1. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded
from your plan of care?
Before log rolling, remove the pillow from under the client’s head and use no pillows between the
client’s legs. Following a laminectomy and spinal fusion, it is important that the back of the patient
be maintained in straight alignment and to support the entire vertebral column to promote
complete healing.
2. A client is admitted from the emergency department with severe-pain and edema in the
right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have
the highest priority?
Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that
cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary
uric acid stones
3. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and
weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her
volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5
years ago. Which would be excluded from the clinical pathway for this client?
Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility
caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can
even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient
4. The nurse includes the important measures for stump care in the teaching plan for a client
with an amputation. Which measure would be excluded from the teaching plan?
Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The “shrinker” bandage
is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the
tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow
5. The client has clear drainage from the nose and ears after a head injury. How can the
nurse determine if the drainage is CSF?
Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result
with the drainage indicate CSF leakage.
6. Which nursing diagnosis is of the highest priority when caring for a client with
myasthenia gravis?
Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve
impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This
leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function.
The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the
airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency
airway
, and mechanical ventilation.
7. A client with head injury is confused, drowsy and has unequal pupils. Which of the
following nursing diagnosis is most important at this time?
Altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral
perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage
8. What would be the MOST therapeutic nursing action when a client’s expressive aphasia
is severe?
Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the
Broca’s area of the frontal lobe. It is a motor speech problem in which the client generally understands what is said but is
unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and
reinforce this behavior positively
9. Which is irrelevant in the pharmacologic management of a client with CVA?
Aspirin is used in the acute management of a completed stroke. The primary goal in the management of CVA is to
improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but
is not used in the acute management of a completed stroke as it may lead to bleeding.
10. Which is considered as the earliest sign of increased ICP that the nurse should
closely observed for?
progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a
decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially
manifested by restlessness.
11. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography.
Nursing care of the client includes the following EXCEPT
Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter
through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area
causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected
extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the
procedure. Ice bag can be applied intermittently to the puncture site.
12. A client is to undergo lumbar puncture. Which is least important information about LP?
A. Specimens obtained should be labeled in their proper sequence.
B. It may be used to inject air, dye or drugs into the spinal canal.
C. Assess movements and sensation in the lower extremities after the
D. Force fluids before and after the procedure
Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF
from your plan of care?
Before log rolling, remove the pillow from under the client’s head and use no pillows between the
client’s legs. Following a laminectomy and spinal fusion, it is important that the back of the patient
be maintained in straight alignment and to support the entire vertebral column to promote
complete healing.
2. A client is admitted from the emergency department with severe-pain and edema in the
right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have
the highest priority?
Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that
cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary
uric acid stones
3. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and
weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her
volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5
years ago. Which would be excluded from the clinical pathway for this client?
Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility
caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can
even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient
4. The nurse includes the important measures for stump care in the teaching plan for a client
with an amputation. Which measure would be excluded from the teaching plan?
Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The “shrinker” bandage
is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the
tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow
5. The client has clear drainage from the nose and ears after a head injury. How can the
nurse determine if the drainage is CSF?
Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result
with the drainage indicate CSF leakage.
6. Which nursing diagnosis is of the highest priority when caring for a client with
myasthenia gravis?
Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve
impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This
leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function.
The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the
airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency
airway
, and mechanical ventilation.
7. A client with head injury is confused, drowsy and has unequal pupils. Which of the
following nursing diagnosis is most important at this time?
Altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral
perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage
8. What would be the MOST therapeutic nursing action when a client’s expressive aphasia
is severe?
Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the
Broca’s area of the frontal lobe. It is a motor speech problem in which the client generally understands what is said but is
unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and
reinforce this behavior positively
9. Which is irrelevant in the pharmacologic management of a client with CVA?
Aspirin is used in the acute management of a completed stroke. The primary goal in the management of CVA is to
improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but
is not used in the acute management of a completed stroke as it may lead to bleeding.
10. Which is considered as the earliest sign of increased ICP that the nurse should
closely observed for?
progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a
decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially
manifested by restlessness.
11. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography.
Nursing care of the client includes the following EXCEPT
Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter
through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area
causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected
extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the
procedure. Ice bag can be applied intermittently to the puncture site.
12. A client is to undergo lumbar puncture. Which is least important information about LP?
A. Specimens obtained should be labeled in their proper sequence.
B. It may be used to inject air, dye or drugs into the spinal canal.
C. Assess movements and sensation in the lower extremities after the
D. Force fluids before and after the procedure
Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF
