MULTIPLE CHOICE 1. A nurse prepares to teach a client who has… MULTIPLE CHOICE1. A nurse prepares to teach a client who has experienced damage to the left temporal lobe ofthe brain. Which action should the nurse take when providing education about newlyprescribed medications to this client?a. Help the client identify each medication by its color.b. Provide written materials with large print size.c. Sit on the client’s right side and speak into the right ear.d. Allow the client to use a white board to ask questions. 2. A nurse plans care for a client who has a hypoactive response to a test of deep tendonreflexes. Which intervention should the nurse include in this client’s plan of care?a. Check bath water temperature with a thermometer.b. Provide the client with assistance when ambulating.c. Place elastic support hose on the client’s legs.d. Assess the client’s feet for wounds each shift. 3. A nurse teaches an 80-year-old client with diminished touch sensation. Which statementshould the nurse include in this client’s teaching?a. “Place soft rugs in your bathroom to decrease pain in your feet.”b. “Bathe in warm water to increase your circulation.”c. “Look at the placement of your feet when walking.”d. “Walk barefoot to decrease pressure ulcers from your shoes.” 4. A nurse assesses a client’s recent memory. Which client statement confirms that the client’sremote memory is intact?a. “A young girl wrapped in a shroud fell asleep on a bed of clouds.”b. “I was born on April 3, 1967, in Johnstown Community Hospital.”c. “Apple, chair, and pencil are the words you just stated.”d. “I ate oatmeal with wheat toast and orange juice for breakfast.” 5. A nurse assesses a client who demonstrates a positive Romberg’s sign with eyes closed butnot with eyes open. Which condition does the nurse associate with this finding?a. Difficulty with proprioceptionb. Peripheral motor disorderc. Impaired cerebellar functiond. Positive pronator drift 6. A nurse asks a client to take deep breaths during an electroencephalography. The client asks,”Why are you asking me to do this?” How should the nurse respond?a. “Hyperventilation causes vascular dilation of cerebral arteries, which decreaseselectoral activity in the brain.”b. “Deep breathing helps you to relax and allows the electroencephalograph to obtaina better waveform.”c. “Hyperventilation causes cerebral vasoconstriction and increases the likelihood ofseizure activity.”d. “Deep breathing will help you to blow off carbon dioxide and decreasesintracranial pressures.” 7. A nurse assesses a client recovering from a cerebral angiography via the client’s rightfemoral artery. Which assessment should the nurse complete?a. Palpate bilateral lower extremity pulses.b. Obtain orthostatic blood pressure readings.c. Perform a funduscopic examination.d. Assess the gag reflex prior to eating. 8. A nurse obtains a focused health history for a client who is scheduled for magneticresonance angiography. Which priority question should the nurse ask before the test?a. “Have you had a recent blood transfusion?”b. “Do you have allergies to iodine or shellfish?”c. “Are you taking any cardiac medications?”d. “Do you currently use oral contraceptives?” 9. A nurse is caring for a client with a history of renal insufficiency who is scheduled for acomputed tomography scan of the head with contrast medium. Which priority interventionshould the nurse implement?a. Educate the client about strict bedrest after the procedure.b. Place an indwelling urinary catheter to closely monitor output.c. Obtain a prescription for intravenous fluids.d. Contact the provider to cancel the procedure. 10. A nurse obtains a focused health history for a client who is scheduled for magneticresonance imaging (MRI). Which condition should alert the nurse to contact the providerand cancel the procedure?a. Creatine phosphokinase (CPK) of 100 IU/Lb. Atrioventricular graftc. Blood urea nitrogen (BUN) of 50 mg/dLd. Internal insulin pump 11. A nurse teaches a client who is scheduled for a positron emission tomography scan of thebrain. Which statement should the nurse include in this client’s teaching?a. “Avoid caffeine-containing substances for 12 hours before the test.”b. “Drink at least 3 liters of fluid during the first 24 hours after the test.”c. “Do not take your cardiac medication the morning of the test.”d. “Remove your dentures and any metal before the test begins.” 12. A nurse cares for a client who is experiencing deteriorating neurologic functions. The clientstates, “I am worried I will not be able to care for my young children.” How should thenurse respond?a. “Caring for your children is a priority. You may not want to ask for help, but youhave to.”b. “Our community has resources that may help you with some household tasks soyou have energy to care for your children.”c. “You seem distressed. Would you like to talk to a psychologist about adjusting toyour changing status?”d. “Give me more information about what worries you, so we can see if we can dosomething to make adjustments.” 13. A nurse plans care for an 83-year-old client who is experiencing age-related sensoryperception changes. Which intervention should the nurse include in this client’s plan ofcare?a. Provide a call button that requires only minimal pressure to activate.b. Write the date on the client’s white board to promote orientation.c. Ensure that the path to the bathroom is free from equipment.d. Encourage the client to season food to stimulate nutritional intake. 14. After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurseassesses the client’s understanding. Which client statement indicates a correct understandingof the teaching?a. “I must increase my fluids because of the dye used for the MRI.”b. “My urine will be radioactive so I should not share a bathroom.”c. “I can return to my usual activities immediately after the MRI.”d. “My gag reflex will be tested before I can eat or drink anything.” 15. A nurse performs an assessment of pain discrimination on an older adult client. The clientcorrectly identifies, with eyes closed, a sharp sensation on the right hand when touched witha pin. Which action should the nurse take next?a. Touch the pin on the same area of the left hand.b. Contact the provider with the assessment results.c. Ask the client about current medications.d. Continue the assessment on the client’s feet. 16. A nurse is teaching a client with cerebellar function impairment. Which statement shouldthe nurse include in this client’s discharge teaching?a. “Connect a light to flash when your door bell rings.”b. “Label your faucet knobs with hot and cold signs.”c. “Ask a friend to drive you to your follow-up appointments.”d. “Use a natural gas detector with an audible alarm.” 17. A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement shouldthe nurse include when delegating care for a client with cranial nerve II impairment?a. “Tell the client where food items are on the breakfast tray.”b. “Place the client in a high-Fowler’s position for all meals.”c. “Make sure the client’s food is visually appetizing.”d. “Assist the client by placing the fork in the left hand.” 18. A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alertthe nurse to contact the health care provider?a. Shingles on the client’s backb. Client is claustrophobicc. Absence of intravenous accessd. Paroxysmal nocturnal dyspnea 19. A nurse assesses a client who is recovering from a lumbar puncture (LP). Whichcomplication of this procedure should alert the nurse to urgently contact the health careprovider?a. Weak pedal pulsesb. Nausea and vomitingc. Increased thirstd. Hives on the chest 20. A nurse cares for a client who is recovering from a single-photon emission computedtomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurseinclude when discussing the plan of care with this client?a. “You may return to your previous activity level immediately.”b. “You are radioactive and must use a private bathroom.”c. “Frequent assessments of the injection site will be completed.”d. “We will be monitoring your renal functions closely.” 21. A nurse assesses a client and notes the client’s position as indicated in the illustration below:How should the nurse document this finding?a. Decorticate posturingb. Decerebrate posturingc. Atypical hyperreflexiad. Spinal cord degeneration 22. A nurse assesses the left plantar reflexes of an adult client and notes the response shown inthe photograph below:Which action should the nurse take next?a. Contact the provider with this abnormal finding.b. Assess bilateral legs for temperature and edema.c. Ask the client about pain in the lower leg and calf.d. Document the finding and continue the assessment. 23. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse callshis name, mumbles in response to questions, and follows simple commands. How should thenurse document this client’s assessment using the Glasgow Coma Scale shown below?a. 8b. 10c. 12d. 14 Select All that Apply1. A nurse assesses a client with an injury to the medulla. Which clinical manifestations shouldthe nurse expect to find? (Select all that apply.)a. Loss of smellb. Impaired swallowingc. Visual changesd. Inability to shrug shoulderse. Loss of gag reflex 2. An emergency department nurse assesses a client who was struck in the temporal lobe witha baseball. For which clinical manifestations that are related to a temporal lobe injury shouldthe nurse assess? (Select all that apply.)a. Memory lossb. Personality changesc. Difficulty with sound interpretationd. Speech difficultiese. Impaired taste 3. After administering a medication that stimulates the sympathetic division of the autonomicnervous system, the nurse assesses the client. For which clinical manifestations should thenurse assess? (Select all that apply.)a. Decreased respiratory rateb. Increased heart ratec. Decreased level of consciousnessd. Increased force of contractione. Decreased blood pressure 4. A nurse assesses a client with a brain tumor. Which newly identified assessment findingsshould alert the nurse to urgently communicate with the health care provider? (Select allthat apply.)a. Glasgow Coma Scale score of 8b. Decerebrate posturingc. Reactive pupilsd. Uninhibited speeche. Diminished cognition 5. A nurse is caring for a client who is prescribed a computed tomography (CT) scan withiodine-based contrast. Which actions should the nurse take to prepare the client for thisprocedure? (Select all that apply.)a. Ensure that an informed consent is present.b. Ask the client about any allergies.c. Evaluate the client’s renal function.d. Auscultate bilateral breath sounds.e. Assess hematocrit and hemoglobin levels. 6. A nurse assesses an older client. Which assessment findings should the nurse identify asnormal changes in the nervous system related to aging? (Select all that apply.)a. Long-term memory lossb. Slower processing timec. Increased sensory perceptiond. Decreased risk for infectione. Change in sleep patterns 7. A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP).Which statements should the nurse include when delegating this client’s care? (Select allthat apply.)a. “Plan to bathe the client in the evening when the client is most alert.”b. “Encourage the client to use a cane when ambulating.”c. “Assess the client for symptoms related to pain and discomfort.”d. “Remind the client to look at foot placement when walking.”e. “Schedule additional time for teaching about prescribed therapies.” Health Science Science Nursing Share QuestionEmailCopy link Comments (0)