NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM
NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM 180
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+||GALEN COLLEGE OF
NURSING
The nurse is caring for a mechanically ventilated client who has an organ donation card and a severe traumatic brain
injury. Which assessment findings indicate that the client will be declared as brain dead? (Select all that apply.)
A.Hypothermia
B. Absence of brainstem reflexes
C. Apnea not due to drugs or diseases
D. Irreversible loss of consciousness
E. Hypotension –
ANS :Answer: B, C, D
Rationale: These three assessment findings meet the American Academy of Neurology guidelines for brain death.
However, ancillary imaging tests may be used to validate these findings.
The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would
note which trend in vital signs if the intracranial pressure is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
C.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
D. .Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure –
ANS :B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
1
, NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM
Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing
temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which
measures in the plan of care to minimize the risk of occurrence? Select all that apply.
1.Keeping the linens wrinkle-free under the client
2.Preventing unnecessary pressure on the lower limbs
3.Limiting bladder catheterization to once every 12 hours
4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least
once a week - ANS
:Answer: 1,2,4,5
Rationale:The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should
be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be
checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining
bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes
include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in
these areas.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which
characteristics are associated with this condition? Select all that apply.
1.The client is aphasic.
2.The client has weakness on the right side of the body.
3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the
face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently.
6.The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without
assistance. –
ANS :Answer: 1,2,4
Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of
the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and
letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis
does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and
needs assistance with feeding, bathing, and ambulating.
2
, NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM
The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises.
Which client activity suggests that teaching is most effective?
1.Taking medications as scheduled
2.Eating large, well-balanced meals
3.Doing muscle-strengthening exercises
4.Doing all chores early in the day while less fatigued –
ANS :1.Taking medications as scheduled
Rationale:Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and
restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is
important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of
exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and
adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?
1.Pruritus
2.Tachycardia
3.Hypertension
4.Impaired voluntary movements –
ANS :4.Impaired voluntary movements
Rationale:Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea,
anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.
The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the
nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching
plan?
1.Pregnancy must be avoided while taking phenytoin.
2.The client may stop the medication if it is causing severe gastrointestinal effects.
3
, NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM
3.There is the potential of decreased effectiveness of birth control pills while taking phenytoin.
4.There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together
. - ANS :3.There is the potential of decreased effectiveness of birth control pills while taking phenytoin.
Rationale:Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth
control pills. Options 1, 2, and 4 are inappropriate instructions. Pregnancy does not need to be "avoided" while
taking phenytoin; however, because phenytoin may cause some risk to the fetus (Pregnancy Category D medication),
consultation with the primary health care provider should be done if pregnancy is considered. Telling a client that
there is an increased risk of thrombophlebitis is incorrect and inappropriate and could cause anxiety in the client. A
client should not be instructed to stop antiseizure medication.
A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal
a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result?
1.Hypotension
2.Tachycardia
3.Slurred speech
4.No abnormal finding
- ANS :3.Slurred speech
Rationale:The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL,
involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia
and slurred speech occur.
A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to
identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity
of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that
the client is in cholinergic crisis?
1.No change in the condition
2.Complaints of muscle spasms
3.An improvement of the weakness
4.A temporary worsening of the condition –
4
NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM 180
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+||GALEN COLLEGE OF
NURSING
The nurse is caring for a mechanically ventilated client who has an organ donation card and a severe traumatic brain
injury. Which assessment findings indicate that the client will be declared as brain dead? (Select all that apply.)
A.Hypothermia
B. Absence of brainstem reflexes
C. Apnea not due to drugs or diseases
D. Irreversible loss of consciousness
E. Hypotension –
ANS :Answer: B, C, D
Rationale: These three assessment findings meet the American Academy of Neurology guidelines for brain death.
However, ancillary imaging tests may be used to validate these findings.
The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would
note which trend in vital signs if the intracranial pressure is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
C.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
D. .Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure –
ANS :B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
1
, NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM
Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing
temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which
measures in the plan of care to minimize the risk of occurrence? Select all that apply.
1.Keeping the linens wrinkle-free under the client
2.Preventing unnecessary pressure on the lower limbs
3.Limiting bladder catheterization to once every 12 hours
4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least
once a week - ANS
:Answer: 1,2,4,5
Rationale:The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should
be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be
checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining
bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes
include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in
these areas.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which
characteristics are associated with this condition? Select all that apply.
1.The client is aphasic.
2.The client has weakness on the right side of the body.
3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the
face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently.
6.The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without
assistance. –
ANS :Answer: 1,2,4
Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of
the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and
letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis
does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and
needs assistance with feeding, bathing, and ambulating.
2
, NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM
The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises.
Which client activity suggests that teaching is most effective?
1.Taking medications as scheduled
2.Eating large, well-balanced meals
3.Doing muscle-strengthening exercises
4.Doing all chores early in the day while less fatigued –
ANS :1.Taking medications as scheduled
Rationale:Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and
restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is
important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of
exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and
adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?
1.Pruritus
2.Tachycardia
3.Hypertension
4.Impaired voluntary movements –
ANS :4.Impaired voluntary movements
Rationale:Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea,
anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.
The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the
nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching
plan?
1.Pregnancy must be avoided while taking phenytoin.
2.The client may stop the medication if it is causing severe gastrointestinal effects.
3
, NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM
3.There is the potential of decreased effectiveness of birth control pills while taking phenytoin.
4.There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together
. - ANS :3.There is the potential of decreased effectiveness of birth control pills while taking phenytoin.
Rationale:Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth
control pills. Options 1, 2, and 4 are inappropriate instructions. Pregnancy does not need to be "avoided" while
taking phenytoin; however, because phenytoin may cause some risk to the fetus (Pregnancy Category D medication),
consultation with the primary health care provider should be done if pregnancy is considered. Telling a client that
there is an increased risk of thrombophlebitis is incorrect and inappropriate and could cause anxiety in the client. A
client should not be instructed to stop antiseizure medication.
A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal
a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result?
1.Hypotension
2.Tachycardia
3.Slurred speech
4.No abnormal finding
- ANS :3.Slurred speech
Rationale:The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL,
involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia
and slurred speech occur.
A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to
identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity
of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that
the client is in cholinergic crisis?
1.No change in the condition
2.Complaints of muscle spasms
3.An improvement of the weakness
4.A temporary worsening of the condition –
4
