LA UNION COLLEGES OF NURSING, ARTS AND SCIENCES

Biday, City of San Fernando, La Union

NCM 104
MIDTERM EXAMINATION
December 14, 2010
One hour and 30 minutes

Direction to the Examinee: Read the questions carefully. Choose the letter
of the best answer and write your answer on your Blue Book. Strictly no erasures
and superimpositions. All answer should be in CAPITAL letter.

1. A client is suffering CVA that left her unable to comprehend speech and
unable to speak. This type of aphasia is
A. Receptive aphasia
B. Global aphasia
C. Expressive aphasia
D. Conduction aphasia

2. An elderly patient may have sustained a skull fracture after slipping and
falling on a side walk. The nurse knows the skull fractures:
A. Are the least significant type of fracture
B. May cause CSF leaks from the nose or ears
C. Have no characteristic findings
D. Are always surgically repaired

3. The nurse is teaching family members of a patient with a concussion

about the early signs of ICP. Which of the following would she site an early
signs of ICP?
A. Headache and vomiting
B. Decreased systolic blood pressure
C. Inability to wake the patient with stimuli
D. Dilated pupils that dont react to light

4. Clear fluid draining from the nose of the client who had a trauma 3 hours
ago. This indicate which of the following
A. Basilar skull fracture
B. Cerebral concussion
C. Sinus infection
D. Cerebral palsy

5. A 56 year old construction worker is brought to the hospital unconscious

after falling from a 2-story building. When assessing the client, the nurse
would be most concerned if the assessment revealed
A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature

6. Which of the following should be included on a client who had craniotomy

as a routine neurological assessment?
A. Orientation to time, place and person
B. Vestibular reflex
C. Hand strength
D. Olfactory cranial nerve functions

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7. The nurse is caring for a client who has undergone craniotomy with
supratentorial incision. The nurse uses which of the following post
operative positions?
A. Head of the bed elevated 30 to 45 degrees, head and neck at
midline
B. Head of the bed flat, head and neck at midline
C. Head of the bed flat, head turned to the nonoperative side
D. Head of the bed elevated 30 to 45 degrees, head turned to the
operative side

8. The nurse is evaluating the status of the client who had craniotomy 3 days
ago. The nurse suspects the client developing meningitis as complications
of surgery if the client exhibits?
A. Negative kernigs sign
B. Absence of nuchal rigidity
C. GCS of 15
D. Positive brudzinski sign

9. The nurse is preparing to give post craniotomy medication for incisional

pain. The family asks the nurse why the client is receiving codeine and not
something stronger. In formulating response, the nurse incorporates that
the understanding that codeine
A. Is one of the strongest narcotic analgesics available
B. Cannot lead to physical or psychological dependence
C. Does not alter respiration or mask neurologic sign as other narcotic
do
D. Does not cause gastrointestinal upset or constipation as other
narcotic do

10. When a client arrived on the medical surgical ward after a closed head
injury, he is confused and disoriented. The nurse can encouraged him to
become oriented by.
A. Asking his family to stay away during visiting hours
B. Keeping a clock, radio. TV or newspaper in his room at all times
C. Ignoring his behavior during nursing procedures
D. Closing window blinds during the day

11. A close head injury client is at risk for developing further seizures. The
nurse should.
A. Observe the client frequently
B. Keep all side rails of the bed down
C. Keep the height of the bed at the lowest possible level
D. Keep a padded tongue blade at the bed side

12. The client is admitted for observation after an auto accident with probable
minor head injury. The nurse plans on leaving the cervical collar in place
until?
A. The results of spinal x-ray are known
B. The physicians makes rounds
C. The family comes to visits
D. The nurse needs to do physical care

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13. A nurse notes that the client has ICP. Which of the following interventions
the nurses use to try to reduce ICP?
A. Keep the head of the bed flat
B. Avoid flexing the neck and hips
C. Maintain the hips in a flexed position
D. Keep the head of the bed elevated to 60 degrees

14. The doctor ordered mannitol for a client with ICP. The reasons for
administering this drug are to.
A. Decrease blood pressure
B. Decrease brain swelling
C. Slow respiration and pulse
D. Prevent further brain damage

15. The nurse is caring for the client with ICP. The nurse assesses which of
the following trends in vital signs if the cranial pressure is rising?
A. Increasing temperature, decreasing pulse, decreasing respiration,
increasing BP
B. Increasing temperature, increasing pulse, increasing respiration,
decreasing BP
C. Decreasing temperature, decreasing pulse, increasing respiration,
decreasing BP
D. decreasing temperature, increasing pulse, decreasing respiration,
increasing BP

16. The nurse is positioning the client with ICP. Which of the following
positions does the nurse avoids?
A. Head midline
B. Head turned to the side
C. Neck in a neutral position
D. Head of the bed elevated 30 to 40 degrees

17. The family of the unconscious client with ICP is talking at the client bed
side. They are discussing the seriousness of the clients condition and
wondering if the client ever recovers. The nurse intervenes, based on the
understanding that
A. The family need immediate crisis intervention
B. It is possible the client can hear the family
C. The family could benefit from a conference with the physician
D. The client might have wanted a visit from a hospital chaplain

18. It is the most sensitive indicator of the changes in neurological status of

the client
A. Mental Status
B. Posturing
C. Level of Consciousness
D. Motor Function

19. A nurse assesses the patients level of consciousness using Glasgow

Coma Scale. Which score indicates severe impairment in neurologic
function
A. 3
B. 6
C. 9
D. 12

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20. The nurse is testing the coordinated functioning of the cranial nerve III, IV
and VI. To do this correctly, the nurse test the
A. Corneal reflex
B. Pupil response to light
C. Six cardinal field of gaze
D. Pupil response to light and accommodation

21. The client has dysfunctions of the cochlear division of the vestibulcochlear
(cranial nerve VIII). The nurse evaluates that the client is adequately
adapting to this problem if the client states a plan to obtain a .
A. Hearing aid
B. Walker
C. Pair of eye glass
D. Bath thermometer

22. The nurse is assessing the motor function of an unconscious client. The
nurse plans to use which of the following to test the clients peripheral
response to pain?
A. Sternal rub
B. Nailbed pressure
C. Pressure of the orbital rim
D. Squeezing of the sternocleidomastoid muscle

23. The client has fluid leaking from the nose following a basilar skull fracture.
The nurse assesses that this is cerebrospinal fluid if the fluid
A. Clear and negative for glucose
B. Is grossly bloody in appearance
C. Clumps together on the dressing and has a pH of 7
D. Separates into concentric ring and tests positive for glucose

24. The client admitted with a neurological problem indicates to the nurse that
magnetic resonance imaging may be done. The nurse interprets that the
client may be ineligible for this procedure based on the clients history
of.
A. Hypertension
B. Prostatic valve replacement
C. COPD
D. Heart failure

25. The client with a spinal cord injury at the level of C5 has a weakened
respiratory effort, ineffective cough, and is using accessory neck muscles
in breathing. The nurse carefully monitors the client and formulates which
of the following nursing diagnosis?
A. Ineffective breathing pattern
B. Impaired gas exchange
C. Risk for aspiration
D. Risk for injury

26. The client with spinal cord injury becomes angry whenever the nurse tries
to administer care. The nurse should
A. Advise the client that rehabilitation progresses quickly with
cooperation
B. Acknowledge the clients anger and continue to encourage
participation of care
C. Leave the client alone until ready to participate
D. Ask the family to deliver the care

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27. The nurse is caring for the client who has suffered spinal cord injury. The
nurse further assesses the client for another sign of Autonomic Dysreflexia
if the client experiences
A. Pallor of the face and neck
B. Severe, throbbing headache
C. Sudden tachycardia
D. Severe and sudden hypotension

28. The family of a spinal cord injury client rushes to the nursing station saying
that the client needs immediate help. Upon entering the room, the nurse
notes that the client is diaphoretic, with a flushed face and neck, and
complains of severe headache. The pulse is 40 and BP is 230/100mmHg.
The nurse acts quickly, knowing that the client is experiencing
A. Autonomic dysreflexia
B. Spinal shock
C. HPN
D. Pulmonary embolism

29. What is the most important to include in the care of the client having a
craniotomy?
A. Frequent pupil and neurologic check
B. Maintenance of adequate respiratory functions
C. Dressings check every 8 hours
D. Vital signs every 4 hours

30. What is the best nursing approach for a head injury, confused client?
A. Decrease the environmental stimuli
B. Devise a reorientation program
C. Request a psychiatric consultation
D. Assign someone to stay with her and implement a safety
precautions

31. The client had undergone CT scanning with a contrast medium. The nurse
evaluates that the clients understands post procedure care if the client
verbalized to
A. Force fluids for the day
B. Eat lightly for the remainder of the day
C. Rest quietly for the remainder of the day
D. Hold medications for at least 4 hours

32. What would be the MOST therapeutic nursing action when a clients
expressive aphasia is severe?
A. Anticipate the client wishes so she will not need to talk
B. Communicate by means of questions that can be answered by the
client shaking the head
C. Keep us a steady flow rank to minimize silence
D. Encourage the client to speak at every possible opportunity.

33. The nurse is administering mouth care to an unconscious client. The

nurse should avoid doing which of the following?
A. Positioning the client on the side
B. Cleansing the mucous membranes with toothpaste
C. Brushing the teeth with small tooth brush
D. Using products with lemon or alcohol

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34. The nurse is assigned to an unconscious client is making initial daily
rounds. Upon entering the room, the nurse notes that the client is lying
supine in bed, with the head of the bed elevated approximately 5 degrees.
The NGT feeding is running at 70 ml/hr as ordered. The nurse auscultates
adventitious breath sounds. Which of the following nursing diagnosis does
the nurse formulates for the client?
A. Risk for altered nutrition: less than body requirements
B. Risk for injury
C. Risk for aspiration
D. Risk for fluid volume deficits

35. The client was seen and treated in the emergency department for
treatment of concussion. The nurse evaluates that the family needs
reinforcement of the discharge instructions for which of the following client
signs and symptoms?
A. Difficulty in speaking
B. Minor headache
C. Difficulty awakening
D. Vomiting

36. The nurse is assessing a patient and notes a brudzinski sign and kernigs
sign. These are the two classic signs of which of the following disorders?
A. CVA
B. Seizure disorder
C. Meningitis
D. Parkinsons disease

37. Many men who suffered spinal injuries continue to be sexually active. The
teaching plan for a man with spinal cord injury should be include sexuality
concern. Which of the following injury would most likely prevent erection
and ejaculation?
A. C5
B. S4
C. T4
D. C7

38. Another patient is being prepared for EEG, what is the most important
nursing responsibility?
A. Give enema a night before
B. Give shampoo to ensure clean scalp
C. Withold any current therapy
D. Put patient on NPO 6 hours before the test

39. What sign indicate damage of the cerebellum?

A. Ataxia
B. Dementia
C. Agnosia
D. Steriognosis

40. A client with head injury is confused, drowsy and has unequal pupils.
Which of the following nursing diagnosis is most important at this time?
A. altered level of cognitive function
B. high risk for injury
C. altered cerebral tissue perfusion
D. sensory perceptual alteration

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41. A diagnostic test is ordered to measure the electrical acivity of the brain.
This test is known as
A. MRI
B. EEG
C. CT scan
D. Myelogram

42. The nurse is assessing the client who is experiencing seizure activity. The
nurse does not need to determine information about which of the following
items as part of routine assessment of seizures?
A. What the client ate in the 2 hours preceding the seizure activity
B. Duration of seizure
C. Seizure progression and type of movements
D. Changes in pupil size or eye deviation

43. The nurse is caring for the client who begins to experience seizure activity
while in bed. Which of the following actions by the nurse is
contraindicated?
A. Loosening restrictive clothing
B. Restraining the clients limb
C. Removing pillow and raising padded side rails
D. Positioning the client to the side if possible with head flexed forward

44. A client receives a dose of Tensilon test IV. The client shows improvement
in muscle strength for a period of time following the injection. The nurse
interprets that this findings is compatible with
A. Myasthenis gravis
B. Multiple sclerosis
C. Muscular dystrophy
D. Amyotrophic lateral sclerosis

45. The client has experienced episodes of myasthenia crisis. The nurse
assesses whether the client has precipitating factors such as
A. To little exercise
B. Increased intake of fatty foods
C. Excess medication
D. Omitted dose of medications

46. The nurse is teaching the client with myasthenia gravis about the
prevention of myasthenia and cholinergic crisis. The nurse tells the client
that this is most effectively done by
A. Doing all chores early in the day while less fatigued
B. Doing muscle strengthening exercise
C. Taking medications on time to maintain therapeutic blood levels
D. Eating large, well balanced meals

47. The client with Parkinsons disease has risk for falls related to abnormal
gait. The nurse assesses that the clients gait is
A. Shuffling and propulsive
B. Broad based and waddling
C. Accelerating with walking on toes
D. Unsteady and staggering

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48. The client recovering from head injury is arousable and participating in
care. The nurse ddetermines that the client understands measure to
prevent elevations in intracranial pressure if the nurse observes the client
doing which of the following?
A. Blowing the nose
B. Valsalva Maneuver
C. Coughing vigorously
D. Exhaling during repositioning

49. The nurse has given instructions to the client with Parkinsons disease
about maintaining mobility. The nurse evaluates that the client
understands the direction if the client states to
A. Exercise in the evening to combat fatigue
B. Rock back and forth to start movement with bradykinesia
C. Sit in soft, deep chair
D. Buy clothing with many buttons to maintain finger dexterity

50. The client with brain attack has residual dysphagia. When a diet order is
initiated, the nurse avoids doing which of the following
A. Giving the client thin liquids
B. Thickening liquids to the consistency of oatmeal
C. Placing food on the unaffected side of the mouth
D. Allowing plenty of time for chewing and swallowing

51. The nurse is reinforcing information given to patient with Bells palsy about
medications used to decrease edema of nerve tissue. The nurse gives the
client specific information about which of the following medications?
A. Prednisone
B. Aspirin
C. Ibuprofen
D. NSAIDS

52. The client is admitted to the hospital with a diagnosis of Guillain-Barre

syndrome. The nurse inquires the nursing admission interview if the client
has a history of
A. Back injury or trauma to the spinal cord
B. Respiratory or gastrointestinal infection during the previous month
C. Seizures or trauma to the brain
D. Meningitis during the past 5 years

53. A nursing student is caring for a client with stroke who is experiencing
unilateral neglect. The nurse intervenes if the student plans to use which
of the following strategies to help the client adapt to this deficit?
A. Tells the client to scan the environment
B. Places the bedside articles on the affected side
C. Approaches the client from the unaffected side
D. Moves the commode and chair to the affected side

54. In assessing a client with Guillain-Barre syndrome, what characteristic

symptoms would the nurse expect to observe?
A. Deteriorating LOC
B. Ascending flaccid motor paralysis
C. Dilated pupils, facial numbness and dysphagia
D. Disorientation with inappropriate behavior and muscle weakness

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55. The client with Multiple Sclerosis is experiencing muscle weakness,
spasticity and an ataxic gait. Based on this information, the nurse
formulates which of the following nursing diagnosis for the client?
A. Activity intolerance
B. Impaired physical Mobility
C. Impaired tissue integrity
D. Self care deficit

56. The client is admitted with an exacerbation of Multiple Sclerosis.The nurse

is assessing the client for possible precipitating factors, if stated by the
client, which of the following does the nurse assess as being unrelated to
the exacerbation?
A. Ingestion of more fruits and vegetables
B. Stressful week at work
C. A recent bout of flu
D. Inability to sleep well

57. A closed head injury client is placed on a mechanical ventilator and

hyperventilated. The nurse knows that this treatment is appropriate for the
patient because.
A. Increases the blood supply to the brain
B. Increases cerebral blood volume
C. Dilates cerebral blood vessels
D. Promotes vasoconstrictions

58. A nurse notes that the client has ICP. Which of the following interventions
the nurses use to try to reduce ICP?
A. Keep the head of the bed flat
B. Avoid flexing the neck and hips
C. Maintain the hips in a flexed position
D. Keep the head of the bed elevated to 60 degrees

59. The nurse has formulated a nursing diagnosis of Ineffective Breathing

Pattern for a client with neurological disorder. The nurse avoids including
which of the following activities in the care plan for this client?
A. Keep the clients lying in a supine position
B. Keep the head and neck in good alignment
C. Elevate the head of the bed to 30 degrees
D. Keep suction equipment at the bed side

60. It involves the stiffening or rigidity of the muscle of the arms and legs and
usually last to 10-20 seconds followed by loss of consciousness?
A. Petit-mal
B. Myoclonic
C. Grand-mal
D. Partial seizure

61. The following are the signs and symptoms of left hemisphere lesion in
CVA except?
A. Disorientation to time, place and person
B. Aphasia
C. Difficulty in the right visual field
D. Sense of guilt

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62. It is a 90 degree flexion of the hip followed by an attempt to extend the
knee results in pain?
A. Brudzinski sign
B. Kernigs sign
C. Nuchal rigidity
D. Tetanus

63. Which of the following is the initial signs and symptoms of meningitis?
A. Tachycardia
B. Headache
C. Lethargy
D. Memory changes

64. It is a flexion of the head and neck toward the chest result in flexion of the
hips and knees?
A. Brudzinski sign
B. Kernigs sign
C. Tetanus
D. Nuchal rigidity

65. The nurse is assessing the motor function of an unconscious client. The
nurse would plan to use which of the following to test the clients
peripheral response to pain.
A. Sterna rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle

66. The nurse is assessing a patient and notes a Brudzinski sign and Kernigs
sign. These are the two classic signs of which of the following disorders?
A. CVA
B. Seizure disorder
C. Meningitis
D. Parkinsons disease

67. The nurse is planning to test the function of the trigeminal nerve (cranial
nerve V). The nurse performs which of the following items to perform the
test?
A. Flashlight, pupil size chart
B. Tuning fork and audiometer
C. Snellens chart, ophthalmoscope
D. Safety pin, hot and water in the teat tube, cotton wisp

68. Which of the following would occur if a client has spinal shock?
A. Spastic paralysis
B. Urinary retention
C. HPN
D. Diaphoresis below the level of the injury

69. The most probable stimulus for autonomic dysreflexia includes all of the
following except
A. Bladder distention
B. Bowel distention
C. Fear
D. Stimulation of urinary sphincter by foley catheter

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 70. The client with spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse avoids which of the following measures to minimize
the risk of occurrence?
A. Strict adherence to a bowel retraining program
B. Limiting bladder catheterization once every 12 hours
C. Keeping the linen wrinkle free under the client
D. Avoiding unnecessary pressure on the lower limbs

71. The nurse is assessing the client with Bells palsy. The nurse would assess
the client for which of the following signs and symptoms related to the
disorder?
A. Tingling sensations and ptosis of the eyelid
B. Burning with intermittent facial paralysis
C. Speech or chewing difficulties accompanied by facial droop
D. Stabbing pain accompanied by twitching of part of face

72. The nurse is performing an admission assessment on a client with a

diagnosis of Bells palsy. The nurse assesses for the major symptom
associated with Bells palsy when the nurse observes the affected side for
A. Upward movement of the eyeball when attempting to close
the eyelid
B. Brudzinskis sign
C. Homans sign
D. Upper eyelid ptosis and a constricted pupil

73. When planning nursing care for a client with Trigeminal Neuralgia (Tic
Douloureux), the nurse should specifically:
A. Apply iced compresses to the affected area
B. Be alert to prevent dehydration or starvation
C. Initiate exercises of the jaw and facial muscles
D. Emphasize the importance of brushing the teeth

74. The nurse would expect a client with Tic Douloureux to exhibit:
A. Multiple petechiae
B. Unilateral muscle weakness
C. Excruciating facial and head pain
D. Uncontrollable tremors of the eyelid

75. To prevent precipitating a painful attack in a client with Tic Doulureux the
nurse should:
A. Avoid walking swiftly past the client
B. Keep the client in the prone position
C. Discontinue oral hygiene temporarily
D. Massage both sides of the face frequently

76. When developing a teaching plan for a client with trigeminal neuralgia, the
nurse should include an explanation that the medication used to treat this
disorder is:
A. Ascorbic acid
B. Morphine sulfate
C. Allopurinol (Zyloprim)
D. Carbamazepine (Tegretol)

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77. The nurse would expect a client with trigeminal neuralgia to demonstrate:
A. Prolonged periods of sleep because of anxiety
B. Hyperactivity because of medications received
C. Exhaustion and fatigue because of extreme pain
D. Excessive talkativeness because of anxiety and apprehension

78. To limit triggering the pain associated with trigeminal neuralgia the nurse
should instruct the client to:
A. Drink iced liquids
B. Avoid oral hygiene
C. Apply warm compresses
D. Chew on the unaffected side
79. The nurse should expect a client with an exacerbation of multiple sclerosis
to experience:
A. Double vision
B. Resting tremors
C. Flaccid paralysis
D. Mental retardation

80. A recently hospitalized female client with multiple sclerosis is concerned

about her fluctuating physical condition and generalized weakness. The
priority nursing intervention for this client would be to:
A. Have one of her parents stay with her
B. Space her activities throughout the day
C. Restrict her activities and encourage bed rest
D. Teach her the limitations imposed by her disease

81. Clients with myasthenia gravis, Guillain-Barre syndrome, or amyotrophic

lateral sclerosis experience:
A. Progressive deterioration until death
B. Increased risk of respiratory complications
C. Deficiencies of essential neurotransmitters
D. Involuntary twitching of small muscle groups

82. The incidence of myasthenia gravis is higher in:

A. Males ages 15 to 35
B. Children ages 5 to 15
C. Females ages 20 to 30
D. Both sexes equally before age 40

83. A client with myasthenia gravis asks the nurse why the disease has
occurred. The nurse bases the reply on the knowledge that there is:
A. genetic defect in the production of acetylcholine
B. A reduced amount of neurotransmitter acetylcholine
C. A decreased number of functioning acetylcholine receptor sites
D. Involuntary twitching of small muscle groups

84. The prognosis for the client with myasthenia gravis is most likely to be:
A. Excellent with proper treatment
B. Slowly progressive without remissions
C. Chronic, with exacerbations and remissions
D. Poor, with death occurring in few months

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85. During lunch a client with myasthenia gravis who has been prescribed bed
rest experiences increased dysphagia. The nurse should:
A. Call the physician
B. Administer oxygen
C. Suction the trachea
D. Raise the head of the bed

86. Respiratory complications are common in individuals with myasthenia

gravis because of:
A. Narrowed airways
B. Impaired immunity
C Ineffective coughing
D. Viscosity of secretions

87. A client with myasthenia gravis has been receiving Neostigmine

(Prostigmin). This drug acts by:
A. Stimulating the cerebral cortex
B. Blocking the action of cholinesterase
C. Replacing deficient neurotransmitters
D. Accelerating transmission along neural sheaths

88. A client with myasthenia gravis continues to become weaker despite

treatment with Neostigmine. Edrophonium Hcl (Tensilon) is ordered to:
A. Rule out cholinergic crisis
B. Promote a synergistic effect
C. Overcome neostigmine resistance
D. Confirm the diagnosis of myasthenia

89. Parkinsons disease is caused by:

A. Disintegration of the myelin sheath
B. Breakdown of the corpora quadrigemini
C. Reduced acetylcholine receptors at synapses
D. Degeneration of the neurons of the basal ganglia

90. When interviewing a client with a tentative diagnosis of Parkinsons

disease about the onset of symptoms, the nurse should expect the client
to say they occurred:
A. Suddenly
B. Overnight
C. Gradually
D. Irregularly

91. A female client with the diagnosis of Parkinsons disease asks why she
drools. The nurses best response would be:
A. We dont know why this happens.
B. There is a paralysis of the throat muscles.
C. You have a loss of involuntary movements.
D. Muscle rigidity prevents normal swallowing.

92. The nurse would expect a client with Parkinsons disease to exhibit:
A. A flattened affect
B. Tonic-clonic seizure
C. Decreased intelligence
D. Changes in pain tolerance

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93. Levodopa (L dopa) appears to be useful in treating Parkinsons disease
because it can:
A. Improve myelination of neurons
B. Increase acetylcholine production
C. Replace the dopamine in the brain cells
D. Cause regeneration if injured thalamic cells

94. Regular oral hygiene is an essential intervention for the client who has had a
cerebrovascular accident (CVA). Which of the following nursing measures
is inappropriate when providing oral hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the clients mouth with a padded tongue blade.
D. Cleansing the clients mouth and teeth with a toothbrush.

95. The client with Parkinsons disease has a nursing diagnosis of, risk for falls
related to an abnormal gait documented on the nursing care plan. The
nurse assesses the client, expecting to observe which type of gait
A. unsteady and staggering
B. shuffling and propulsive
C. broad based and waddling
D. accelerating with walking on the toes

96. For the client who is experiencing expressive aphasia, which nursing
intervention is most helpful in promoting communication?
A. Speaking loudly
B. Using a picture board
C. Writing directions so client can read them
D. Speaking in short sentences

97. The nurse is teaching the family of a client with dysphagia about
decreasing the risk of aspiration while eating. Which of the following
strategies is inappropriate?
A. Maintaining an upright position
B. Maintaining the diet to liquids until swallowing improves
C. Introducing foods on the unaffected side of the mouth
D Keeping distractions to a minimum

98. Which food-related behaviors would the nurse observe in a client who has
had a CVA that has left him with homonymous hemianopsia?
A. Increased preference for foods high in salt
B. Eating food in only half of the plate
C. Forgetting the names of foods
D. Inability to swallow liquids

99. The nurse has instructed the family with stroke who has homonymous
hemianopsia about measures to help the client overcome the deficit. The
nurse determines that the family understand the measures to use of they
state that they wil
A. place objects in the clients impaired field of vision
B. discourage the client form wearing eyeglass
C. approach from the impaired field of vision
D. remind the client to turn the head to scan the lost visual field

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100. When communicating with a client who has aphasia, which of the following
nursing interventions is inappropriate?
A. Present one thought at a time
B. Encourage the client not to write messages
C. Speak with normal volume
D. Make use of gestures

Prepared by:

EDITHA C. SABALBORO
NCM 104 Instructor

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