks the client if something upsetting happens, and the client response is vague and not focused on nurses question. The nurse assesses the clients level of anxiety as: A. Mild B. Moderate C. Severe D. Panic

Rationale: Option C is the answer. Severe anxiety is characterized by preoccupation with feelings of discomfort ( racing thoughts)/ sense of impending doom; reduced range of perception (vague response to the nurse); interference in the effective functioning (pacing); increased pulse/ respiration with reports of dizziness, tingling sensations, headache and so on (Doenges, 85). Mild anxiety is characterized by alertness, more awareness of the environment, and focused attention (Doenges, 85). Mild anxiety is not the answer since the client is not alert and not aware of the environment as evidenced by the clients response that is vague and not focused. Moderate anxiety is characterized by narrower perception and increased concentration (Doenges, 85). Moderate anxiety is not the answer since the client doesnt have increased concentration as evidenced by the clients response that is vague and not focused. Panic Anxiety is characterized by disruption of the ability to concentrate and the client does not have a realistic perception of what is happening (Doenges, 85). The patient may have delusions and hallucinations (Videbeck, 251). It is not the answer since base on the above situation there is no alteration in perception. 35. Which of the following is a behavior is a manifestation of anxiety, except: A. Tachycardia B. Hyperventilation C. Tachypnea D. Panic Rationale: Anxiety is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response and a feeling of apprehension caused by anticipation of danger (Schultz, 56). Panic is the answer, it is not a manifestation but rather an Anxiety level (Videbeck, 251). Other choices are manifestations (Videbeck, 251). Situation 8 - A 23 year-old man was voluntarily admitted to the inpatient unit with a diagnosis of paranoid schizophrenia. 36. As Nurse Sitti approaches the client, he says, If you come any closer, Ill die. This is an example of: A. Delusion B. Illusion C. Hallucination D. Ideas of reference Rationale: Option A is the answer. Delusion is a fixed false belief. In the above situation the patient is experiencing persecutory or paranoid delusion. This means that the client believes that others are planning to harm him etc (Videbeck, 155, 288). Option B is an inappropriate answer. Illusion is a misperception of actual environmental stimuli (Videbeck, 288). Hallucination is a false sensory perceptions or perceptual experiences that do not really existing reality. Hallucination involves the 5 senses, auditory hallucination is the most common (Videbeck, 156). Option C is also an inappropriate, the above situation does not manifest visual hallucination since there is no visual distortion but rather a false belief that the nurse is going to harm him. Option D is also incorrect, Ideas of reference is a false impression that the external events have special meaning for a person (Videbeck, 276). 37. Delusion is: A. Psychomotor disturbance B. Mood disturbance C. Disturbance of perception D. Disturbance of thought Rationale: Option D is the answer. Thought process refers to how client thinks. Delusion is a fixed false belief and a disturbance of thought (Videbeck, 155, 288). Other options are wrong. Psychomotor disturbance relates to the psychological processes associated with muscular

movement and to the production of voluntary movements. Delusion is not a psychological disturbance. Mania ia an example of a mood disturbance. Mania is a distinct period during which the mood is abnormally and persistently elevated, expansive and irritable.
Hallucination not delusion is a disturbance of perception. Hallucination is a false sensory perceptions or perceptual experience that do not really exist (Videbeck, 541). http://dictionary.webmd.com/terms/psychomotor.xml 38. When communicating with a paranoid client, the main principle is to: A. Use logic and be persistent B. Express doubt and do not argue C. Provide an anxiety-free environment D. Encourage ventilation of anger 39. The client tells Nurse Sitti that hes scheduled to meet the Pope a special time, making it impossible for the client to leave his room for dinner. Which of the following responses by the nurse is most appropriate? A. The Pope told me to take you to dinner. B. Its meal time. Lets go so that you can eat.

C. Your physician expects you to follow the units schedule. D. People who dont eat on this unit arent being cooperative. Rationale: Option B is the answer, others are inappropriate response. Option A is reinforcing the clients delusion-untherapeutic. Option C is inappropriate, the nurse should exercise autonomy. Option D is judgmental-untherapeutic. Using the process of elimination Option B is the answer. It is a consistent and straightforward. Being particularly straightforward is essential for the success of the nurse-client relationship for paranoid patients (Videbeck, 352). 40. A schizophrenic patient who began taking haloperidol 1 week ago now exhibit jerking movements of the neck and mouth. These are signs of: A. Dystonia B. Neuroleptic Malignant syndrome C. Akathisia D. Pseudoparkinsonism Rationale: Dystonia is the answer. Dystonia includes acute muscular rigidity and cramping, a stiff and thick tongue with difficulty in swallowing and in severe cases, laryngospasm and respiratory difficulties (Videbeck, 29-30). Spasms or stiffness in the muscle groups can produce torticollis (twisted head and neck), opisthotonus (tightness in the entire body with the head and an arched neck), or oculogyric crisis (eyes rolled back in a locked position). NMS is potentially fatal. Major symptoms of NMS are rigidity, high fever, autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium and elevated levels of enzymes, particularly creatine phosphokinase (Videbeck, 30-31). Akathisia is reported by the client as the intense need to move about. The client has inability to sit still or rest which often leads the client to discontinue their medication (Videbeck, 30). Pseudoparkinsonism resembles the symptoms of Parkinsons disease and include stiff, stooped posture, a masklike facies, decreased arm swing; a shuffling, festinating gait; cogwheel rigidity; drooling; tremor; bradycardia; and coarse pill rolling movements of the thumb and fingers while at rest (Videbeck, 30). Situation 9 - A 34-year old is hospitalized with bipolar disorder. 41. Nurse Drztyn knows that the major factor that distinguishes a bipolar disorder is the: A. Higher incidence in women B. Severity of the depression C. Genetic etiology D. Presence of mania 42. At 2 a.m. Nurse Rholyn finds him phoning friends all across the country to discuss his plan for eradicating world hunger. His excited explanations are keeping the entire unit awake, but he wont quiet down. The nurse caring for him knows the drug most likely to be prescribed for this client is: A. Amitriptyline (Elavil) B. Phenelzine (Nardil) C. Lithium carbonate (Eskalith) D. Diazepam (Valium) Rationale: Lithium is the most established mood stabilizing agents. Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the clients mood, preventing or minimizing the highs and lows that characterized bipolar illness, and treating acute episodes of mania (Videbeck, 35). Amitriptyline (Elavil) is an antidepressant. It is thought to act primarily by blocking the reuptake of norepinephrine and to a lesser degree, serotonin (Varcarolis, 69). Phenelzine (Nardil)is an antidepressant (MAOI). They act by inhibiting the enzyme and interfering in the destruction of the monoamine neurotransmitters (Varcarolis, 71). Diazepam (Valium) is used to treat extrapiramidal side effects of neuroleptics (Videbeck, 30). Valium has the ability to bind to specific receptors adjacent to the GABA receptors (Varcarolis, 74). 43. Supportive therapy for a client who is exhibiting manic behavior may include all of the following EXCEPT: A. Cognitive therapy B. Interpersonal therapy C. Psychoanalysis D. Problem-solving therapy 44. The client is creating considerable chaos in a day treatment program with dominating and manipulative behavior. Which of the following nursing intervention is most appropriate? A. Recommend the client to be hospitalized for treatment B. Allow the peer group to intervene C. Describe acceptable behavior and set realistic limits with the client D. Tell client that his behavior is not appropriate 45. The client is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse expect to include in the clients plan of care? A. Watching television

B. Leading a group activity C. Reading the newspaper D. Cleaning the dayroom tables Situation 10 - A client is admitted with diagnosis of Parkinsons disease. 46. Which of the following is an initial sign of Parkinsons disease? A. Tremor B. Rigidity C. Bradykinesia D. Akinesia 47. The nurse develops a teaching plan for a client newly diagnosed with Parkinsons disease. Which of the following topics that the nurse plans to discuss is the most important? A. Maintaining a balanced nutritional diet B. Maintaining a safe environment C. Enhancing the immune system D. Engaging in diversional activity Rationale: In dealing with patient with Parkinsons disease SAFETY is the priority. Maintaining balance in nutrition, rest and activity, nutrition, hydration and elimination comes next. Option C is inappropriate, Parkinsons disease does not affect the immune system. Although Diversional activity is appropriate patients safety is the priority (Videbeck, 483, 487). 48. When does the nurse encourage a client with Parkinsons disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? A. Early in the morning, when the clients energy level is high B. Immediately after a rest period C. When family members will be available D. To coincide with peak action of drug therapy 49. Which goal is the realistic and appropriate for client diagnosed with Parkinsons disease? A. To cure the disease B. To stop the progression of the disease C. To begin preparations for terminal care D. To maintain optimal body function Rationale: Option D is the answer. One of the goals for patients with dementia is to maintain an adequate balance of activity and rest, nutrition, hydration, and elimination. Options A and B are wrong, medications only slows down, not stop or cure, the disease. Although Option C can be appropriate, Option D offers the best and more specific answer. 50. The client needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which statements is the nurses best initial response in this situation? A. Suggest to the client that if she insists on self care, she should at least modify her routine B. Tell the client firmly that she needs assistance and help her with her care C. Praise the client for her desire to be independent and give her extra time and encouragement D. Tell the client that she is being unrealistic about her abilities and accept that she needs help Rationale: One of the goals for patients who has dementia is for them to function as independently as possible. Praising the client for her desire to be independent is the BEST INITIAL response for the nurse. This will reinforce the clients desire to be independent and will promote cooperation. Options B and D is contrary to the nursing goals. Option may be correct but it doesnt reinforce independence (Videbeck, 486). Situation 11 - A 46-year old is admitted to the hospital because her family is unable to manage her constant hand washing rituals. 51. Her family reports she washes her hands at least 30 times each day. The nurse noticed the clients hands are reddened, scaly and cracked. The main nursing goal is to: A. Remind the client several times of her appointment B. Limit the number of hand washings C. Tell her it is her responsibility to be there on time D. Provide ample time for her to complete her rituals Rationale: Based on Maslows hierarchy of Needs it is physiologic first before psychologic. Since the patient already had a reddened, scaly and cracked hands the nurse should limit hand washing to prevent further skin breakdown. Option D is only appropriate if the patients skin integrity is okay. Options A and C are distractors, an appointment was not stated in the above situation. 52. Which of the following is an appropriate treatment for this client? A. A structured schedule of activities B. An unstructured schedule of activities

C. Intense counseling D. Negative reinforcement every time she performs her rituals 53. The most effective way for the nurse to intervene with her hand and face washing is to: A. Allow her a certain amount of time each shift to engage in this behavior B. Interrupt the activity briefly and frequently C. Lock the door to her room and restrict access to the bathroom D. Tell her to stop each time she is observed doing it 54. The client is also constipated and dehydrated. Which nursing intervention would the client be most likely to comply with? A. Drinking ensure between meals B. Drinking extra fluids with meals C. Drinking 8 oz water every hour between meals D. Drinking adequate amounts of fluid during the day 55. Upon admission she was also dehydrated and underweight. The nurse and the client will know that discharge planning is appropriate when the client: A. Is able to start talking about her guilt and anxiety B. Limits her hand and face washing to few times a day C. Regains her normal body weight D. Expresses a desire to leave the hospital Situation 12 - Angel, 16 year old was committed to a mental health facility with diagnosis of personality disorder. He has a history of promiscuity and running away. He tells the staff I cant stand this place, I want to go away. 56. How would the nurse deal effectively with Angels threat to run away? A. Tell him firmly that if he does not control herself, the staff will help him control herself B. Ignore the threat C. Tell him to stay in her room D. Lock him in her room 57. The early experiences of Angel may indicate a history of: A. Severe temper tantrums B. Failure to identify positively with father C. Severe parenteral rejection D. Failure in interpersonal relationship 58. How would you describe parenteral rejection? A. Failure to identify with father B. Lack of recognition as a person C. Lack of capacity to trust others D. Lack of parental love and discipline 59. What should the nurse do to prevent Angel from manipulating and dominating others? A. Ignore his demands B. Protects others from being manipulated C. Isolate Angel D. Observe him closely 60. In dealing with manipulative behavior, the nurse should convey an attitude of: A. Active friendliness B. Consistency C. Permissiveness D. Love and understanding Situation 13 - The client is admitted to outpatient surgery for cataract extraction on the right eye. 61. The client asks, What does the lens of my eye do? Nurse Euler should explain that the lens of the eye: A. Holds the rods and cones B. Focuses light rays into the retina C. Produces aqueous humor D. Regulates the amount of light entering the eye 62. The client would most likely to complain of which symptoms? A. Eye pain and irritation that worsens at night B. Halos and rainbow around lights C. Blurred and hazy vision D. Eye strain and headache when doing close work 63. Nurse Allen is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into a clients right eye before cataract removal surgery. This preparation acts in the eye to produce: A. Dilatation of the pupils and constriction of blood vessels B. Dilatation of the pupils and blood vessels C. Constriction of the pupils and constriction of the blood vessels

D. Constriction of the pupil and dilatation of blood 64. A short time after cataract surgery, the client complains nausea. Which of the following represents the nurses best course of action? A. Instruct the client to take a few deep breaths until the nausea subsides B. Tell the client to call the nurse promptly if vomiting occurs C. Explain that this is a common feeling that will pass quickly D. Medicate the client with antiemetic, as ordered 65. Discharge planning would include: A. Lifting objects is acceptable B. Wearing eye patches for the first 72 hours C. Bending the knees and keep the head straight D. Bending the waist is acceptable if slowly done Situation 14 - A nurse must be aware of the latest issues on Child Abuse and Family Violence. 66. Nurse Yvette was taking care of a 24 month old child who sustained fracture. The nurse asked the mother what caused the fracture. Which of the following responses by the mother will the nurse suspect for an abuse? A. My child drops on the floor while running B. My child fell on the floor while sitting on a high chair C. My child fell from the stairs, it was horrible D. My child had an accident while ridding a tricycle Rationale: Warning signs of child abuse includes unusual injuries for the childs age and level of development (Videbeck, 201). Option D is the answer. Option D is only appropriate for a 3 year old child other options are consistent with the childs developmental stage. Source: http://en.wikipedia.org/wiki/Child_development_stages#Toddlers_.2812-24_months.29 67. Hiyas, a 16 years old young lady was left with her stepfather and with a mother who is working in the office the whole day. As a nurse, what would be your advice? A. Tell the mother to keep watching her daughter B. Tell the child to get to her regular activities C. Ask the child to get away from her stepfather D. Let the child stay with the relatives Rationale: Option B is the best answer. Options A, C and D are too judgemental and advising is untherapeutic. 68. The best way a nurse can advise an abused child is to call the: A. Police station B. Bantay Bata 163 C. School D. Parish Rationale: Option A is the correct answer. The police is the proper government agency who has the authority over this case. Bantay Bata is a 24/7 hotline which provides telephone counseling and referral of reported cases of child abuse. More importantly, it provides rescue services in response to crisis situations, with local government and police assistance. Trained social workers field about 5,000 calls every day, with almost 1.3 % of these calls necessitating attention. The school and the parish are not the proper agency to call.` Source: http://www.abscbnfoundation.org/programs/bantaybata/index.html 69. When planning the care for an abused child, which of the following measures would be most important to include? A. Being compassionate and empathetic B. Teaching the client about abuse and the cycle of violence C. Explaining to the client his or her personal and legal rights D. Helping the client develop safety plan Rationale: Option D is the answer. SAFETY is the priority. The first part of treatment for child abuse or neglect is to ensure the childs safety and well-being. This may involve removing the child from the home, which also can be traumatic. Given the high risk for psychological problems, a thorough psychiatric evaluation is also indicated (Videbeck, 201). Other options, although applicable, can be done later after the clients safety is ensured. 70. During the session with the nurse, a client who is being abused states, I dont know what to do anymore. He doesnt want me to go anywhere while hes at work, not even to visit my friends. Which of the following nursing diagnosis would the nurse formulate in respect to this information? A. Risk for violence related to abusive husband, as evidenced by victims statement of being battered. B. Low self esteem related to victimization, as evidenced by not being able to leave the house C. Powerlessness related to abusive husband, as evidenced by inability to make decisions D. Ineffective coping related to victimization, as evidenced by crying

Situation 15 - Mark was brought to the National Center for Mental Health for substance abuse. 71. Which of the following behaviors would indicate stimulant intoxication? A. Relaxed inhibitions, increased appetite, distorted perceptions B. Depersonalization, dilated pupils, visual hallucinations C. Slurred speech, unsteady gait, tremors D. Hyperactivity, talkativeness, euphoria Rationale: Option D is the answer. Intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity, talkativeness, anxiety, grandiosity, hallucinations, anger, fighting, and impaired judgment (Videbeck, 384). Option C is for inhalant intoxication; other choices does not refer to stimulant intoxication. 72. Which of the following statements would indicate the teaching about Naltrexone (Revia) had been effective? A. Ill get sick if I used heroin on this medication. B. This medication will block the effects of any opioid substance I take. C. If I use opioid while taking naltrexone, Ill become extremely ill. D. Using naltrexone may make me dizzy. 73. Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which of the following nursing assessments is essential before giving the dose of this medication? A. Determining when the clients last use of an opiate B. Monitoring the client for tremors C. Assessing the clients blood pressure D. Completing a thorough physical assessment Rationale: Option C is the best answer. Clonidine was initially marketed for high blood pressure, but it is also an effective somatic treatment for some chemically dependent individuals when combined with naltrexone (Varcarolis, 777). 74. The nurse has provided an in-service program on impaired professionals. She knows that teaching has been effective when staff identify the following as the greatest risk for substance abuse among professionals: A. Most nurses come from dysfunctional families and the risk for developing addiction B. Most nurses are exposed to various substances and believe they are not risk to develop the disease C. Most nurses are codependent in their personal and professional relationships. D. Most nurses have preconceived ideas about what kind of people become addicted 75. The client tells the nurse that she takes a drink every morning to calm her nerves and stops her tremors. The nurse realizes that the client is at risk for: A. A neurological disorder B. An anxiety disorder C. Physical dependence D. Psychological addiction Situation 16 - A client is admitted with diagnosis of Alzheimers disease. 76. When developing a plan of care for a client with Alzheimers disease who is experiencing moderate impairment, which of the following types of care would the nurse expect to include? A. Managing complex medication schedule B. Constant supervision and total care C. Considerable assistance with activities daily living D. Supervision of risky activities, such as shaving 77. Which of the following would be priority to include in the plan of care for client with Alzheimer s disease who is experiencing difficulty processing and completing complex tasks? A. Repeating the directions until the client follows them B. Asking the client to do one step of the task at a time C. Maintaining routine and structure for the client D. Demonstrating for the client how to do the task 78. Clients with Alzheimers disease may have delusions about being harmed by the staff and others. When the client expresses fear of being killed by staff, which of the following responses would be most appropriate? A. What makes you think we want to kill you? B. We like you too much to want to kill you. C. You are in a hospital. We are nurses trying to help you. D. Oh dont be silly. No one wants to kill you here. 79. When helping the families of clients with Alzheimers disease to cope with vulgar or sexual behaviors, which of the following suggestions would be most helpful? A. Ignore the behaviors, but try to identify the purposes B. Give feedback on the inappropriateness of the behaviors C. Employ anger management strategies D. Administer the prescribed risperidone (Risperdal)

80. The nurse determines that the son of the client with Alzheimers disease needs further education about the disease when he makes which of the following statements? A. I didnt realize the deterioration would be so incapacitating. B. The Alzheimers support group has so much good information. C. I get tired of the same old stories, but I know its important for Dad. D. I woke up this morning hoping that my old Dad would be back. Situation 17- As a nurse you should be familiar with the common psychotropic medications. Rationale: Psychotropics, or psychotropic medications, are drugs that affect the mind / perception, behavior and mood. Source: http://bipolar.about.com/od/medications/g/gl_psychotropic.htm 81. The antihypertensive drug that is also the treatment of choice for opioid withdrawal is: A. Nocotine patch B. Catapres C. Naltrexone D. Methodone Rationale: Option B is the answer. Clonidine (Catapres) was initially marketed for high blood pressure, but it is also an effective somatic treatment for some chemically dependent individuals when combined with naltrexone. Clonidine is a nonopioid suppresser of opioid withdrawal symptoms. It is also nonaddicting (Varcarolis, 777). Other choices are not antihypertensive drugs. A nicotine patch is a transdermal patch that releases nicotine into the body through the skin. It is usually used as a method to quit smoking. Naltrexone (Revia) is a relatively pure antagonist that blocks the euphoric effects of opioids. It has low toxicity with few side effects. It has also been approved for the treatment of alcoholism because it decreases the pleasant, reinforcing effects of alcohol (Varcarolis, 777). Methadone (dolophine) is a synthetic opiate that at certain doses blocks the craving for, and effects of, heroin. Methadone is the only medication currently approved for the treatment of the pregnant opioid addict (Varcarolis, 776). Source: http://en.wikipedia.org/wiki/Nicotine_patch 82. James is prescribed with MAOI. MAOI is contraindicated with the intake of the following EXCEPT: A. Cottage cheese B. Lasagna C. Pizza D. Peanuts Rationale: Foods (containing tyramine)to avoid when taking MAOIs: Aged meats such as pepperoni and salami. Italian beans, tofu, banana peel, overripe fruit, avocado All tap beers and microbrewery beer Soysauce or soybean condiment Yogurt, sour cream, PEANUTS, brewers yeast, MSG Mature or aged cheese or dishes made with cheese, such as LASAGNA or PIZZA. All cheese is considered aged EXCEPT for COTTAGE CHEESE, cream cheese, ricotta cheese and processed cheese slices. Option A is the answer. 83. When the nurse is going to administer MAOI, what is the primary side effect to monitor resulting from interaction with MAOI and creation drugs or foods? A. Renal Failure B. EPS C. Hypertensive crisis D. Sedation Rationale: Hypertensive Crisis is the answer. Particular concern with MAOIs is the potential for a life-threatening hypertensive crisis if the client ingests food that contains tyramine or takes sympathomimetic drugs. Because the enzyme MAOI is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, which causes severe hypertension, hyperpyrexia, tachycardia, diaphoresis, and cardiac dysrhythmias (Videbeck, 34). Renal Failure is a toxic effect of lithium (Videbeck, 36). EPS is a serious neurologic side effect of antipsychotic drugs (Videbeck, 29). Sedation is a side effect of benzodiazepines (Videbeck, 38). 84. Nurse TM is taking a history of a patient who has been on anti-psychotic medication. She is assessing extrapyramidal symptoms. A side effect is generally considered irreversible is: A. Dystonia B. Akathisia

C. Tardive dyskenisia D. NMS Rationale: Tardive dyskenisia is the answer. Tardive dyskenisia is a syndrome of permanent involuntary movements. Once it has developed, TD is irreversible, although decreasing or discontinuing antipsychotic medications can arrest its progression. The symptoms of TD includes involuntary movements of the tongue, facial and neck muscles, upper and lower extremities and truncal musculature (Videbeck, 31). Other choices are reversible. Dystonia includes muscular rigidity and cramping, a stiff and thick tongue with difficulty of swallowing and in severe cases, laryngospasm and respiratory difficulties (Videbeck, 29). Akathisia is reported by the client as the intense need to move about. The client has inability to sit still or rest which often leads the client to discontinue their medication (Videbeck, 30). NMS is potentially fatal. Major symptoms of NMS are rigidity, high fever, autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium and elevated levels of enzymes, particularly creatine phosphokinase (Videbeck, 30-31). 85. Andrew has been taking Thorazine for 10 days and becomes very restless and tells the nurse, I cant sit still. The nurse identified that this is A. Dystonia B. NMS C. Akathisia D. Pseudoparkinsonism Rationale: Akathisia is the answer. Akathisia is reported by the client as the intense need to move about. The client has inability to sit still or rest which often leads the client to discontinue their medication (Videbeck, 30). Dystonia includes muscular rigidity and cramping, a stiff and thick tongue with difficulty of swallowing and in severe cases, laryngospasm and respiratory difficulties (Videbeck, 29). NMS is potentially fatal. Major symptoms of NMS are rigidity, high fever, autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium and elevated levels of enzymes, particularly creatine phosphokinase (Videbeck, 30-31). Pseudoparkinsonism resembles the symptoms of Parkinsons disease and include stiff, stooped posture, a masklike facies, decreased arm swing; a shuffling, festinating gait; cogwheel rigidity; drooling; tremor; bradycardia; and coarse pill rolling movements of the thumb and fingers while at rest (Videbeck, 30). Situation 18 - A nurse generalist should have enough knowledge about alcohol abuse and withdrawal. 86. A client was admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: A. Begin after 7 days B. Not occur at all because the time period for their occurrence has passed C. Begin anytime within the next 1-2 days D. Begin within 2-7 days Rationale: Option C is the answer. Options A and D are too late; Option B is too early. Symptoms of withdrawal usually begin 4-12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting (Videbeck, 381). 87. A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time? A. Keeping the client restrained in bed B. Checking the clients blood pressure every 15 minutes and offering juices C. Providing a quite environment and administering medication as needed and prescribed D. Restraining the client and measuring BP every 30 minutes 88. Which assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. BP of 100/70 mmHg D. BP of 140/80 mmHg Rationale: Symptoms of withdrawal usually begin 4-12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, ELEVATED PULSE and blood pressure, insomnia, anxiety, and nausea or vomiting (Videbeck, 381). Option A is the answer. Option B is wrong, it should be tachycardia not bradycardia. Options C and D are normal. 89. The nurse is caring for a client being treated with alcoholism. Before initiating therapy with disulfram (Antabuse), the nurse teaches the client that he must read the labels carefully on which of the following products? A. soft drink B. Aftershave lotion C. Toothpaste D. Cheese

Rationale: Disulfram should always be prescribed with the full knowledge and consent of the client. The client needs to be told about the side effects and must be well aware that any substance that contains alcohol can trigger an adverse reaction. Three primary sources of hidden alcohol exist- food, medication and preparations that are applied to the skin (Videbeck, 776). Option B is the answer. Aftershave is a lotion, gel, or liquid used mainly by men after they have finished shaving. It may contain an antiseptic agent such as alcohol to prevent infection from cuts as well as numb damaged skin, a perfume to enhance scent, and a moisturizer to soften the skin. Toothpastes, cheese and carbonated beverages does not contain alcohol. Active ingredient for toothpaste is fluoride, and milk for cheese. The name "soft drink" specifies a lack of alcohol. Source:http://en.wikipedia.org/wiki/Aftershave;http://en.wikipedia.org/wiki/Soft_drink http://en.wikipedia.org/wiki/Cheese;http://en.wikipedia.org/wiki/Toothpaste#Ingredients_and_flavors 90. A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory test reveals a blood alcohol level of 0.2%. The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness on the hands and feet. The nurse realizes that these symptoms probably result from: A. Thiamine deficiency B. Acetate accumulation C. Triglyceride buildup D. A below-normal potassium level Rationale: Option A is the answer. Thiamine (Vitamin B1) deficiency is often present in pateients who has alcohol withdrawal. Thiamine replacement is given in order to prevent Wernickes syndrome. Wernickes syndrome is characterized by nystagmus, ptosis, ataxia, confusion, coma and possible death (Varcarolis, 776). Situation 19 - Drug abuse is prevalent in our society. As a future nurse generalist you should be equip with the knowledge and skills in handling patients that are substance abusers. 91. A client whos actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phyncyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP? A. Hypotension B. Paranoia C. Blank stare D. Dilated pupils Rationale: Phencyclidine piperidine (PCP) is also known as angel dust, horse tranquilizer, or peace pill. The signs and symptoms of PCP intoxication range from acute anxiety to acute psychosis. The cardinal signs include a blank stare, ataxia, muscle rigidity, nystagmus and hypertension not hypotension (Varcarolis, 761). Other choices are inappropriate. Dilated pupils and paranoia are seen in people who abused hallucinogens (Varcarolis, 762). Hypotension is seen in opiate abusers (Varcarolis, 760). 92. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using? A. Suppression B. Sublimation C. Repression D. Denial Rationale: Denial is the answer. Substance use typically includes the use of defense mechanisms, especially denial (Videbeck, 389). Denial is the failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue (Videbeck, 51). Suppression is replacing the desired gratification with one that is more readily available (Videbeck, 52). Sublimation is exhibiting behavior to make up for or negate unacceptable behavior (Videbeck, 52). Repression is excluding emotionally painful or anxiety provoking thoughts and feelings from conscious awareness (Videbeck, 51). 93. The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with A. Dopamine agonist B. Methadone (Dolophine) C. Phencyclidine piperidine D. Buspirone (BuSpar) Rationale: Option B is the answer. Opiate withdrawal is usually treated by methadone tapering (Varcarolis, 760). Methadone is a synthetic opiate that at certain doses blocks the craving and effects of heroin (Varcarolis, 776). Dopamine agonist is used for treatment of cocaine-crack withdrawal (Varcarolis, 759). A dopamine agonist is a compound that activates dopamine receptors, mimicking the effect of the neurotransmitter dopamine.

Phencyclidine piperidine (PCP) is a hallucinogen that alters ones mental state in a short period (Varcarolis, 761). Buspirone is a drug that reduces anxiety, without havng a strong sedative-hypnotic properties (Varcarolis, 75). Source: http://en.wikipedia.org/wiki/Dopamine_agonist 94. Ed has bloodshot eyes, voracious appetite (especially for junk foods) and a dry mouth. Which drug would be the nurse should most likely suspect? A. Marijuana B. Amphetamine C. Barbiturates D. LSD Rationale: Marijuana is the answer. Physiologic effect of marijuana includes bloodshot eyes, dry mouth, hypotension, increased appetite and tachycardia (Videbeck, 384). Other choices are inappropriate. Amphetamine intoxication may result to dilated pupils not bloodshot eyes. Other signs include tachycardia, elevated BP, Nausea and vomiting and insomnia (Varcarolis, 759). Barbiturates intoxication may produce symptoms like slurred speech, drowsiness and decreased BP (Varcarolis, 756). LSD (Lysergic acid diethylamide) may result to dilated pupils, tachycardia, diaphoresis, palpitations and tremors, elevated temperature, pulse and respiration (Varcarolis, 762). 95. Which of the following signs should the nurse expect in a client with known amphetamine intoxication? A. Hypotension B. Tachycardia C. hypersomnia D. Constricted pupils Rationale: Option B is the answer. Intoxication of Amphetamine may result to tachycardia; elevated BP not hypotension; dilated pupils not constricted and insomnia not hypersomnia (Varcarolis, 759). Situation 20 - Nurse Jonah Mae was taking care of patient with Bells palsy. 96. Bells palsy is the most common type of peripheral paralysis. As a nurse generalist, Jonah Mae knows that Bells palsy affects the: A. Cranial Nerve IV B. Cranial Nerve IX C. Cranial Nerve II D. Cranial Nerve VII Rationale: Bells palsy affects the motor aspect of the facial nerve, the seventh cranial nerve. Bells palsy results in a unilateral paralysis of the facial muscles of expression (Black, 2154). The 12 pairs of cranial nerves are traditionally abbreviated by the corresponding Roman numerals.

Number

Name Cranial nerve zero (CN0 is not traditionally recognized.) Olfactory nerve Optic nerve Oculomotor nerve Trochlear nerve Trigeminal nerve Abducens nerve

Function

0 I II III IV V VI

New research indicates CN0 may play a role in the detection of pheromones Transmits the sense of smell Transmits visual information to the brain Innervates levator palpebrae superioris, superior rectus, medial rectus, inferior rectus, and inferior oblique, which collectively perform most eye movements Innervates the superior oblique muscle, which depresses, pulls laterally, and intorts the eyeball Receives sensation from the face and innervates the muscles of mastication Innervates the lateral rectus, which abducts the eye Provides motor innervation to the muscles of facial expression and stapedius, receives the special sense of taste from the anterior 2/3 of the tongue, and provides secretomotor innervation to the salivary glands (except parotid) and the lacrimal gland Senses sound, rotation and gravity (essential for balance &

VII

Facial nerve

VIII

Vestibulocochlear nerve (or

auditory-vestibular nerve or statoacustic nerve) IX Glossopharyngeal nerve

movement) Receives taste from the posterior 1/3 of the tongue, provides secretomotor innervation to the parotid gland, and provides motor innervation to the stylopharyngeus Supplies branchiomotor innervation to most laryngeal and pharyngeal muscles; provides parasympathetic fibers to nearly all thoracic and abdominal viscera down to the splenic flexure; and receives the special sense of taste from the epiglottis Controls muscles of the neck and overlaps with functions of the vagus Provides motor innervation to the extrinsic muscles of the tongue and other glossal muscles

Vagus nerve

XI XII

Accessory nerve (or cranial accessory nerve or spinal accessory nerve) Hypoglossal nerve

Source:http://en.wikipedia.org/wiki/Cranial_nerve 97. A client with Bells palsy asks why artificial tears were ordered by the physician. The nurse BEST response is: A. Because your eye remains closed, foreign matter can be trapped beneath the lid. B. Artificial tears will remove the purulent drainage from the eye, which speeds healing. C. Because you cannot blink the affected eye, it can become dry and irritated. D. Because it is what is best for you. 98. Which nursing diagnosis takes priority for patient with Bells palsy? A. Risk for dysfunctional grieving B. Risk for injury related to corneal laceration C. Risk for chronic low self-esteem D. Risk for impaired physical mobility 99. The nurse observes that the clients right eye does not close completely. Based on this, which of the following nursing interventions would be most appropriate? A. Making sure the client wears her eyeglasses at all times B. Placing an eye patch over the eye C. Instilling artificial tears once every shift D. Cleansing the eye with clean washcloth every shift 100. The client has a feeling of stiffness and a drawing sensation of the face. What would be an important teaching to the patient? A. Eyes is susceptible to injury when eyelid does not close B. Drooling from an increased saliva on affected area may occur C. Cleaning the eye will prevent ulceration D. All of the above