ADULT 2 FINAL TEST 2026 QUESTIONS
WITH CORRECT ANSWERS GRADED A+
◍ SCI level C1-C3.
Answer: o Functionally relevant mm innervated: sternocleidomastoid,
cervical paraspinal, neck accessorieso Mvmt possible: neck flexion,
extension, rotationo Patterns of weakness: total paralysis of trunk, UE, LE,
dependent on vento Functional expectation Respiratory- likely will be
ventilator dependent ADLs- dependent w/c mobility• power w/c with
alternative control- independent• manual w/c- dependent tilt in space w/c
◍ A client with gouty arthritis reports tenderness and swelling of the right
ankle and great toe. The nurse observes the area of inflammation extends
above the ankle area. The client receives prescriptions for colchicine and
indomethacin. Which instruction should the nurse include in the discharge
teaching? a. eat high protein foods to achieve ideal body weightb. drink at
least 8 cups of water per day c. use electronic heating pad when pain is at its
worsed. encourage active range of motion to limit stiffness.
Answer: b. drink at least 8 cups of water per day
◍ SCI level T1-T9.
Answer: o Functionally relevant mm innervated: intrinsic of the hand
including thumbs; internal and external intercostals; erector spinae,
lumbricals, flex/ext/abductor polliciso Mvmt possible- UE fully intact;
limited upper trunk stability; endurance increased secondary to innervation
of intercostalso Patterns of weakness- lower trunk paralysis; total paralysis
of LEo Functional expectations I in all ADLs w/c propulsion- I
transportation- I in car, including loading/unloading w/c
◍ The nurse is obtaining a health history from a new client who has a history
of kidney stones. Which statement by the client indicates an increased risk
, for renal calculi? a. Eats a vegetarian diet with cheese 2 to 3 times a day b.
Experiences additional stress since adopting a childc. Jogs more frequently
than usual daily routined. Drinks several bottles of carbonated water daily.
Answer: a. Eats a vegetarian diet with cheese 2 to 3 times a day
◍ SCI Tx in AC.
Answer: o Edu pt and family Understanding injury Importance of skin care
Prevention of secondary complicationso BADLso Goals may depend on
whether or not the pt has funding to transfer to IPR This may be the only
therapy that the pt receives If pt doesn't go to rehab, the therapist must
address equipment needs, preparing the home, and advocating for pt needs
◍ possible assessments for GBS.
Answer: o Pain scaleo Berg depression scaleo FIMo COPMo 7-point GBS
disability scaleo Semmes Weinsteino ROMo MMTo Dynamometer Grip,
pinch, 3 point, lateral pinch
◍ myotome C6.
Answer: wrist extension (myotome)
◍ SCIM-SC independence measure.
Answer: Questionnaire regarding functional independence for pt with SCI
◍ ASIA- B incomplete.
Answer: sensory but no motor function is preserved below neurological
level
◍ A client with orthopnea expresses concern about the ability to "get enough
air" during a scheduled thoracentesis. On which information should the
nurse's response be based on?a. a thoracentesis is a brief procedure that has
minimal discomfort b. orthopnea is frequently caused by a client's
uncontrolled anxietyc. the procedure is performed with a client in an upright
position d. Extra pillows can be used if needed to elevate the clients head.
Answer: c. the procedure is performed with a client in an upright position
◍ The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following
, vital signs: Heart rate 140 beats/min, respirations 26 breaths/minutes, and
blood pressure 140/90 mmHg. Which intervention is most important for the
nurse to implement? a. Medicate for pain and monitor vital signs according
to protocol b. Administer IV fluid bolus as prescribed by the providerc.
Apply oxygen at 10 L via non-rebreather mask and monitor pulse
oximeterd. Encourage the client to splint the incision with a pillow to cough
and deep breathe.
Answer: a. Medicate for pain and monitor vital signs according to protocol
◍ phase III of GBS.
Answer: progressive recovery
◍ while caring for a client with a full thickness burn covering 40% of the
body, the nurse observes purulent drainage at the wound. Before reporting
this finding to the healthcare provider, the nurse should review which of the
following laboratory values? a. White blood cell count b. platelet countc.
Blood pH level d. hematocrit.
Answer: a. White blood cell count
◍ A client who was involved in a motor vehicle collision is admitted with a
fractured left femur which is immobilized using a fracture traction splint in
preparation for an open reduction internal fixation (ORIF). The nurse
determines that the client's distal pulses are diminished in the left foot.
Which interventions should the nurse implement? (select all) a. Verify pedal
pulses using a doppler pulse deviceb. Evaluate the application of the splint
to the left leg. c. Offer ice chips and oral clear liquids. d. Monitor left leg for
pain, pallor, paresthesia, paralysis, pressure3. Administer oral
antispasmodics and narcotic analgesics.
Answer: a. Verify pedal pulses using a doppler pulse deviceb. Evaluate the
application of the splint to the left leg d. Monitor left leg for pain, pallor,
paresthesia, paralysis, pressure
◍ AT for SCI.
Answer: o Becoming less expensiveo Allows greater freedom for higher
injury levelso Can coordinate with power w/c electronics
, ◍ assessments for MS- pain, tremors, ataxia, dysphagia.
Answer: o Pain scaleo Multidimensional assessment of tremor (MAT)o
COPMo Modified barium swallow study (MBSS)- SLP performso 6 min
walk testo MS walking scaleo Sleep Hx questionnaire/diaryo Home
assessmento Beck depression inventory- fast screeno Mobility section of
FIMo ADL, IADL, and dysphagia assessmentso 9-hole pego Purdue
pegboardo Semmes Weinsteino MMTo ROM o Dynamometero Vestibular
eval
◍ An obese client with emphysema who smokes at least a pack of cigarettes
daily is admitted after experiencing a sudden increase in dyspnea and
activity intolerance. Oxygen therapy is initiated and it is determined that the
client will be discharged with oxygen. Which information is most important
for the nurse to emphasize in the discharge teaching plan? a. Methods for
weight lossb. guidelines for oxygen usec. Approaches to conserve energy d.
Strategies for smoking cessation.
Answer: b. guidelines for oxygen use
◍ An older adult client with long term type 2 diabetes mellitus is seen in the
clinic for a routine health assessment. which assessments would the nurse
complete to determine if a patient with type diabetes mellitus is
experiencing long term complications? (select all) a. Sign of respiratory tract
infection b. Sensation in feet and legs c. Skin condition of lower extremities
d. Serum creatine and blood urea nitrogen (BUN)e. Visual acuity.
Answer: b. Sensation in feet and legs c. Skin condition of lower extremities
e. Visual acuity
◍ DVT.
Answer: formation of blood clot, most often in LE, abdomen, or pelvis; may
develop further, dislodge from the venous wall, and turn into an embolus;
OT is part of team that monitors for asymmetries in color, size, and/temp;
Tx involves bed rest and anticoagulants to prevent embolus
◍ ALS LMN involvement.
Answer: results in weakness/muscle atrophy of extremities, cervical
WITH CORRECT ANSWERS GRADED A+
◍ SCI level C1-C3.
Answer: o Functionally relevant mm innervated: sternocleidomastoid,
cervical paraspinal, neck accessorieso Mvmt possible: neck flexion,
extension, rotationo Patterns of weakness: total paralysis of trunk, UE, LE,
dependent on vento Functional expectation Respiratory- likely will be
ventilator dependent ADLs- dependent w/c mobility• power w/c with
alternative control- independent• manual w/c- dependent tilt in space w/c
◍ A client with gouty arthritis reports tenderness and swelling of the right
ankle and great toe. The nurse observes the area of inflammation extends
above the ankle area. The client receives prescriptions for colchicine and
indomethacin. Which instruction should the nurse include in the discharge
teaching? a. eat high protein foods to achieve ideal body weightb. drink at
least 8 cups of water per day c. use electronic heating pad when pain is at its
worsed. encourage active range of motion to limit stiffness.
Answer: b. drink at least 8 cups of water per day
◍ SCI level T1-T9.
Answer: o Functionally relevant mm innervated: intrinsic of the hand
including thumbs; internal and external intercostals; erector spinae,
lumbricals, flex/ext/abductor polliciso Mvmt possible- UE fully intact;
limited upper trunk stability; endurance increased secondary to innervation
of intercostalso Patterns of weakness- lower trunk paralysis; total paralysis
of LEo Functional expectations I in all ADLs w/c propulsion- I
transportation- I in car, including loading/unloading w/c
◍ The nurse is obtaining a health history from a new client who has a history
of kidney stones. Which statement by the client indicates an increased risk
, for renal calculi? a. Eats a vegetarian diet with cheese 2 to 3 times a day b.
Experiences additional stress since adopting a childc. Jogs more frequently
than usual daily routined. Drinks several bottles of carbonated water daily.
Answer: a. Eats a vegetarian diet with cheese 2 to 3 times a day
◍ SCI Tx in AC.
Answer: o Edu pt and family Understanding injury Importance of skin care
Prevention of secondary complicationso BADLso Goals may depend on
whether or not the pt has funding to transfer to IPR This may be the only
therapy that the pt receives If pt doesn't go to rehab, the therapist must
address equipment needs, preparing the home, and advocating for pt needs
◍ possible assessments for GBS.
Answer: o Pain scaleo Berg depression scaleo FIMo COPMo 7-point GBS
disability scaleo Semmes Weinsteino ROMo MMTo Dynamometer Grip,
pinch, 3 point, lateral pinch
◍ myotome C6.
Answer: wrist extension (myotome)
◍ SCIM-SC independence measure.
Answer: Questionnaire regarding functional independence for pt with SCI
◍ ASIA- B incomplete.
Answer: sensory but no motor function is preserved below neurological
level
◍ A client with orthopnea expresses concern about the ability to "get enough
air" during a scheduled thoracentesis. On which information should the
nurse's response be based on?a. a thoracentesis is a brief procedure that has
minimal discomfort b. orthopnea is frequently caused by a client's
uncontrolled anxietyc. the procedure is performed with a client in an upright
position d. Extra pillows can be used if needed to elevate the clients head.
Answer: c. the procedure is performed with a client in an upright position
◍ The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following
, vital signs: Heart rate 140 beats/min, respirations 26 breaths/minutes, and
blood pressure 140/90 mmHg. Which intervention is most important for the
nurse to implement? a. Medicate for pain and monitor vital signs according
to protocol b. Administer IV fluid bolus as prescribed by the providerc.
Apply oxygen at 10 L via non-rebreather mask and monitor pulse
oximeterd. Encourage the client to splint the incision with a pillow to cough
and deep breathe.
Answer: a. Medicate for pain and monitor vital signs according to protocol
◍ phase III of GBS.
Answer: progressive recovery
◍ while caring for a client with a full thickness burn covering 40% of the
body, the nurse observes purulent drainage at the wound. Before reporting
this finding to the healthcare provider, the nurse should review which of the
following laboratory values? a. White blood cell count b. platelet countc.
Blood pH level d. hematocrit.
Answer: a. White blood cell count
◍ A client who was involved in a motor vehicle collision is admitted with a
fractured left femur which is immobilized using a fracture traction splint in
preparation for an open reduction internal fixation (ORIF). The nurse
determines that the client's distal pulses are diminished in the left foot.
Which interventions should the nurse implement? (select all) a. Verify pedal
pulses using a doppler pulse deviceb. Evaluate the application of the splint
to the left leg. c. Offer ice chips and oral clear liquids. d. Monitor left leg for
pain, pallor, paresthesia, paralysis, pressure3. Administer oral
antispasmodics and narcotic analgesics.
Answer: a. Verify pedal pulses using a doppler pulse deviceb. Evaluate the
application of the splint to the left leg d. Monitor left leg for pain, pallor,
paresthesia, paralysis, pressure
◍ AT for SCI.
Answer: o Becoming less expensiveo Allows greater freedom for higher
injury levelso Can coordinate with power w/c electronics
, ◍ assessments for MS- pain, tremors, ataxia, dysphagia.
Answer: o Pain scaleo Multidimensional assessment of tremor (MAT)o
COPMo Modified barium swallow study (MBSS)- SLP performso 6 min
walk testo MS walking scaleo Sleep Hx questionnaire/diaryo Home
assessmento Beck depression inventory- fast screeno Mobility section of
FIMo ADL, IADL, and dysphagia assessmentso 9-hole pego Purdue
pegboardo Semmes Weinsteino MMTo ROM o Dynamometero Vestibular
eval
◍ An obese client with emphysema who smokes at least a pack of cigarettes
daily is admitted after experiencing a sudden increase in dyspnea and
activity intolerance. Oxygen therapy is initiated and it is determined that the
client will be discharged with oxygen. Which information is most important
for the nurse to emphasize in the discharge teaching plan? a. Methods for
weight lossb. guidelines for oxygen usec. Approaches to conserve energy d.
Strategies for smoking cessation.
Answer: b. guidelines for oxygen use
◍ An older adult client with long term type 2 diabetes mellitus is seen in the
clinic for a routine health assessment. which assessments would the nurse
complete to determine if a patient with type diabetes mellitus is
experiencing long term complications? (select all) a. Sign of respiratory tract
infection b. Sensation in feet and legs c. Skin condition of lower extremities
d. Serum creatine and blood urea nitrogen (BUN)e. Visual acuity.
Answer: b. Sensation in feet and legs c. Skin condition of lower extremities
e. Visual acuity
◍ DVT.
Answer: formation of blood clot, most often in LE, abdomen, or pelvis; may
develop further, dislodge from the venous wall, and turn into an embolus;
OT is part of team that monitors for asymmetries in color, size, and/temp;
Tx involves bed rest and anticoagulants to prevent embolus
◍ ALS LMN involvement.
Answer: results in weakness/muscle atrophy of extremities, cervical
