Medsurg 2 Final Exam TB CH. 38-
41
QUESTIONS AND CORRECT
ANSWERS
GRADE A+
1. The nurse teaches an 80-year-old client with diminished peripheral sensation. Which statement
would 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 injuries from your shoes." ANS: C
Older clients with decreased sensation are at risk of injury from the inability to sense changes in
terrain when walking. To compensate for this loss, the client is instructed to look at the
placement of his or her feet when walking. Throw rugs can slip and increase fall risk. Bath water
that is too warm places the client at risk for thermal injury.
2. The nurse assesses a client's recent memory. Which statement by the client confirms that
recent 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."
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c. "Apple, chair, and pencil are the words you just stated."
d. "I ate oatmeal with wheat toast and orange juice for breakfast." ANS: D
Asking clients about recent events that can be verified, such as what the client ate for breakfast,
assesses recent memory. Asking clients about certain facts from the past that can be verified
assesses remote or long-term memory. Asking the client to repeat words assesses immediate
memo
3. A client is admitted to the emergency department with a probable traumatic brain injury.
Which assessment finding would be the priority for the nurse to report to the primary health care
provider?
a. Mild temporal headache
b. Pupils equal and react to light
and oriented
c.Alert and oriented x3
d. Decreasing level of consciousness D
,4. A nurse asks a client to take deep breaths during an electroencephalography. The client asks,
"Why are you asking me to do this?" How would the nurse respond?
a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases
electoral activity in the brain."
b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain
a better waveform."
c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity."
d. "Deep breathing will help you to blow off carbon dioxide and decreases
intracranial pressures." ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood
of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other
responses are not accurate.
5. A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.
Which assessment would 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. ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery.
The extremity is kept immobilized after the procedure. The nurse checks the extremity for
adequate circulation by noting skin color and temperature, presence and quality of pulses distal
to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic
blood pressure readings cannot be performed. The funduscopic (eye) examination would not be
affected by cerebral angiography. The client is not given general anesthesia; therefore, the
client's gag reflex would not be compromised.
6. When assessing a client who had a traumatic brain injury, the nurse notes that the client is
drowsy but easily aroused. What level of consciousness will the nurse document to describe this
client's current level of consciousness?
a. Alert
b. Lethargic
c. Stuporous
d. Comatose ANS: B
The client is categorized as being lethargic because he or she can be easily aroused even though
drowsy. The nurse would carefully monitor the client to determine any decrease in the level of
consciousness (LOC).
7. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.
What assessment findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain ANS: D
Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in
the face. When affected by a health problem, the client experiences severely facial pain.
Expressive aphasia resultsTfrEomSTdBamAaNgKeStoEtLheLBErRoc.aCsOpeMech area in the
frontal lobe of the brain. Ptosis can result from damage to CN III and slurred speech often occurs
, from either damage to several cranial nerves or from damage to the motor strip in the frontal lobe
of the brain.
8. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language ANS: A
CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid
movement.
DIF: Reme
9. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client
states, "I am worried I will not be able to care for my young children." How would the nurse
respond?
a. "Caring for your children is a priority. You may not want to ask for help, but you
really have to."
b. "Our community has resources that may help you with some household tasks so
you have energy to care for your children."
c. "You seem distressed. Would you like to talk to a psychologist about adjusting to
your changing status?"
d. "Can you tell me more about what worries you, so we can see if we can do
something to make adjustments?" ANS: D
Investigate specific concerns about situational or role changes before providing additional
information. The nurse would not tell the client what is or is not a priority for him or her.
Although community resources may be available, they may not be appropriate for the patient.
Consulting a psychologist would not be appropriate without obtaining further information from
the client related to curre
10. A nurse plans care for a 77-year-old client who is experiencing age-related
peripheral sensory perception changes. Which intervention would the nurse include in this
client's plan of care?
a. Provide a call button that requires only minimal pressure to activate.
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b. Write the date on the client's white board to promote orientation.
c. Ensure that the path to the bathroom is free from clutter.
d. Encourage the client to season food to stimulate nutritional intake. ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical
impairment related to illness can be expected. Providing opportunities for hazard-free ambulation
will maintain strength and mobility (and ensure safety). Providing a call button, providing the
date, and seasoning food do not address the client's impaired sensory perception.
11. After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse
assesses the client's understanding. Which statement indicates client understanding of 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. "My gag reflex will be tested before I can eat or drink anything."
d. "I can return to my usual activities immediately after the MRI." ANS: D
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41
QUESTIONS AND CORRECT
ANSWERS
GRADE A+
1. The nurse teaches an 80-year-old client with diminished peripheral sensation. Which statement
would 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 injuries from your shoes." ANS: C
Older clients with decreased sensation are at risk of injury from the inability to sense changes in
terrain when walking. To compensate for this loss, the client is instructed to look at the
placement of his or her feet when walking. Throw rugs can slip and increase fall risk. Bath water
that is too warm places the client at risk for thermal injury.
2. The nurse assesses a client's recent memory. Which statement by the client confirms that
recent 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."
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c. "Apple, chair, and pencil are the words you just stated."
d. "I ate oatmeal with wheat toast and orange juice for breakfast." ANS: D
Asking clients about recent events that can be verified, such as what the client ate for breakfast,
assesses recent memory. Asking clients about certain facts from the past that can be verified
assesses remote or long-term memory. Asking the client to repeat words assesses immediate
memo
3. A client is admitted to the emergency department with a probable traumatic brain injury.
Which assessment finding would be the priority for the nurse to report to the primary health care
provider?
a. Mild temporal headache
b. Pupils equal and react to light
and oriented
c.Alert and oriented x3
d. Decreasing level of consciousness D
,4. A nurse asks a client to take deep breaths during an electroencephalography. The client asks,
"Why are you asking me to do this?" How would the nurse respond?
a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases
electoral activity in the brain."
b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain
a better waveform."
c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity."
d. "Deep breathing will help you to blow off carbon dioxide and decreases
intracranial pressures." ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood
of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other
responses are not accurate.
5. A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.
Which assessment would 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. ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery.
The extremity is kept immobilized after the procedure. The nurse checks the extremity for
adequate circulation by noting skin color and temperature, presence and quality of pulses distal
to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic
blood pressure readings cannot be performed. The funduscopic (eye) examination would not be
affected by cerebral angiography. The client is not given general anesthesia; therefore, the
client's gag reflex would not be compromised.
6. When assessing a client who had a traumatic brain injury, the nurse notes that the client is
drowsy but easily aroused. What level of consciousness will the nurse document to describe this
client's current level of consciousness?
a. Alert
b. Lethargic
c. Stuporous
d. Comatose ANS: B
The client is categorized as being lethargic because he or she can be easily aroused even though
drowsy. The nurse would carefully monitor the client to determine any decrease in the level of
consciousness (LOC).
7. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.
What assessment findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain ANS: D
Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in
the face. When affected by a health problem, the client experiences severely facial pain.
Expressive aphasia resultsTfrEomSTdBamAaNgKeStoEtLheLBErRoc.aCsOpeMech area in the
frontal lobe of the brain. Ptosis can result from damage to CN III and slurred speech often occurs
, from either damage to several cranial nerves or from damage to the motor strip in the frontal lobe
of the brain.
8. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language ANS: A
CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid
movement.
DIF: Reme
9. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client
states, "I am worried I will not be able to care for my young children." How would the nurse
respond?
a. "Caring for your children is a priority. You may not want to ask for help, but you
really have to."
b. "Our community has resources that may help you with some household tasks so
you have energy to care for your children."
c. "You seem distressed. Would you like to talk to a psychologist about adjusting to
your changing status?"
d. "Can you tell me more about what worries you, so we can see if we can do
something to make adjustments?" ANS: D
Investigate specific concerns about situational or role changes before providing additional
information. The nurse would not tell the client what is or is not a priority for him or her.
Although community resources may be available, they may not be appropriate for the patient.
Consulting a psychologist would not be appropriate without obtaining further information from
the client related to curre
10. A nurse plans care for a 77-year-old client who is experiencing age-related
peripheral sensory perception changes. Which intervention would the nurse include in this
client's plan of care?
a. Provide a call button that requires only minimal pressure to activate.
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b. Write the date on the client's white board to promote orientation.
c. Ensure that the path to the bathroom is free from clutter.
d. Encourage the client to season food to stimulate nutritional intake. ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical
impairment related to illness can be expected. Providing opportunities for hazard-free ambulation
will maintain strength and mobility (and ensure safety). Providing a call button, providing the
date, and seasoning food do not address the client's impaired sensory perception.
11. After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse
assesses the client's understanding. Which statement indicates client understanding of 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. "My gag reflex will be tested before I can eat or drink anything."
d. "I can return to my usual activities immediately after the MRI." ANS: D
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