NSG 223 Med Surg II Exam 1:100% Verified Questions
& Answers: Updated A+ Guide Solution
/A client sustains a head trauma after falling from a roof. The nurse observes clear fluid
leaking from the nose. What is the priority action by the nurse?
a. Use a Q-tip to gently clean the nasal passages.
b. Pack the nose with nasal packing.
c. Have the client blow the nose to clear the passages.
d. Have the fluid checked for glucose. - Answer-Answer: d
Cognitive Level: Analyze
Explanation: If a client sustains head trauma and fluid is noted leaking from the ears or
nose, this fluid should be tested for glucose, which is present in CSF. If the glucose test
is positive, notify a healthcare provider immediately, because leaking CSF usually
indicates a life-threatening situation.
/.A client suffers a stroke located in the medulla. What is the priority action by the
nurse?
a. Support the client's respiratory function.
b. Assist the client with ambulation.
c. Orient the client to surroundings frequently.
d. Monitor the client for swallowing food and fluid. - Answer-Answer: a
Cognitive Level: Analyze
Explanation: The medulla contains centers for many vital body functions, including the
cardiac center (regulates heart rate), vasomotor center (regulates the diameter of blood
vessels, thereby regulating blood pressure), and respiratory center (regulates
breathing). Other activities of the medulla are concerned with reflexes, such as
swallowing, coughing, sneezing, hiccupping, and vomiting. Although all of the options
are important nursing interventions, the priority action would be the support of the
respiratory system. Since the affected area is in the medulla, if the respiratory system is
not supported by artificial means such as a bag-valve-mask or a mechanical ventilator,
the client will not be able to sustain life. The client will not be able to ambulate or
swallow food and fluid and will require enteral feedings. Orientation is part of nursing
interventions even though the client most likely will be comatose.
/.A client with chronic alcoholism and late stage cirrhosis of the liver has significant
damage to Wernicke's area. What data obtained by the nurse is indicative of this
damage?
a. The client is unable to ambulate independently.
b. The client does not comprehend written and spoken language but speaks.
c. The client has speech impairment, but is able to comprehend language.
d. The client's left hand is experiencing paralysis. - Answer-Answer: b
, Cognitive Level: Analyze
Explanation: Damage to Wernicke's area in the brain impairs the client's ability to
comprehend written and spoken language, but the client is still able to speak.
/.A client who sustained head trauma in a motor vehicle crash is determined to have an
increase in intracranial pressure (ICP). What related complications should the nurse be
aware of? Select all that apply.
a. Brain hypoxia
b. Herniation of the brain
c. Brain compression
d. Paralysis of the lower extremities
e. Urinary retention - Answer-Answer: a, b, c
Cognitive Level: Apply
Explanation: The skull is a rigid container that contains brain tissue, CSF, and blood.
The volume of these components determines ICP. A large increase in any of these
factors can increase ICP. This can cause brain hypoxia (oxygen deprivation), herniation
of the brain (brain contents being pushed through an opening), brain compression (the
brain is pushed against the rigid skull), necrosis (death) of brain tissue in a specific
area, or death of the individual.
/.A client is having a colonoscopy and suddenly the client's heart rate drops from 72
beats per minute (BPM) to 52 BPM. What cranial nerve does the nurse determine has
been stimulated?
a. Cranial Nerve I (Olfactory)
b. Cranial Nerve V (Trigeminal)
c. Cranial Nerve IX (Glossopharyngeal)
d. Cranial Nerve X (Vagus) - Answer-Answer: d
Cognitive Level: Analyze
Explanation: Branches of the vagus nerve innervate muscles of the pharynx, larynx,
respiratory tract, heart, esophagus, and parts of the abdominal viscera. Therefore, the
vagus nerve has reflex control of heart rate, sneezing, hunger, secretions from glands in
the stomach, and constrictions within the respiratory tract. If the client's heart rate has
dropped then it is likely that cranial nerve X, the vagus nerve, has been stimulated.
/.The nurse witnesses a client having a tonic-clonic seizure in the bed. What is the
priority action by the nurse?
a. Insert a tongue blade between the client's teeth.
b. Place the client in the prone position.
c. Turn the head to the side.
d. Insert an indwelling catheter. - Answer-Answer: c
Cognitive Level: Apply
Explanation: The priority action by the nurse would be to turn the client's head to the
side to avoid aspiration. The nurse should not attempt to place anything in between the
& Answers: Updated A+ Guide Solution
/A client sustains a head trauma after falling from a roof. The nurse observes clear fluid
leaking from the nose. What is the priority action by the nurse?
a. Use a Q-tip to gently clean the nasal passages.
b. Pack the nose with nasal packing.
c. Have the client blow the nose to clear the passages.
d. Have the fluid checked for glucose. - Answer-Answer: d
Cognitive Level: Analyze
Explanation: If a client sustains head trauma and fluid is noted leaking from the ears or
nose, this fluid should be tested for glucose, which is present in CSF. If the glucose test
is positive, notify a healthcare provider immediately, because leaking CSF usually
indicates a life-threatening situation.
/.A client suffers a stroke located in the medulla. What is the priority action by the
nurse?
a. Support the client's respiratory function.
b. Assist the client with ambulation.
c. Orient the client to surroundings frequently.
d. Monitor the client for swallowing food and fluid. - Answer-Answer: a
Cognitive Level: Analyze
Explanation: The medulla contains centers for many vital body functions, including the
cardiac center (regulates heart rate), vasomotor center (regulates the diameter of blood
vessels, thereby regulating blood pressure), and respiratory center (regulates
breathing). Other activities of the medulla are concerned with reflexes, such as
swallowing, coughing, sneezing, hiccupping, and vomiting. Although all of the options
are important nursing interventions, the priority action would be the support of the
respiratory system. Since the affected area is in the medulla, if the respiratory system is
not supported by artificial means such as a bag-valve-mask or a mechanical ventilator,
the client will not be able to sustain life. The client will not be able to ambulate or
swallow food and fluid and will require enteral feedings. Orientation is part of nursing
interventions even though the client most likely will be comatose.
/.A client with chronic alcoholism and late stage cirrhosis of the liver has significant
damage to Wernicke's area. What data obtained by the nurse is indicative of this
damage?
a. The client is unable to ambulate independently.
b. The client does not comprehend written and spoken language but speaks.
c. The client has speech impairment, but is able to comprehend language.
d. The client's left hand is experiencing paralysis. - Answer-Answer: b
, Cognitive Level: Analyze
Explanation: Damage to Wernicke's area in the brain impairs the client's ability to
comprehend written and spoken language, but the client is still able to speak.
/.A client who sustained head trauma in a motor vehicle crash is determined to have an
increase in intracranial pressure (ICP). What related complications should the nurse be
aware of? Select all that apply.
a. Brain hypoxia
b. Herniation of the brain
c. Brain compression
d. Paralysis of the lower extremities
e. Urinary retention - Answer-Answer: a, b, c
Cognitive Level: Apply
Explanation: The skull is a rigid container that contains brain tissue, CSF, and blood.
The volume of these components determines ICP. A large increase in any of these
factors can increase ICP. This can cause brain hypoxia (oxygen deprivation), herniation
of the brain (brain contents being pushed through an opening), brain compression (the
brain is pushed against the rigid skull), necrosis (death) of brain tissue in a specific
area, or death of the individual.
/.A client is having a colonoscopy and suddenly the client's heart rate drops from 72
beats per minute (BPM) to 52 BPM. What cranial nerve does the nurse determine has
been stimulated?
a. Cranial Nerve I (Olfactory)
b. Cranial Nerve V (Trigeminal)
c. Cranial Nerve IX (Glossopharyngeal)
d. Cranial Nerve X (Vagus) - Answer-Answer: d
Cognitive Level: Analyze
Explanation: Branches of the vagus nerve innervate muscles of the pharynx, larynx,
respiratory tract, heart, esophagus, and parts of the abdominal viscera. Therefore, the
vagus nerve has reflex control of heart rate, sneezing, hunger, secretions from glands in
the stomach, and constrictions within the respiratory tract. If the client's heart rate has
dropped then it is likely that cranial nerve X, the vagus nerve, has been stimulated.
/.The nurse witnesses a client having a tonic-clonic seizure in the bed. What is the
priority action by the nurse?
a. Insert a tongue blade between the client's teeth.
b. Place the client in the prone position.
c. Turn the head to the side.
d. Insert an indwelling catheter. - Answer-Answer: c
Cognitive Level: Apply
Explanation: The priority action by the nurse would be to turn the client's head to the
side to avoid aspiration. The nurse should not attempt to place anything in between the
