Eye1. The clinic nurse is preparing to test the visual acuity of a client using a Snellen’s chart. Which of the following

identifies the accurate procedure for this visual acuity test?1. Both eyes are assessed together, followed by the assessment of the right and then the left eye.2. The right eye is tested followed by the left eye, and then both eyes are tested.3. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on

the chart.4. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200

ft away by an individual with unimpaired vision.2.     The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client’s chart. The nurse reviews the results of the Snellen’s chart test expecting to note which of the following?

1. 20/20 vision2. 20/40 vision3. 20/60 vision4. 20/200 vision

3.     The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as 20/60. The nurse interprets this as:

1. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.2. The client is legally blind.3. The client’s vision is normal4. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet. 

4.     Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client’s chart and understands that normal intraocular pressure is:

1. 2-7 mmHg2. 10-21 mmHg3. 22-30 mmHg4. 31-35 mmHg

5.      The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care?

1. Self-care deficit2. Imbalanced nutrition3. Disturbed sensory perception4. Anxiety

6.     The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:

1. Eye pain2. Floating spots3. Blurred vision4. Diplopia

7.     In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled?

1. An osmotic diuretic2. A miotic agent3. A mydriatic medication4. A thiazide diuretic

8.     During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to:

1. Call the physician2. Administer the ordered main medication and antiemetic3. Reassure the client that this is normal.4. Turn the client on his or her operative side

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9.     The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions?

1. “I will take Aspirin if I have any discomfort.”2. “I will sleep on the side that I was operated on.”3. “I will wear my eye shield at night and my glasses during the day.”4. “I will not lift anything if it weighs more that 10 pounds.”

10.     The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is:1. “Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to

the treatment plan.”2. “Your vision will return as soon as the medications begin to work.”3. “Your vision will never return to normal.”4. “Your vision loss is temporary and will return in about 3-4 weeks.” 

11.     The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care?

1. Decrease fluid intake to control the intraocular pressure2. Avoid overuse of the eyes3. Decrease the amount of salt in the diet4. Eye medications will need to be administered lifelong.

12.     The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder?

1. Pain in the affected eye2. Total loss of vision3. A sense of a curtain falling across the field of vision4. A yellow discoloration of the sclera.

13.     The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment?

1. Complaints of a burst of black spots or floaters2. A sudden sharp pain in the eye3. Total loss of vision4. A reddened conjunctiva

14.     The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately?

1. Notify the physician2. Irrigate the eye with cold water3. Apply ice to the affected eye4. Accompany the client to the emergency room

15.     The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye, what is the initial nursing action?

1. Remove the piece of wood using a sterile eye clamp2. Apply an eye patch3. Perform visual acuity tests4. Irrigate the eye with sterile saline.

16.     The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to:

1. Begin visual acuity testing2. Irrigate the eye with sterile normal saline3. Swab the eye with antibiotic ointment4. Cover the eye with a pressure patch.

17.     The nurse is caring for a client following enucleation. The nurse notes the presence of bright red blood drainage on the dressing. Which nursing action is appropriate?

1. Notify the physician2. Continue to monitor the drainage3. Document the finding

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4. Mark the drainage on the dressing and monitor for any increase in bleeding.18.     When using a Snellen alphabet chart, the nurse records the client’s vision as 20/40. Which of the following statements best describes 20/40 vision?

1. The client has alterations in near vision and is legally blind.2. The client can see at 20 feet what the person with normal vision can see at 40 feet.3. The client can see at 40 feet what the person with normal vision sees at 20 feet.4. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye.

19.     Which of the following instruments is used to record intraocular pressure?1. Goniometer2. Ophthalmoscope3. Slit lamp4. Tonometer

20.     After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic examination, which of the following instructions would be given to the client?

1. “Be careful because the blink reflex is paralyzed.”2. “Avoid wearing your regular glasses when driving.”3. “Be aware that the pupils may be unusually small.”4. “Wear dark glasses in bright light because the pupils are dilated.”

21.     Which of the following procedures or assessments must the nurse perform when preparing a client for eye surgery?

1. Clipping the client’s eyelashes2. Verifying the affected eye has been patched 24 hours before surgery3. Verifying the client has been NPO since midnight, or at least 8 hours before surgery.4. Obtaining informed consent with the client’s signature and placing the forms on the chart.

22.     Cataract surgery results in aphakia. Which of the following statements best describes this term?1. Absence of the crystalline lens2. A “keyhole” pupil3. Loss of accommodation4. Retinal detachment

23.     When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress?

1. Glaucoma is easily corrected with eyeglasses2. White and Asian individuals are at the highest risk for glaucoma.3. Yearly screening for people ages 20-40 years is recommended.4. Glaucoma can be painless and vision may be lost before the person is aware of a problem.

24.     For a client having an episode of acute narrow-angle glaucoma, a nurse expects to give which of the following medications?

1. Acetazolamide (Diamox)2. Atropine3. Furisemide (Lasix)4. Urokinase (Abbokinase)

25.     Which of the following symptoms would occur in a client with a detached retina?1. Flashing lights and floaters2. Homonymous hemianopia3. Loss of central vision4. Ptosis

26.     A male client has just had a cataract operation without a lens implant. In discharge teaching, the nurse will instruct the client’s wife to:

1. Feed him soft foods for several days to prevent facial movement2. Keep the eye dressing on for one week3. Have her husband remain in bed for 3 days4. Allow him to walk upstairs only with assistance.

 Answers

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1. 2. Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart.

2. 4. Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.

3. 4. Vision that is 20/20 is normal, that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 only can read at a distance of 20 feet of what a person with normal vision can read at 60 feet.

4. 2. Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mmHg are considered within normal range.

5. 3. The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Disturbed sensory perception (visual) related to lens extraction and replacement. Although the other options identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery.

6. 3. A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.

7. 3. A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medication act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

8. 1. Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate.

9. 3. The client is instructed to wear a metal or plastic shield to protect the eye from accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds.

10. 1. Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client.

11. 4. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.

12. 3. A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

13. 1. Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment.

14. 3. Treatment for contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.

15. 3. If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the sclera. (The only option that will prevent further disruption is to assess visual acuity.)

16. 2. Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed.

17. 1. If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this indicated hemorrhage.

18. 2. The numerator refers to the client’s vision while comparing the normal vision in the denominator.

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19. 4. A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

20. 4. Atropine, an anticholinergic drug, has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn’t paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision.

21. 3. Maintaining NPO status for at least 8 hours before surgical procedures prevents vomiting and aspiration. There is no need to patch an eye before most surgeries or to clip the eyelashes unless specifically ordered by the physician. The physician is responsible for obtaining informed consent; the nurse validates that the consent is obtained.

22. 1. Aphakia means without lens, a keyhole pupil results from iridectomy. Loss of accommodation is a normal response to aging. A retinal detachment is usually associated with retinal holes created by vitreous traction.

23. 4. Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. Blacks have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened.

24. 1. Acetazolamide, a carbonic anhydrase inhibitor, decreases intraocular pressure (IOP) by decreasing the secretion of aqueous humor. Atropine dilates the pupil and decreases outflow of aqueous humor, causing further increase in IOP. Lasix is a loop diuretic, and Urokinase is a thrombolytic agent; they aren’t used for the treatment of glaucoma. (Remember surgical nursing and PVD? Ha!)

25. 1. Signs and symptoms of retinal detachment include abrupt flashing lights, floaters, loss of peripheral vision, or a sudden shadow or curtain in the vision. Occasionally visual loss is gradual.

26. 4. Without a lens, the eye cannot accommodate. It is difficult to judge distance and climb stairs when the eyes cannot accommodate. Therefore, the client should walk up and down stairs only with assistance.

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Renal2. Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis?

A. Jaundice and flank painB. Costovertebral angle tenderness and chillsC. Burning sensation on urinationD. Polyuria and nocturia

3. You have a patient that might have a urinary tract infection (UTI). Which statement by the patient suggests that a UTI is likely?

A. “I pee a lot.”B. “It burns when I pee.”C. “I go hours without the urge to pee.”D. “My pee smells sweet.”

4. Which instructions do you include in the teaching care plan for a patient with cystitis receiving phenazopyridine (Pyridium).

A. If the urine turns orange-red, call the doctor.B. Take phenazopyridine just before urination to relieve pain.C. Once painful urination is relieved, discontinue prescribed antibiotics.D. After painful urination is relieved, stop taking phenazopyridine.

5. Which patient is at greatest risk for developing a urinary tract infection (UTI)?A. A 35 y.o. woman with a fractured wristB. A 20 y.o. woman with asthmaC. A 50 y.o. postmenopausal womanD. A 28 y.o. with angina

6. You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining?

A. Check for kinks in the outflow tubing.B. Raise the drainage bag above the level of the abdomen.C. Place the patient in a reverse Trendelenburg position.D. Ask the patient to cough.

7. What is the appropriate infusion time for the dialysate in your 38 y.o. patient with chronic renal failure?A. 15 minutesB. 30 minutesC. 1 hourD. 2 to 3 hours

8. A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device?

A. Insert I.V. lines above the fistula.B. Avoid taking blood pressures in the arm with the fistula.C. Palpate pulses above the fistula.D. Report a bruit or thrill over the fistula to the doctor.

9. Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect?

A. InfectionB. Disequilibrium syndromeC. Air embolusD. Acute hemolysis

 9.    Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps?

A. Increase the rate of dialysisB. Infuse normal saline solutionC. Administer a 5% dextrose solutionD. Encourage active ROM exercises

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10.  Your patient with chronic renal failure reports pruritus. Which instruction should you include in this patient’s teaching plan?

A. Rub the skin vigorously with a towelB. Take frequent bathsC. Apply alcohol-based emollients to the skinD. Keep fingernails short and clean

11.  Which intervention do you plan to include with a patient who has renal calculi?A. Maintain bed restB. Increase dietary purinesC. Restrict fluidsD. Strain all urine

12.  An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student’s health history?

A. Renal calculiB. Renal traumaC. Recent sore throatD. Family history of acute glomerulonephritis

13.  Which drug is indicated for pain related to acute renal calculi?A. Narcotic analgesicsB. Nonsteroidal anti-inflammatory drugs (NSAIDS)C. Muscle relaxantsD. Salicylates

14.  Which of the following causes the majority of UTI’s in hospitalized patients?A. Lack of fluid intakeB. Inadequate perineal careC. Invasive proceduresD. Immunosuppression

15.  Clinical manifestations of acute glomerulonephritis include which of the following?A. Chills and flank painB. Oliguria and generalized edemaC. Hematuria and proteinuriaD. Dysuria and hypotension

16.  You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less than:A. 200mlB. 400mlC. 800mlD. 1000ml

17.  The most common early sign of kidney disease is:A. Sodium retentionB. Elevated BUN levelC. Development of metabolic acidosisD. Inability to dilute or concentrate urine

18.  A patient is experiencing which type of incontinence if she experiences leaking urine when she coughs, sneezes, or lifts heavy objects?

A. OverflowB. ReflexC. StressD. Urge

19.  Immediately post-op after a prostatectomy, which complications requires priority assessment of your patient?

A. PneumoniaB. HemorrhageC. Urine retentionD. Deep vein thrombosis

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20.  The most indicative test for prostate cancer is:A. A thorough digital rectal examinationB. Magnetic resonance imaging (MRI)C. Excretory urographyD. Prostate-specific antigen

21.  A 22 y.o. patient with diabetic nephropathy says, “I have two kidneys and I’m still young. If I stick to my insulin schedule, I don’t have to worry about kidney damage, right?” Which of the following statements is the best response?

A. “You have little to worry about as long as your kidneys keep making urine.”B. “You should talk to your doctor because statistics show that you’re being unrealistic.”C. “You would be correct if your diabetes could be managed with insulin.”D. “Even with insulin, kidney damage is still a concern.”

22.  A patient diagnosed with sepsis from a UTI is being discharged. What do you plan to include in her discharge teaching?

A. Take cool bathsB. Avoid tampon useC. Avoid sexual activityD. Drink 8 to 10 eight-oz glasses of water daily

23.  You’re planning your medication teaching for your patient with a UTI prescribed phenazopyridine (Pyridium). What do you include?

A. “Your urine might turn bright orange.”B. “You need to take this antibiotic for 7 days.”C. “Take this drug between meals and at bedtime.”D. “Don’t take this drug if you’re allergic to penicillin.”

24.  Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient?A. Dysuria, frequency, and urgencyB. Back pain, nausea, and vomitingC. Hypertension, oliguria, and fatigueD. Fever, chills, and right upper quadrant pain radiating to the back

25.  What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease?A. Activity intoleranceB. Fluid volume excessC. Knowledge deficitD. Pain

26.  A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which intervention do you include in his plan of care?

A. Apply pressure to the needle site upon discontinuing hemodialysisB. Keep the ehad of the bed elevated 45 degreesC. Place the left arm on an arm board for at least 30 minutesD. Keep the left arm dry

27.  Your 60 y.o. patient with pyelonephritis and possible septicemia has had five UTIs over the past two years. She is fatigued from lack of sleep, has lost weight, and urinates frequently even in the night. Her labs show: sodium, 154 mEq/L; osmolarity 340 mOsm/L; glucose, 127 mg/dl; and potassium, 3.9 mEq/L. Which nursing diagnosis is priority?

A. Fluid volume deficit related to osmotic diuresis induced by hyponatremiaB. Fluid volume deficit related to inability to conserve waterC. Altered nutrition: Less than body requirements related to hypermetabolic stateD. Altered nutrition: Less than body requirements related to catabolic effects of insulin deficiency

28.  Which sign indicated the second phase of acute renal failure?A. Daily doubling of urine output (4 to 5 L/day)B. Urine output less than 400 ml/dayC. Urine output less than 100 ml/dayD. Stabilization of renal function

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29.  Your patient had surgery to form an arteriovenous fistula for hemodialysis. Which information is important for providing care for the patient?

A. The patient shouldn’t feel pain during initiation of dialysisB. The patient feels best immediately after the dialysis treatmentC. Using a stethoscope for auscultating the fistula is contraindicatedD. Taking a blood pressure reading on the affected arm can cause clotting of the fistula

30.  A patient with diabetes mellitus and renal failure begins hemodialysis. Which diet is best on days between dialysis treatments?

A. Low-protein diet with unlimited amounts of waterB. Low-protein diet with a prescribed amount of waterC. No protein in the diet and use of a salt substituteD. No restrictions

31.  After the first hemodialysis treatment, your patient develops a headache, hypertension, restlessness, mental confusion, nausea, and vomiting. Which condition is indicated?

A. Disequilibrium syndromeB. Respiratory distressC. HypervolemiaD. Peritonitis

32.  Which action is most important during bladder training in a patient with a neurogenic bladder?A. Encourage the use of an indwelling urinary catheterB. Set up specific times to empty the bladderC. Encourage Kegel exercisesD. Force fluids

33.  A patient with diabetes has had many renal calculi over the past 20 years and now has chronic renal failure. Which substance must be reduced in this patient’s diet?

A. CarbohydratesB. FatsC. ProteinD. Vitamin C

34.  What is the best way to check for patency of the arteriovenous fistula for hemodialysis?A. Pinch the fistula and note the speed of filling on releaseB. Use a needle and syringe to aspirate blood from the fistulaC. Check for capillary refill of the nail beds on that extremityD. Palpate the fistula throughout its length to assess for a thrill

35.  You have a paraplegic patient with renal calculi. Which factor contributes to the development of calculi?1. Increased calcium loss from the bones2. Decreased kidney function3. Decreased calcium intake4. High fluid intake

36.  What is the most important nursing diagnosis for a patient in end-stage renal disease?1. Risk for injury2. Fluid volume excess3. Altered nutrition: less than body requirements4. Activity intolerance

37.  Frequent PVCs are noted on the cardiac monitor of a patient with end-stage renal disease. The priority intervention is:

1. Call the doctor immediately2. Give the patient IV lidocaine (Xylocaine)3. Prepare to defibrillate the patient4. Check the patient’s latest potassium level

38.  A patient who received a kidney transplant returns for a follow-up visit to the outpatient clinic and reports a lump in her breast. Transplant recipients are:

1. At increased risk for cancer due to immunosuppression caused by cyclosporine (Neoral)2. Consumed with fear after the life-threatening experience of having a transplant

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3. At increased risk for tumors because of the kidney transplant4. At decreased risk for cancer, so the lump is most likely benign

39.  You’re developing a care plan with the nursing diagnosis risk for infection for your patient that received a kidney transplant. A goal for this patient is to:

1. Remain afebrile and have negative cultures2. Resume normal fluid intake within 2 to 3 days3. Resume the patient’s normal job within 2 to 3 weeks4. Try to discontinue cyclosporine (Neoral) as quickly as possible

40.  You suspect kidney transplant rejection when the patient shows which symptoms?1. Pain in the incision, general malaise, and hypotension2. Pain in the incision, general malaise, and depression3. Fever, weight gain, and diminished urine output4. Diminished urine output and hypotension

41.  Your patient returns from the operating room after abdominal aortic aneurysm repair. Which symptom is a sign of acute renal failure?

1. Anuria2. Diarrhea3. Oliguria4. Vomiting

42.  Which cause of hypertension is the most common in acute renal failure?1. Pulmonary edema2. Hypervolemia3. Hypovolemia4. Anemia

43.  A patient returns from surgery with an indwelling urinary catheter in place and empty. Six hours later, the volume is 120ml. The drainage system has no obstructions. Which intervention has priority?

1. Give a 500ml bolus of isotonic saline2. Evaluate the patient’s circulation and vital signs3. Flush the urinary catheter with sterile water or saline4. Place the patient in the shock position, and notify the surgeon

44.  You’re preparing for urinary catheterization of a trauma patient and you observe bleeding at the urethral meatus. Which action has priority?

A. Irrigate and clean the meatus before catheterizationB. Check the discharge for occult blood before catheterizationC. Heavily lubricate the catheter before insertionD. Delay catheterization and notify the doctor

45.  What change indicates recovery in a patient with nephritic syndrome?1. Disappearance of protein from the urine2. Decrease in blood pressure to normal3. Increase in serum lipid levels4. Gain in body weight

46.  Which statement correctly distinguishes renal failure from prerenal failure?1. With prerenal failure, vasoactive substances such as dopamine (Intropin) increase blood pressure2. With prerenal failure, there is less response to such diuretics as furosemide (Lasix)3. With prerenal failure, an IV isotonic saline infusion increases urine output4. With prerenal failure, hemodialysis reduces the BUN level

47.  Which criterion is required before a patient can be considered for continuous peritoneal dialysis?1. The patient must be hemodynamically stable2. The vascular access must have healed3. The patient must be in a home setting4. Hemodialysis must have failed

48.  Polystyrene sulfonate (Kayexalate) is used in renal failure to:1. Correct acidosis2. Reduce serum phosphate levels

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3. Exchange potassium for sodium4. Prevent constipation from sorbitol use

49.  Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which subjective data supports a diagnosis of renal calculi?

1. Pain radiating to the right upper quadrant2. History of mild flu symptoms last week3. Dark-colored coffee-ground emesis4. Dark, scant urine output

 1. 2. Costovertebral angle tenderness, flank pain, and chills are symptoms of acute pyelonephritis. Jaundice

indicates gallbladder or liver obstruction. A burning sensation on urination is a sign of lower urinary tract infection.

2. 2. A common symptom of a UTI is dysuria. A patient with a UTI often reports frequent voiding of small amounts and the urgency to void. Urine that smells sweet is often associated with diabetic ketoacidosis.

3. 4. Pyridium is taken to relieve dysuria because is provides an analgesic and anesthetic effect on the urinary tract mucosa. The patient can stop taking it after the dysuria is relieved. The urine may temporarily turn red or orange due to the dye in the drug. The drug isn’t taken before voiding, and is usually taken 3 times a day for 2 days.

4. 3. Women are more prone to UTI’s after menopause due to reduced estrogen levels. Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection. Angina, asthma and fractures don’t increase the risk of UTI.

5. 1. Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement.

6. 1. Dialysate should be infused quickly. The dialysate should be infused over 15 minutes or less when performing peritoneal dialysis. The fluid exchange takes place over a period ranging from 30 minutes to several hours.

7. 2. Don’t take blood pressure readings in the arm with the fistula because the compression could damage the fistula. IV lines shouldn’t be inserted in the arm used for hemodialysis. Palpate pulses below the fistula. Lack of bruit or thrill should be reported to the doctor.

8. 2. Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures.

9. 2. Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed to quickly during dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.

10.  4. Calcium-phosphate deposits in the skin may cause pruritus. Scratching leads to excoriation and breaks in the skin that increase the patient’s risk of infection. Keeping fingernails short and clean helps reduce the risk of infection.11.  4. All urine should be strained through gauze or a urine strainer to catch stones that are passed. The stones are then analyzed for composition. Ambulation may help the movement of the stone down the urinary tract. Encourage fluid to help flush the stones out.12.  3. The most common form of acute glomerulonephritis is caused by goup A beta-hemolytic streptococcal infection elsewhere in the body.13.  1. Narcotic analgesics are usually needed to relieve the severe pain of renal calculi. Muscle relaxants are typically used to treat skeletal muscle spasms. NSAIDS and salicylates are used for their anti-inflammatory and antipyretic properties and to treat less severe pain.14.  3. Invasive procedures such as catheterization can introduce bacteria into the urinary tract. A lack of fluid intake could cause concentration of urine, but wouldn’t necessarily cause infection.15.  3. Hematuria and proteinuria indicate acute glomerulonephritis. These finding result from increased permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most often in nephrosis.16.  2. Oliguria is defined as urine output of less than 400ml/24hours.

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17.  2. Increased BUN is usually an early indicator of decreased renal function.18.  3. Stress incontinence is an involuntary loss of a small amount of urine due to sudden increased intra-abdominal pressuer, such as with coughing or sneezing.19.  2. Hemorrhage is a potential complication. Urine retention isn’t a problem soon after surgery because a catheter is in place. Pneumonia may occur if the patient doesn’t cough and deep breathe. Thrombosis may occur later if the patient doesn’t ambulate.20.  4. An elevated prostate-specific antigen level indicates prostate cancer, but it can be falsely elevated if done after the prostate gland is manipulated. A digital rectal examination should be done as part of the yearly screening, and then the antigen test is done if the digital exam suggests cancer. MRI is used in staging the cancer.21.  4. Kidney damage is still a concern. Microavascular changes occur in both of the patient’s kidneys as a complication of the diabetes. Diabetic nephropathy is the leading cause of end-stage renal disease. The kidneys continue to produce urine until the end stage. Nephropathy occurs even with insulin management.22.  4. Drinking 2-3L of water daily inhibits bacterial growth in the bladder and helps flush the bacteria from the bladder. The patient should be instructed to void after sexual activity.23.  1. The drug turns the urine orange. It may be prescribed for longer than 7 days and is usually ordered three times a day after meals. Phenazopyridine is an azo (nitrogenous) analgesic; not an antibiotic.24.  3. Mild to moderate HTN may result from sodium or water retention and inappropriate rennin release from the kidneys. Oliguria and fatigue also may be seen. Other signs are proteinuria and azotemia.25.  2. Fluid volume excess because the kidneys aren’t removing fluid and wastes. The other diagnoses may apply, but they don’t take priority.26.  1. Apply pressure when discontinuing hemodialysis and after removing the venipuncture needle until all the bleeding has stopped. Bleeding may continue for 10 minutes in some patients.27.  2.28.  1. Daily doubling of the urine output indicates that the nephrons are healing. This means the patient is passing into the second phase (dieresis) of acute renal failure.29.  4. Pressure on the fistula or the extremity can decrease blood flow and precipitate clotting, so avoid taking blood pressure on the affected arm.30.  2. The patient should follow a low-protein diet with a prescribed amount of water. The patient requires some protein to meet metabolic needs. Salt substitutes shouldn’t be used without a doctor’s order because it may contain potassium, which could make the patient hyperkalemic. Fluid and protein restrictions are needed.31.  1. Disequilibrium occurs when excess solutes are cleared from the blood more rapidly than they can diffuse from the body’s cells into the vascular system.32.  2. Instruct the patient with neurogenic bladder to write down his voiding pattern and empty the bladder at the same times each day.33.  3. Because of damage to the nephrons, the kidney can’t excrete all the metabolic wastes of protein, so this patient’s protein intake must be restricted. A higher intake of carbs, fats, and vitamin supplements is needed to ensure the growth and maintenance of the patient’s tissues.34.  4. The vibration or thrill felt during palpation ensures that the fistula has the desired turbulent blood flow. Pinching the fistula could cause damage. Aspirating blood is a needless invasive procedure.35.  1. Bones lose calcium when a patient can no longer bear weight. The calcium lost from bones form calculi, a concentration of mineral salts also known as a stone, in the renal system.36.  2. Kidneys are unable to rid the body of excess fluids which results in fluid volume excess during ESRD.37.  4. The patient with ESRD may develop arrhythmias caused by hypokalemi. Call the doctor after checking the patient’s potassium values. Lidocaine may be ordered if the PVCs are frequent and the patient is symptomatic.38.  1. Cyclosporine suppresses the immune response to prevent rejection of the transplanted kidney. The use of cyclosporine places the patient at risk for tumors.39.  1. The immunosuppressive activity of cyclosporine places the patient at risk for infection, and steroids can mask the signs of infection. The patient may not be able to resume normal fluid intake or return to work for an extended period of time and the patient may need cyclosporine therapy for life.40.  3. Symptoms of rejection include fever, rapid weight gain, hypertension, pain over the graft site, peripheral edema, and diminished urine output.

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41.  3. Urine output less than 50ml in 24 hours signifies oliguria, an early sign of renal failure. Anuria is uncommon except in obstructive renal disorders.42.  2. Acute renal failure causes hypervolemia as a result of overexpansion of extracellular fluid and plasma volume with the hypersecretion of rennin. Therefore, hypervolemia causes hypertension.43.  2. A total UO of 120ml is too low. Assess the patient’s circulation and hemodynamic stability for signs of hypovolemia. A fluid bolus may be required, but only after further nursing assessment and a doctor’s order.44.  4. Bleeding at the urethral meatus is evidence that the urethra is injured. Because catheterization can cause further harm, consult with the doctor.45.  1. With nephrotic syndrome, the glomerular basement membrane of the kidney becomes more porous, leading to loss of protein in the urine. As the patient recovers, less protein is found in the urine.46.  3. Prerenal failure is caused by such conditions as hypovolemia that impairs kidney perfusion; giving isotonic fluids improves urine output. Vasoactive substances can increase blood pressure in both conditions.47.  1. Hemodynamic stability must be established before continuous peritoneal dialysis can be started.48.  3. In renal failure, patients become hyperkalemic because they can’t excrete potassium in the urine. Polystyrene sulfonate acts to excrete potassium by pulling potassium into the bowels and exchanging it for sodium.49.  4. Patients with renal calculi commonly have blood in the urine caused by the stone’s passage through the urinary tract. The urine appears dark, tests positive for blood, and is typically scant.

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Renal failure, dialysis

1. Dialysis allows for the exchange of particles across a semipermeable membrane by which of the following actions?1. Osmosis and diffusion2. Passage of fluid toward a solution with a lower solute concentration3. Allowing the passage of blood cells and protein molecules through it.4. Passage of solute particles toward a solution with a higher concentration.

2. A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include which of the following instructions?

1. Follow a high potassium diet2. Strictly follow the hemodialysis schedule3. There will be a few changes in your lifestyle.4. Use alcohol on the skin and clean it due to integumentary changes.

3. A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first?

1. Change the client’s position.2. Call the physician.3. Check the catheter for kinks or obstruction.4. Clamp the catheter and instill more dialysate at the next exchange time.

4. A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first?

1. Administer oxygen2. Elevate the foot of the bed3. Restrict the client’s fluids4. Prepare the client for hemodialysis.

5. A client has a history of chronic renal failure and received hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which of the following interventions is included in this client’s plan of care?

1. Keep the AV fistula site dry.2. Keep the AV fistula wrapped in gauze.3. Take the blood pressure in the left arm4. Assess the AV fistula for a bruit and thrill

6. Which of the following factors causes the nausea associated with renal failure?1. Oliguria2. Gastric ulcers3. Electrolyte imbalances4. Accumulation of waste products

7. Which of the following clients is at greatest risk for developing acute renal failure?1. A dialysis client who gets influenza2. A teenager who has an appendectomy3. A pregnant woman who has a fractured femur4. A client with diabetes who has a heart catherization

8. In a client in renal failure, which assessment finding may indicate hypocalcemia?1. Headache2. Serum calcium level of 5 mEq/L3. Increased blood coagulation4. Diarrhea

9. A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent?

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1. Absence of bruit on auscultation of the fistula.2. Palpation of a thrill over the fistula3. Presence of a radial pulse in the left wrist4. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand.

10. The client with chronic renal failure is at risk of developing dementia related to excessive absorption of aluminum. The nurse teaches that this is the reason that the client is being prescribed which of the following phosphate binding agents?

1. Alu-cap (aluminum hydroxide)2. Tums (calcium carbonate)3. Amphojel (aluminum hydroxide)4. Basaljel (aluminum hydroxide)

11. The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for:

1. Hypertension, tachycardia, and fever2. Hypotension, bradycardia, and hypothermia3. restlessness, irritability, and generalized weakness4. Headache, deteriorating level of consciousness, and twitching.

12. A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client’s status after dialysis?

1. Potassium level and weight2. BUN and creatinine levels3. VS and BUN4. VS and weight.

13. The hemodialysis client with a left arm fistula is at risk for steal syndrome. The nurse assesses this client for which of the following clinical manifestations?

1. Warmth, redness, and pain in the left hand.2. Pallor, diminished pulse, and pain in the left hand.3. Edema and reddish discoloration of the left arm4. Aching pain, pallor, and edema in the left arm.

14. A client is admitted to the hospital and has a diagnosis of early stage chronic renal failure. Which of the following would the nurse expect to note on assessment of the client?

1. Polyuria2. Polydipsia3. Oliguria4. Anuria

15. The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client’s temperature is 100.2. Which of the following is the most appropriate nursing action?

1. Encourage fluids2. Notify the physician3. Monitor the site of the shunt for infection4. Continue to monitor vital signs

16. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action?

1. Notify the physician2. Monitor the client3. Elevate the head of the bed4. Medicate the client for nausea

17. The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which of the following food items, if selected by the client, would indicate an understanding of this dietary restriction?

1. Cantaloupe2. Spinach3. Lima beans

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4. Strawberries 18. The nurse is reviewing a list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response knowing that the glucose:

1. Prevents excess glucose from being removed from the client.2. Decreases risk of peritonitis.3. Prevents disequilibrium syndrome4. Increases osmotic pressure to produce ultrafiltration.

19. The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the following would be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis?

1. Monitor the clients level of consciousness2. Maintain strict aseptic technique3. Add heparin to the dialysate solution4. Change the catheter site dressing daily

20. A client newly diagnosed with renal failure is receiving peritoneal dialysis. During the infusion of the dialysate the client complains of abdominal pain. Which action by the nurse is most appropriate?

1. Slow the infusion2. Decrease the amount to be infused3. Explain that the pain will subside after the first few exchanges4. Stop the dialysis

21. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of the risk of:

1. Infection2. Hyperglycemia3. Fluid overload4. Disequilibrium syndrome

22. The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan which of the following as a priority action?

1. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration.2. Encourage increased vegetables in the diet3. Place the client on a cardiac monitor4. Check the sodium level

23. The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication:

1. Just before dialysis2. During dialysis3. On return from dialysis4. The day after dialysis

24. The client with chronic renal failure has an indwelling catheter for peritoneal dialysis in the abdomen. The client spills water on the catheter dressing while bathing. The nurse should immediately:

1. Reinforce the dressing2. Change the dressing3. Flush the peritoneal dialysis catheter4. Scrub the catheter with providone-iodine

25. The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The nurse should:

1. Continue the dialysis at a slower rate after checking the lines for air2. Discontinue dialysis and notify the physician3. Monitor vital signs every 15 minutes for the next hour4. Bolus the client with 500 ml of normal saline to break up the air embolism.

26. The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information given if the client states to record the daily:

1. Pulse and respiratory rate

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2. Intake, output, and weight3. BUN and creatinine levels4. Activity log

27. The client with an arteriovenous shunt in place for hemodialysis is at risk for bleeding. The nurse would do which of the following as a priority action to prevent this complication from occurring?

1. Check the results of the PT time as they are ordered.2. Observe the site once per shift3. Check the shunt for the presence of a bruit and thrill4. Ensure that small clamps are attached to the AV shunt dressing.

28. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take.

1. Place the client in good body alignment2. Check the level of the drainage bag3. Contact the physician4. Check the peritoneal dialysis system for kinks5. Reposition the client to his or her side.

29. The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Based on these data, which of the following nursing diagnoses is appropriate?

1. Excess fluid volume related to the kidney’s inability to maintain fluid balance.2. Increased cardiac output related to fluid overload.3. Ineffective tissue perfusion related to interrupted arterial blood flow.4. Ineffective therapeutic Regimen Management related to lack of knowledge about therapy.

30. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

1. Excess Fluid Volume2. Imbalanced Nutrition; Less than Body Requirements3. Activity Intolerance4. Impaired Gas Exchange5. Pain.

31. What is the primary disadvantage of using peritoneal dialysis for long term management of chronic renal failure?

1. The danger of hemorrhage is high.2. It cannot correct severe imbalances.3. It is a time consuming method of treatment.4. The risk of contacting hepatitis is high.

32. The dialysis solution is warmed before use in peritoneal dialysis primarily to:1. Encourage the removal of serum urea.2. Force potassium back into the cells.3. Add extra warmth into the body.4. Promote abdominal muscle relaxation.

33. During the client’s dialysis, the nurse observes that the solution draining from the abdomen is consistently blood tinged. The client has a permanent peritoneal catheter in place. Which interpretation of this observation would be correct?

1. Bleeding is expected with a permanent peritoneal catheter2. Bleeding indicates abdominal blood vessel damage3. Bleeding can indicate kidney damage.4. Bleeding is caused by too-rapid infusion of the dialysate.

34. Which of the following nursing interventions should be included in the client’s care plan during dialysis therapy?

1. Limit the client’s visitors2. Monitor the client’s blood pressure3. Pad the side rails of the bed4. Keep the client NPO.

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35. Aluminum hydroxide gel (Amphojel) is prescribed for the client with chronic renal failure to take at home. What is the purpose of giving this drug to a client with chronic renal failure?

1. To relieve the pain of gastric hyperacidity2. To prevent Curling’s stress ulcers3. To bind phosphorus in the intestine4. To reverse metabolic acidosis.

36. The nurse teaches the client with chronic renal failure when to take the aluminum hydroxide gel. Which of the following statements would indicate that the client understands the teaching?

1. “I’ll take it every 4 hours around the clock.”2. “I’ll take it between meals and at bedtime.”3. “I’ll take it when I have a sour stomach.”4. “I’ll take it with meals and bedtime snacks.”

37. The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk of magnesium) at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid (Metamucil) because:

1. MOM can cause magnesium toxicity2. MOM is too harsh on the bowel3. Metamucil is more palatable4. MOM is high in sodium

38. In planning teaching strategies for the client with chronic renal failure, the nurse must keep in mind the neurologic impact of uremia. Which teaching strategy would be most appropriate?

1. Providing all needed teaching in one extended session.2. Validating frequently the client’s understanding of the material.3. Conducting a one-on-one session with the client.4. Using videotapes to reinforce the material as needed.

39. The nurse helps the client with chronic renal failure develop a home diet plan with the goal of helping the client maintain adequate nutritional intake. Which of the following diets would be most appropriate for a client with chronic renal failure?

1. High carbohydrate, high protein2. High calcium, high potassium, high protein3. Low protein, low sodium, low potassium4. Low protein, high potassium

40. A client with chronic renal failure has asked to be evaluated for a home continuous ambulatory peritoneal dialysis (CAPD) program. The nurse should explain that the major advantage of this approach is that it:

1. Is relatively low in cost2. Allows the client to be more independent3. Is faster and more efficient than standard peritoneal dialysis4. Has fewer potential complications than standard peritoneal dialysis

41. The client asks whether her diet would change on CAPD. Which of the following would be the nurse’s best response?

1. “Diet restrictions are more rigid with CAPD because standard peritoneal dialysis is a more effective technique.”

2. “Diet restrictions are the same for both CAPD and standard peritoneal dialysis.”3. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because dialysis is

constant.”4. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because CAPD works

more quickly.”42. Which of the following is the most significant sign of peritoneal infection?

1. Cloudy dialysate fluid2. Swelling in the legs3. Poor drainage of the dialysate fluid4. Redness at the catheter insertion site

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Answers1. 1. Osmosis allows for the removal of fluid from the blood by allowing it to pass through the semipermeable membrane to an area of high concentrate (dialysate), and diffusion allows for passage of particles (electrolytes, urea, and creatinine) from an area of higher concentration to an area of lower concentration. Fluid passes to an area with a higher solute concentration. The pores of a semipermeable membrane are small, thus preventing the flow of blood cells and protein molecules through it.2. 2. To prevent life-threatening complications, the client must follow the dialysis schedule. Alcohol would further dry the client’s skin more than it already is. The client should follow a low-potassium diet because potassium levels increase in chronic renal failure. The client should know hemodialysis is time-consuming and will definitely cause a change in current lifestyle.3. 3. The first intervention should be to check for kinks and obstructions because that could be preventing drainage. After checking for kinks, have the client change position to promote drainage. Don’t give the next scheduled exchange until the dialysate is drained because abdominal distention will occur, unless the output is within parameters set by the physician. If unable to get more output despite checking for kinks and changing the client’s position, the nurse should then call the physician to determine the proper intervention.4. 1. Airway and oxygenation are always the first priority. Because the client is complaining of shortness of breath and his oxygen saturation is only 89%, the nurse needs to try to increase his levels by administering oxygen. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have his fluids restricted, but the first interventions should be aimed at the immediate treatment of hypoxia. The foot of the bed may be elevated to reduce edema, but this isn’t the priority.5. 4. Assessment of the AV fistula for bruit and thrill is important because, if not present, it indicates a non-functioning fistula. No blood pressures or venipunctures should be taken in the arm with the AV fistula. When not being dialyzed, the AV fistula site may get wet. Immediately after a dialysis treatment, the access site is covered with adhesive bandages.6. 4. Although clients with renal failure can develop stress ulcers, the nausea is usually related to the poisons of metabolic wastes that accumulate when the kidneys are unable to eliminate them. The client has electrolyte imbalances and oliguria, but these don’t directly cause nausea.7. 4. Clients with diabetes are prone to renal insufficiency and renal failure. The contrast used for heart catherization must be eliminated by the kidneys, which further stresses them and may produce acute renal failure. A teenager who has an appendectomy and a pregnant woman with a fractured femur isn’t at increased risk for renal failure. A dialysis client already has end-stage renal disease and wouldn’t develop acute renal failure.8. 4. In renal failure, calcium absorption from the intestine declines, leading to increased smooth muscle contractions, causing diarrhea. CNS changes in renal failure rarely include headache. A serum calcium level of 5 mEq/L indicates hypercalcemia. As renal failure progresses, bleeding tendencies increase.9. 2. The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.10. 2. Phosphate binding agents that contain aluminum include Alu-caps, Basaljel, and Amphojel. These products are made from aluminum hydroxide. Tums are made from calcium carbonate and also bind phosphorus. Tums are prescribed to avoid the occurrence of dementia related to high intake of aluminum. Phosphate binding agents are needed by the client in renal failure because the kidneys cannot eliminate phosphorus.11. 4. Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, and vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.12. 4. Following dialysis, the client’s vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client’s predialysis weight to determine

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effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.13. 2. Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, which is due to tissue ischemia. Warmth, redness, and pain more likely would characterize a problem with infection.14. 1. Polyuria occurs early in chronic renal failure and if untreated can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal functions of the kidney. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal failure.15. 4. The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity purposes.16. 1. Disequilibrium syndrome may be due to the rapid decrease in BUN levels during dialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsant medications and barbituates may be necessary to prevent a life-threatening situation. The physician must be notified.17. Cantaloupe (1/4 small), spinach (1/2 cooked) and strawberries (1 ¼ cups) are high potassium foods and average 7 mEq per serving. Lima beans (1/3 c) averages 3 mEq per serving.18. 4. Increasing the glucose concentration makes the solution increasingly more hypertonic. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration and thus the greater amount of fluid removed from the client during an exchange.19. 2. The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although option 4 may assist in preventing infection, this option relates to an external site.20. 3. Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.21. 2. An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.22. 3. The client with hyperkalemia is at risk for developing cardiac dysrhythmias and cardiac arrest. Because of this the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse may also assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action at this time.23. 3. Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.24. 2. Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria for bacteria to reach the catheter insertion site. The nurse assures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnecting of peritoneal dialysis.25. 2. If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed.26. 2. The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day.27. 4. An AV shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental connection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site to use if needed. The shunt site should be assessed at least every four hours.

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28. 1, 2, 4, 5. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.29. 1. Crackles in the lungs, weight gain, and elevated blood pressure are indicators of excess fluid volume, a common complication in chronic renal failure. The client’s fluid status should be monitored carefully for imbalances on an ongoing basis.30. 1, 2, 3. Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.31. 3. The disadvantages of peritoneal dialysis in long-term management of chronic renal failure is that is requires large blocks of time. The risk of hemorrhage or hepatitis is not high with PD. PD is effective in maintaining a client’s fluid and electrolyte balance.32. 1. The main reason for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing solution also contributes to client comfort by preventing chilly sensations, but this is a secondary reason for warming the solution. The warmed solution does not force potassium into the cells or promote abdominal muscle relaxation.33. 2. Because the client has a permanent catheter in place, blood tinged drainage should not occur. Persistent blood tinged drainage could indicate damage to the abdominal vessels, and the physician should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys. Too rapid infusion of the dialysate can cause pain.

34. 2. Because hypotension is a complication of peritoneal dialysis, the nurse records intake and output, monitors VS, and observes the client’s behavior. The nurse also encourages visiting and other diversional activities. A client on PD does not need to be placed in bed with padded side rails or kept NPO.35. 3. A client in renal failure develops hyperphosphatemia that causes a corresponding excretion of the body’s calcium stores, leading to renal osteodystrophy. To decrease this loss, aluminum hydroxide gel is prescribed to bind phosphates in the intestine and facilitate their excretion. Gastric hyperacidity is not necessarily a problem associated with chronic renal failure. Antacids will not prevent Curling’s stress ulcers and do not affect metabolic acidosis.36. 3. Aluminum hydroxide gel is administered to bind the phosphates in ingested foods and must be given with or immediately after meals and snacks. There is no need for the client to take it on a 24-hour schedule. It is not administered to treat hyperacidity in clients with CRF and therefore is not prescribed between meals.37. 1. Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium can accumulate and cause severe neurologic problems. MOM is harsher than Metamucil, but magnesium toxicity is a more serious problem. A client may find both MOM and Metamucil unpalatable. MOM is not high in sodium.38. 2. Uremia can cause decreased alertness, so the nurse needs to validate the client’s comprehension frequently. Because the client’s ability to concentrate is limited, short lesions are most effective. If family members are present at the sessions, they can reinforce the material. Written materials that the client can review are superior to videotapes, because the clients may not be able to maintain alertness during the viewing of the videotape.39. 3. Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.40. 2. The major benefit of CAPD is that it frees the client from daily dependence on dialysis centers, home health care personnel, and machines for life-sustaining treatment. The independence is a valuable outcome for some people. CAPD is costly and must be done daily. Side effects and complications are similar to those of standard peritoneal dialysis.41. 3. Dietary restrictions with CAPD are fewer than those with standard peritoneal dialysis because dialysis is constant, not intermittent. The constant slow diffusion of CAPD helps prevent accumulation of toxins and

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allows for a more liberal diet. CAPD does not work more quickly, but more consistently. Both types of peritoneal dialysis are effective.42. 1. Cloudy drainage indicates bacterial activity in the peritoneum. Other signs and symptoms of infection are fever, hyperactive bowel sounds, and abdominal pain. Swollen legs may be indicative of congestive heart failure. Poor drainage of dialysate fluid is probably the result of a kinked catheter. Redness at the insertion site indicates local infection, not peritonitis. However, a local infection that is left untreated can progress to the peritoneum.

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Psych – Substance Abuse1)      The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client?

1. Ping pong2. Writing3. Chess4. Basketball

2)      A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this diagnosis is:

1. Explain to the client the importance of a good nutritional intake2. Weight the client 3 times per week before breakfast3. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as

possible.4. Consult with the nutritionist, offer the client several small meals per day, and schedule brief nursing

interactions with the client during these times.3)      In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best?

1. Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a puzzle or reading a book.

2. Plan nothing until the client asks to participate in milieu.3. Offer the client a menu of daily activities and insist the client participate in all of them4. Provide a structured daily program of activities and encourage the client to participate.

4)      The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as “I’m such a failure… I can’t do anything right!” The best nursing response would be:

1. To tell the client this is not true; that we all have a purpose in life.2. To remain with the client and sit in silence; this will encourage the client to verbalize feelings3. To reassure the client that you know how the client is feeling and that things will get better4. To identify recent behaviors or accomplishments that demonstrates skill ability.

5)      A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client’s:

1. Disturbed thought processes2. Imbalanced nutrition3. Self-care deficit4. Deficient knowledge

6)      A depressed client is ready for discharge. The nurse feels comfortable that the client has a good understanding of the disease process when the client states:

1. “I’ll never let this happen to me again. I won’t let my boss or my job or my family get to me!”2. “It’s important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or

not sleep well, I’ve got to get in to see my doctor.”3. “I’ve learned that I’m a good person and that I am worthy of giving and receiving love. I don’t need

anyone; I have myself to rely on!”4. “I don’t know what happened to me. I’ve always been able to make decisions for myself and for my

business. I don’t ever want to feel so weak or vulnerable again!”7)      The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse’s immediate intervention is the client’s:

1. Outlandish behaviors and inappropriate dress2. Grandiose delusions of being a royal descendent of King Arthur.3. Nonstop physical activity and poor nutritional intake4. Constant, incessant talking that includes sexual innuendoes and teasing the staff

8)      The nurse reviews the activity schedule for the day and plans which activity for the manic client?1. Brown-bag luncheon and book review2. Tetherball

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3. Paint-by-number activity4. Deep breathing and progressive relaxation group

9)      A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The client’s mother begins to cry and states “My son’s brain will be destroyed. How can the doctor do this to him?” The nurses best response is:

1. “It sounds as though you need to speak with the psychiatrist”2. “Your son has decided to have this treatment. You should be supportive to him.”3. “Perhaps you’d like to see the ECT room and speak to the staff.”4. “It sounds as though you have some concerns about the ECT procedure. Why don’t we sit down

together and discuss any concerns you may have.”10)  The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the most appropriate action would be to:

1. With assistance, escort the manic client to her room and administer Haldol as prescribed if needed2. Tell the client that smoking privileges are revoked for 24 hours3. Orient the client to time, person, and place4. Tell the client that the behavior is not appropriate.

11)  Select all nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior.

1. Communicate expected behaviors to the client2. Enforce rules and inform the client the he or she will not be allowed to attend group therapy sessions.3. Ensure that the client knows that he or she is not in charge of the nursing unit4. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.5. Assist the client in testing out alternative behaviors for obtaining needs

12)  A woman comes into the ER in a severe state of anxiety following a car accident. The most appropriate nursing intervention is to:

1. Remain with the client2. Put the client in a quiet room3. Teach the client deep breathing4. Encourage the client to talk about their feelings and concern.

13)  When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. The most appropriate maintenance goal should focus on which of the following?

1. Continued contact with a crisis counselor2. Identifying anxiety-producing situations3. Ignoring feelings of anxiety4. Eliminating all anxiety from daily situations

14)  The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremors?

1. Hypertension, changes in LOC, hallucinations2. Hypotension, ataxia, hunger3. Stupor, agitation, muscular rigidity4. Hypotension, coarse hand tremors, agitation

15)  The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse “I should get out of this bad situation.” The most helpful response by the nurse would be:

1. “I agree with you. You should get out of this situation.”2. “What do you find difficult about this situation?”3. “Why don’t you tell your husband about this?”4. “This is not the best time to make that decision.”

16)  The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group when she hears the wife say:

1. “My attendance at the meetings has helped me to see that I provoke my husband’s violence.”2. “I no longer feel that I deserve the beatings my husband inflicts on me.”3. “I can tolerate my husband’s destructive behavior now that I know they are common with alcoholics.”

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4. “I enjoy attending the meetings because they get me out of the house and away from my husband.”17)  The client has been hospitalized and is participating in a substance abuse therapy group sessions. On discharge, the client has consented to participate in AA community groups. The nurse is monitoring the client’s response to the substance abuse sessions. Which statement by the client best indicates that the client has developed effective coping response styles and has processed information effectively for self use?

1. “I know I’m ready to be discharged. I feel I can say ‘no’ and leave a group of friends if they are drinking… ‘No Problem.’”

2. “This group has really helped a lot. I know it will be different when I go home. But I’m sure that my family and friends will all help me like the people in this group have… They’ll all help me… I know they will… They won’t let me go back to my old ways.”

3. “I’m looking forward to leaving here. I know that I will miss all of you. So, I’m happy and I’m sad, I’m excited and I’m scared. I know that I have to work hard to be strong and that everyone isn’t going to be as helpful as you people.”

4. “I’ll keep all my appointments; go to all my AA groups; I’ll do everything I’m supposed to… Nothing will go wrong that way.”

18)  A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go. I don’t want anymore treatment. I have things that I have to do right away.” The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. The most important nursing action is to:

1. Restrain the client until the physician can be reached2. Call security to block all areas3. Tell the client that the client cannot return to this hospital again if the client leaves now.4. Call the nursing supervisor.

19)  Select the appropriate interventions for caring for the client in alcohol withdrawal.1. Monitor vital signs2. Provide stimulation in the environment3. Maintain NPO status4. Provide reality orientation as appropriate5. Address hallucinations therapeutically

20)  Which of the following nursing actions would be included in a care plan for a client with PTSD who states the experience was “bad luck”?

1. Encourage the client to verbalize the experience2. Assist the client in defining the experience3. Work with the client to take steps to move on with his life4. Help the client accept positive and negative feelings

21)  Which of the following psychological symptoms would the nurse expect to find in a hospitalized client who is the only survivor of a train accident?

1. Denial2. Indifference3. Perfectionism4. Trust

22)  Which of the following communication guidelines should the nurse use when talking with a client experiencing mania?

1. Address the client in a light and joking manner2. Focus and redirect the conversation as necessary3. Allow the client to talk about several different topic4. Ask only open ended questions to facilitate conversations

23)  What information is important to include in the nutritional counseling of a family with a member who has bipolar disorder?

1. If sufficient roughage isn’t eaten while taking lithium, bowel problems will occur.2. If the intake of carbohydrates increases, the lithium level increases.3. If the intake of calories is reduced, the lithium level will increase4. If the intake of sodium increases, the lithium level will decrease.

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24)  In conferring with the treatment team, the nurse should make which of the following recommendations for a client who tells the nurse that everyday thoughts of suicide are present?

1. A no-suicide contract2. Weekly outpatient therapy3. A second psychiatric opinion4. Intensive inpatient treatment

25)  Which of the following short term goals is most appropriate for a client with bipolar disorder who is having difficulty sleeping?

1. Obtain medication for sleep2. Work on solving a problem3. Exercise before bedtime4. Develop a sleep ritual

ANSWERS5. B. Solitary activities that require a short attention span with mild physical exertion are the most

appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games can stimulate aggression and increase psychomotor activity.

6. D. Change in appetite is one of the major symptoms of depression. Reporting to the psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would increase food intake.

7. D. A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Option 3 is a forceful and absolute approach.

8. D. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging but will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client’s feelings.

9. A. major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 1 is correct.

10. B. The exact cause of depression is not known but is believed to be related to biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatment for the disease process.

11. C. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominately elevated, expansive, or irritable. All options reflect a client’s possible symptomatology. Option 3, however, clearly presents a problem that compromises one’s physiological integrity and needs to be addressed immediately.

12. B. A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow use of excess energy yet not endanger others during the process. Options 1, 3, and 4 are relatively sedate activities that require concentration, a quality that is lacking in the manic state. Such activities lead to increased frustration and anxiety for the client. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy that the client is experiencing.

13. D. The nurse encourages the client and the family to verbalize fears and concerns. The other options avoid dealing with concerns and are blocks to communication.

10.  A. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to Haldol. Option 2 may increase the agitation that already exists in this client. Orientation will not

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halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse.11.  A, D, and E. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a non-punishment manner; and assisting the client in identifying strengths and in testing out alternative behaviors for obtaining needs. Enforcing rules and informing the client that he or she will not be allowed to attend group therapy sessions is a violation of the client’s rights. Ensuring the client knows that he or she is not in charge of the nursing unit is inappropriate, power struggles need to be avoided.12.  A. If a client with severe anxiety is left alone; the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.13.  B. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination anxiety from life is impossible.14.  A. Some of the symptoms associated with delirium tremors typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation, fever, and delusions.15.  B. The most helpful response is one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.16.  B. Al-Anon support groups are protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavior changes. Option 2 is the most healthy response because is exemplifies and understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control.17.  C. In the defense mechanism of denial the person denies reality. Option 1 identifies denial. In option 2 the client is relying heavily on others, and the client’s focus of control is external. In option 4 the client is concrete and procedure oriented; again the client identifies that “Nothing will go wrong that way” if the client follows all the directions. In option 3 the client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in that statement.18.  D. A nurse can be charged with false imprisonment if a client is made to believe wrongfully that the client cannot leave the hospital. Most health care facilities have documents that the client is asked to sign that relate to the client’s responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold him against his will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.19.  A, D, and E. When the client is experiencing withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained.20.  B. The client must define the experience as traumatic to realize the situation wasn’t under his personal control. Encouraging the client to verbalize the experience without first addressing the denial isn’t a useful strategy. The client can move on with life only after acknowledging the trauma and processing the experience. Acknowledgement of the actual trauma and verbalization of the event should come before the acceptance of feelings.21.  A. Denial can act as a protective response. The client tends to be overwhelmed and disorganized by the trauma, not indifferent to it. Perfectionism is more commonly seen in clients with eating disorders, not in clients with PTSD. Clients who have had a severe trauma often experience an inability to trust others.22.  B. To decrease stimulation, the nurse should attempt to redirect and focus the client’s communication, not allow the client to talk about different topics. By addressing the client in a light and joking manner, the conversation may contribute to the client’s feeling out of control. For a manic client, it’s best to ask closed

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questions because open-minded questions may enable the client to talk endlessly, again possibly contributing to the client’s feeling out of control.23.  D. Any time the level of sodium increases, such as with a change in the dietary intake, the levels of lithium will decrease.24.  D. For a client thinking about suicide on a daily basis, inpatient care would be the best intervention. Although a no-suicide contract is an important strategy, this client needs additional care. The client needs a more intensive level of care than weekly outpatient therapy. Immediate intervention is paramount, not a second psychiatric opinion.25.  D. A sleep ritual or nighttime routine helps the client to relax and prepare for sleep. Obtaining sleep medication is a temporary solution. Working on problem solving may excite the client rather than tire him. Exercise before retiring is inappropriate.

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Psych – Personality Disorders1)      The nursing diagnosis that would be most appropriate for a 22-year old client who uses ritualistic behavior would be:

1. Ineffective coping2. Impaired adjustment3. personal identity disturbance4. Sensory/perceptual alterations

2)      A psychiatrist prescribes an anti-obsessional agent for a client who is using ritualistic behavior. A common anti-anxiety medication used for this type of client would be:

1. Fluvoxamine (Luvox)2. Benztropine (Cogentin)3. Amantadine (Symmetrel)4. Diphenhydramine (Benadryl)

3)      A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply.

1. Impulsiveness2. Lability of mood3. Ritualistic behavior4. psychomotor retardation5. self-destructive behavior

4)      A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit’s rules. This behavior should be confronted because it will help the client:

1. Control anger2. reduce anxiety3. Set realistic goals4. Become more self-aware

5)      When working with the nurse during the orientation phase of the relationship, a client with a borderline personality disorder would probably have the most difficulty in:

1. Controlling anxiety2. terminating the session on time3. Accepting the psychiatric diagnosis4. Setting mutual goals for the relationship

6)      A client with a diagnosis of borderline personality disorder has negative feelings toward the other clients on the unit and considers them all to be “bad.” The nurse understands this defense is known as:

1. Splitting2. Ambivalence3. Passive aggression4. Reaction formation

7)      The client with antisocial personality disorder:1. Suffers from a great deal of anxiety2. Is generally unable to postpone gratification3. Rapidly learns by experience and punishment4. Has a great sense of responsibility toward others

8)      A person with antisocial personality disorder has difficulty relating to others because of never having learned to:

1. Count on others2. Empathize with others3. Be dependent on others4. Communicate with others socially

9)      A young, handsome man with a diagnosis of antisocial personality disorder is being discharged from the hospital next week. He asks the nurse for her phone number so that he can call her for a date. The nurse’s best response would be:

1. “We are not permitted to date clients.”

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2. “No, you are a client and I am a nurse.”3. “I like you, but our relationship is professional.”4. “It’s against my professional ethics to date clients.”

10)   When caring for a client with a diagnosis of schizotypal personality disorder, the nurse should:1. Set limits on manipulative behavior2. encourage participation in group therapy3. Respect the client’s needs for social isolation4. Understand that seductive behavior is expected.

11)   A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down and talk. The client requesting the nurse’s attention is extremely manipulative and uses socially acting-out behaviors when demands are unmet. The nurse should:

1. Suggest that the client requesting attention speak with another staff member2. Leave the new client and talk with the other client to avoid precipitating acting out behavior3. Tell the interrupting client to sit down and be patient, stating, “I’ll be back as soon as possible.”4. Introduce the two clients and suggest that the client join the new client and the nurse on the tour

12)   A client with a diagnosis of narcissistic personality disorder has been given a day pass from the psychiatric hospital. The client is due to return at 6pm. At 5pm the client telephones the nurse in charge of the unit and says “6 o’clock is too early. I feel like coming back at 7:30.” The nurse would be most therapeutic by telling the client to:

1. Return immediately, to demonstrate control2. Return on time or restrictions will be imposed3. come back at 6:45, as a compromise to set limits4. Come back as soon as possible or the police will be sent

13)   An adult client with a borderline personality disorder become nauseated and vomits immediately after drinking after drinking 2 ounces of shampoo as a suicide gesture. The most appropriate initial response by the nurse would be to:

1. Promptly notify the attending physician2. Immediately initiate suicide precautions3. Sit quietly with the client until nausea and vomiting subsides4. Assess the client’s vital signs and administer syrup of ipecac

14)   A nurse notices that a client is mistrustful and shows hostile behavior. Which of the following types of personality disorder is associated with these characteristics?

1. Antisocial2. Avoidant3. Borderline4. Paranoid

15)   Which of the following statements is typical for a client diagnosed with a personality disorder?1. “I understand you’re the one to blame.”2. “I must be seen first; it’s not negotiable.”3. “I see nothing humorous in this situation.”4. “I wish someone would select the outfit for me.”

16)   Which of the following characteristics is expected for a client with paranoid personality disorder who receives bad news?

1. The client is overly dramatic after hearing the facts2. The client focuses on self to not become over-anxious3. The client responds from a rational, objective point of view4. The client doesn’t spend time thinking about the information.

17)   Which of the following types of behavior is expected from a client diagnosed with a paranoid personality disorder?

1. Eccentric2. exploitative3. Hypersensitive4. Seductive

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18)   Which of the following interventions is important for a client with paranoid personality disorder taking olanzapine (Zyprexa)?

1. Explain effects of serotonin syndrome2. Teach the client to watch for extrapyramidal adverse reactions3. Explain that the drug is less effective if the client smokes4. Discuss the need to report paradoxical effects such as euphoria.

19)   A client with antisocial personality is trying to convince a nurse that he deserves special privileges and that an exception to the rules should be made for him. Which of the following responses is the most appropriate?

1. “I believe we need to sit down and talk about this.”2. “Don’t you know better than to try to bend the rules?”3. “What you’re asking me to do is unacceptable.”4. “Why don’t you bring this request to the community meeting?”

20)   A nurse notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers?

1. Lack of honesty2. Belief in superstitions3. Show of temper tantrums4. Constant need for attention

21)   Which of the following characteristics or client histories substantiates a diagnosis of antisocial personality disorder?

1. Delusional thinking2. Feelings of inferiority3. Disorganized thinking4. Multiple criminal charges

22)   A client with borderline personality disorder is admitted to the unit after slashing his wrist. Which of the following goals is most important after promoting safety?

1. Establish a therapeutic relationship with the client2. Identify whether splitting is present in the client’s thoughts3. Talk about the client’s acting out and self-destructive tendencies.4. Encourage the client to understand why he blames others

23)   Which of the following characteristics or situations is indicated when a client with borderline personality disorder has a crisis?

1. Antisocial behavior2. Suspicious behavior3. Relationship problems4. Auditory hallucinations

24)   Which of the following assessment findings is seen in a client diagnosed with borderline personality disorder?

1. Abrasions in various healing stages2. intermittent episodes of hypertension3. Alternating tachycardia and bradycardia4. Mild state of euphoria with disorientation

25)   In planning care for a client with borderline personality disorder, a nurse must be aware that this client is prone to develop which of the following conditions?

1. Binge eating2. Memory loss3. Cult membership4. Delusional thinking

26)   Which of the following statements is expected from a client with borderline personality disorder with a history of dysfunctional relationships?

1. “I won’t get involved in another relationship.”2. “I’m determined to look for the perfect partner.”

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3. “I’ve decided to use better communication skills.”4. “I’m going to be an equal partner in a relationship.”

27)   Which of the following conditions is likely to coexist in clients with a diagnosis of borderline personality disorder?

1. Avoidance2. Delirium3. Depression4. Disorientation

28)   Which of the following nursing interventions has priority for a client with borderline personality disorder?

1. Maintain consistent and realistic limits2. Give instructions for meeting basic self-care needs3. Engage in daytime activities to stimulate wakefulness4. Have the client attend group therapy on a daily basis

29)   A nurse is assessing a client diagnosed with dependent personality disorder. Which of the following characteristics is a major component to this disorder?

1. Abrasive to others2. Indifferent to others3. Manipulative of others4. Overreliance on others

30)   Which of the following information must be included for the family of a client diagnosed with dependent personality disorder?

1. Address coping skills2. Explore panic attacks3. Promote exercise programs4. Decrease aggressive outbursts

31)   Which of the following behaviors by a client with dependent personality disorder shows the client has made progress toward the goal of increasing problem solving skills?

1. The client is courteous2. The client asks questions3. The client stops acting out4. The client controls emotions

32)   A client with schizotypal personality disorder is sitting in a puddle of urine. She’s playing in it, smiling, and softly singing a child’s song. Which action would be best?

1. Admonish the client for not using the bathroom2. Firmly tell the client that her behavior is unacceptable3. Ask the client if she’s ready to get cleaned up now4. Help the client to the shower, and change the bedclothes.

33)   A client with avoidant personality disorder says occupational therapy is boring and doesn’t want to go. Which action would be best?

1. State firmly that you’ll escort him to OT.2. Arrange with OT for the client to do a project on the unit.3. Ask the client to talk about why OT is boring4. Arrange for the client not to attend OT until he is feeling better

34)   A nurse discusses job possibilities with a client with schizoid personality disorder. Which suggestion by the nurse would be helpful?

1. “You can work in a family restaurant part-time on the weekend and holidays.”2. “Maybe your friend could get you that customer service job where you work only on the weekends.”3. “Your idea of applying for the position of filing and organizing records is worth pursuing.”4. “Being an introvert limits the employment opportunities you can pursue.”

35)   When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.

1. The client functions well in other areas of his life.

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2. The degree of aggressiveness is out of proportion to the stressor.3. The violent behavior is mist often justified by the stressor.4. The client has a history of parental alcoholism and chaotic, abusive family life.5. The client has no remorse about the inability to control his anger.

ANSWERS1. 1. Ineffective coping is the impairment of a person’s adaptive behaviors and problem-solving abilities in

meeting life’s demands; ritualistic behavior fits under this category as a defining characteristic.2. 1. This drug blocks the uptake of serotonin.3. 1, 2, 5.4. 4. Client’s must first become aware of their behavior before they can change it. (3) Occurs after the client is

aware of the behavior and has a desire to change the behavior.5. 4. Clients with borderline personality disorders frequently demonstrate a pattern of unstable interpersonal

relationships, impulsiveness, affective instability, and frantic efforts to avoid abandonment; these behaviors usually create great difficulty in establishing mutual goals.

6. 1. Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others.

7. 2. Individuals with this disorder tend to be self-centered and impulsive. They lack judgment and self-control and do not profit from their mistakes.

8. 2. The lack of superego control allows the ego and the id to control the behavior. Self-motivation and self-satisfaction are of paramount concern.

9. 3. This accepts the client as a person of worth rather than being cold or implying rejection. However, the nurse maintains a professional rather than a social role.

10. 3. These clients are withdrawn, aloof, and socially distant; allowing distance and providing support may encourage the eventual development of a therapeutic alliance. Group therapy would increase this client’s anxiety; cognitive or behavioral therapy would be more appropriate.

11. 3. This sets realistic limits on behavior without rejecting the client12. 2. This sets limits, points out reality, and places responsibility for behavior on the client.13. 3. This intervention demonstrates the nurse’s caring presence which is vital for this client. (1) Although the

treatment team does need to know about the event, notification is not the immediate concern. (2) This is premature and it reinforces the client’s predisposition to manipulative behavior. (4) This medication is inappropriate in this situation; vomiting would be expected after the ingestion of shampoo.

14. 4. Paranoid individuals have a need to constantly scan the environment for signs of betrayal, deception, and ridicule, appearing mistrustful and hostile. They expect to be tricked or deceived by others.

15. 3. Clients with paranoid personality disorder tend to be extremely serious and lack a sense of humor.16. 3. Clients with paranoid personality disorder are affectively restricted, appear unemotional, and appear

rational and objective.17. 3. People with paranoid personality disorders are hypersensitive to perceived threats. Schizotypal

personalities appear eccentric and engage in activities others find perplexing. Clients with narcissistic personality disorder are interpersonally exploitative to enhance themselves or indulge in their own desires. A client with histrionic personality disorder can be extremely seductive when in search of stimulation and approval.

18. 3. Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Olanzapine doesn’t cause euphoria (damn), and extrapyramidal side effects aren’t a problem. However, the client should be aware of adverse effects such as tardive dyskinesia.

19. 3. These clients often try to manipulate the nurse to get special privileges or make exceptions to the rules on their behalf. By informing the client directly when actions are inappropriate, the nurse helps the client learn to control unacceptable behaviors by setting limits. By sitting down to talk about the request, the nurse is telling the client there’s room for negotiating when there is none.

20. 1. Clients with antisocial personality disorder tend to engage in acts of dishonesty, shown by lying.21. 4. Clients with antisocial personality disorder are often sent for treatment by the court after multiple

crimes or for the use of illegal substances.22. 1. After promoting safety, the nurse establishes a rapport with the client to facilitate appropriate

expression of feelings. At this time, the client isn’t ready to address unhealthy behavior. A therapeutic

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relationship must be established before the nurse can effectively work with the client on self-destructive tendencies and the issues of splitting.

23. 3. Relationship problems can precipitate a crisis because they bring up issues of abandonment. Clients with borderline personality disorder aren’t usually suspicious; they’re more likely to be depressed or highly anxious.

24. 1. Clients with borderline personality disorder tend to self-mutilate and have abrasions in various stages of healing.

25. 1. Clients with borderline personality disorder are likely to develop dysfunctional coping and act out in self-destructive ways such as binge eating.

26. 2. Clients with borderline personality disorder would decide to look for a perfect partner. This characteristic is a result of the dichotomous manner in which these clients view the world. They go from relationship to relationship without taking responsibility for their behavior. It’s unlikely that an unsuccessful relationship will cause clients to make a change. They tend to be demanding and impulsive in relationships. There’s no thought given to what one wants or needs from a relationship. Because they tend to blame others for problems, it’s unlikely they would express a desire to learn communication skills.

27. 3. Chronic feelings of emptiness and sadness predispose a client to depression. About 40% of the clients with borderline struggle with depression.

28. 1. Clients with borderline who are needy, dependent, and manipulative will benefit greatly from maintaining consistent and realistic limits. They don’t tend to have difficulty meeting their self-care needs. They enjoy attending group therapy because they often attempt to use the opportunity to become the center of attention. They don’t tend to have sleeping difficulties.

29. 4. Clients with dependent personality disorder are extremely overreliant on others; they aren’t abrasive or assertive. They’re clinging and demanding of others; they don’t manipulate.

30. 1. The family needs information about coping skills to help the client learn to handle stress. Clients with dependent personality disorder don’t have aggressive outbursts; they tend to be passive and submit to others. They don’t tend to have panic attacks. Exercise is a health promotion activity for all clients. Clients with dependent personality disorder wouldn’t need exercise promoted more than other people.

31. 2. The client with dependent personality disorder is passive and tries to please others. By asking questions, the client is beginning to gather information, the first step of decision making.

32. 4. A client with schizotypal personality disorder can experience high levels of anxiety and regress to childlike behaviors. This client may require help needing self-care needs. The client may not respond to the other options or those options may generate more anxiety.

33. If given the chance, a client with avoidant personality disorder typically elects to remain immobilized. The nurse should insist that the client participate in OT. Arranging for the client to do a project on the unit validates and reinforces the client’s desire to avoid getting to OT. Addressing an invalid issue such as the client’s perceived boredom avoids the real issue: the client’s need for therapy.

34. 3. Clients with schizoid personality disorder prefer solitary activities, such as filing, to working with others. Working as a cashier or in customer service would involve interacting with many people.

35. 1, 2, 4. A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

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Neuro – ICP, LOC, meningitis1)      A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?10. Vomiting continues11. Intracranial pressure (ICP) is increased12. The client needs mechanical ventilation13. Blood is anticipated in the cerebralspinal fluid (CSF)2)      A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

5. To reduce intraocular pressure6. To prevent acute tubular necrosis7. To promote osmotic diuresis to decrease ICP8. To draw water into the vascular system to increase blood pressure

3)      A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

5. Urine output increases6. Pupils are 8 mm and nonreactive7. Systolic blood pressure remains at 150 mm Hg8. BUN and creatinine levels return to normal

4)      Which of the following values is considered normal for ICP?5. 0 to 15 mm Hg6. 25 mm Hg7. 35 to 45 mm Hg8. 120/80 mm Hg

5)      Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?5. Ataxia and confusion6. Sodium depletion7. Tonic-clonic seizure8. Urinary incontinence

6)      Which of the following signs and symptoms of increased ICP after head trauma would appear first?5. Bradycardia6. Large amounts of very dilute urine7. Restlessness and confusion8. Widened pulse pressure

7)      Problems with memory and learning would relate to which of the following lobes?5. Frontal6. Occipital7. Parietal8. Temporal

8)      While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?5. Frontal6. Occipital7. Parietal8. Temporal

9)      The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?

5. Sternal rub6. Pressure on the orbital rim7. Squeezing the sternocleidomastoid muscle8. Nail bed pressure

10)  The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

5. Side-lying, with legs pulled up and head bent down onto the chest

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6. Side-lying, with a pillow under the hip7. Prone, in a slight Trendelenburg’s position8. Prone, with a pillow under the abdomen.

11)  A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

5. A cerebral lesion6. A temporal lesion7. An intact brainstem8. Brain death

12)  The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

5. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.6. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.7. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.8. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

13)  The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:

5. A positive Brudzinski’s sign6. A negative Kernig’s sign7. Absence of nuchal rigidity8. A Glascow Coma Scale score of 15

14)  A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:

5. Tolerate the pain6. Decrease the perception of pain7. Escape the source of pain8. Divert attention from the source of pain.

15)  During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?

5. Limiting conversation with the child6. Keeping extraneous noise to a minimum7. Allowing the child to play in the bathtub8. Performing treatments quickly

16)  Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?

5. Hemorrhagic skin rash6. Edema7. Cyanosis8. Dyspnea on exertion

17)  When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis?

5. Bladder infection6. Middle ear infection7. Fractured clavicle8. Septic arthritis

18)  The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

5. Head tilt6. Vomiting7. Polydipsia8. Lethargy9. Increased appetite10. Increased pulse

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19)  A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis?

5. Cloudy CSF, decreased protein, and decreased glucose6. Cloudy CSF, elevated protein, and decreased glucose7. Clear CSF, elevated protein, and decreased glucose8. Clear CSF, decreased pressure, and elevated protein

20)  A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?

5. No precautions are required as long as antibiotics have been started6. Maintain enteric precautions7. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics8. Maintain neutropenic precautions

21)  A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present?

5. Abnormal flexion of the upper extremities and extension of the lower extremities6. Rigid extension and pronation of the arms and legs7. Rigid pronation of all extremities8. Flaccid paralysis of all extremities

22)  Which of the following assessment data indicated nuchal rigidity?5. Positive Kernig’s sign6. Negative Brudzinski’s sign7. Positive homan’s sign8. Negative Kernig’s sign

23)  Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions?5. Congenital anatomic abnormality of the meninges6. Lack of acquired resistance to the various etiologic organisms7. Occlusion or narrowing of the CSF pathway8. Natural affinity of the CNS to certain pathogens

24)  Which of the following pathologic processes is often associated with aseptic meningitis?5. Ischemic infarction of cerebral tissue6. Childhood diseases of viral causation such as mumps7. Brain abscesses caused by a variety of pyogenic organisms8. Cerebral ventricular irritation from a traumatic brain injury

ANSWERS5. 2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors

herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn’t strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

6. 3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

7. 1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

8. 1. Normal ICP is 0-15 mm Hg.9. 1. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of

toxicity include confusion and ataxia. Phenytoin doesn’t cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

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10. 3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there’s damage to the posterior pituitary.

11. 4. The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

12. 3. The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

13. 4. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

10.  1. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.11.  3. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.12.  2. 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 arise.13.  1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski’s sign, and positive Kernig’s sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.14.  3. The client’s innate responses to pain are directed initially toward escaping from the source of pain. Variations in individuals’ tolerance and perception of pain are apparent only in conscious clients, and only conscious clients are able to employ distraction to help relieve pain.15.  2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.16.  1. DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.17.  2. Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumonococcus. A chronically draining ear is frequently also found.18.  1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.19.  2. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.20.  3. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.21.  2. Decebrate posturing is characterized by the rigid extension and pronation of the arms and legs.

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22.  1. A positive Kernig’s sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski’s sign is also indicative of the condition.23.  2. Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility.24.  2. Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Incidences of brain abscess are high in bacterial meningitis, and ischemic infarction of cerebral tissue can occur with tubercular meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.

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Neuro – CVA (Stroke)14. Regular oral hygiene is an essential intervention for the client who has had a stroke.  Which of the following

nursing measures is inappropriate when providing oral hygiene?A. Placing the client on the back with a small pillow under the head.B. Keeping portable suctioning equipment at the bedside.C. Opening the client’s mouth with a padded tongue blade.D. Cleaning the client’s mouth and teeth with a toothbrush.

15. A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech.  Which nursing intervention is priority?

A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).B. Discuss the precipitating factors that caused the symptoms.C. Schedule for A STAT computer tomography (CT) scan of the head.D. Notify the speech pathologist for an emergency consult.

16. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration.  Which is the priority nursing assessment?

A. Current medications.B. Complete physical and history.C. Time of onset of current stroke.D. Upcoming surgical procedures.

17. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:

A. PulseB. RespirationsC. Blood pressureD. Temperature

18. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

A. Cholesterol levelB. Pupil size and papillary responseC. Vowel soundsD. Echocardiogram

19. What is the expected outcome of thrombolytic drug therapy?A. Increased vascular permeability.B. Vasoconstriction.C. Dissolved emboli.D. Prevention of hemorrhage

20. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA).  Which medication would the nurse anticipate being ordered for the client on discharge?

A. An oral anticoagulant medication.B. A beta-blocker medication.C. An anti-hyperuricemic medication.D. A thrombolytic medication.

21. Which client would the nurse identify as being most at risk for experiencing a CVA?A. A 55-year-old African American male.B. An 84-year-old Japanese female.C. A 67-year-old Caucasian male.D. A 39-year-old pregnant female.

22. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?A. A blood glucose level of 480 mg/dl.B. A right-sided carotid bruit.C. A blood pressure of 220/120 mm Hg.D. The presence of bronchogenic carcinoma.

23. The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis.  Which action by the UAP requires the nurse to intervene?

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A. The assistant places a gait belt around the client’s waist prior to ambulating.B. The assistant places the client on the back with the client’s head to the side.C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.D. The assistant praises the client for attempting to perform ADL’s independently.

 9. 1.  A helpless client should be positioned on the side, not on the back.  This lateral position helps secretions

escape from the throat and mouth, minimizing the risk of aspiration.  It may be necessary to suction, so having suction equipment at the bedside is necessary. Padded tongue blades are safe to use.   A toothbrush is appropriate to use.

10. 3.  A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder.  This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA.  This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated.  Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching.  Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.

11. 3.  The time of onset of a stroke to t-PA administration is critical.  Administration within 3 hours has better outcomes.  A complete history is not possible in emergency care.  Upcoming surgical procedures will need to be delay if t-PA is administered.  Current medications are relevant, but onset of current stroke takes priority.

12. 3.  Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy.  Blood pressure should be maintained according to physician and is specific to the client’s ischemic tissue needs and risks of bleeding from treatment.  Other vital signs are monitored, but the priority is blood pressure.

13. 2.  It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.  Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation.  Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours.  An echocardiogram is not needed for the client with a thrombotic stroke.

14. 3.  Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.15. 1.  Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to

prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge verses intravenous.  Beta blockers slow the heart rate and lower the blood pressure.  Anti-hyperuricemic medication is given to clients with gout.  Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge.

16. 1.  Africana Americans have twice the rate of CVA’s as Caucasians; males are more likely to have strokes than females except in advanced years.  Oriental’s have a lower risk, possibly due to their high omega-3 fatty acids.  Pregnancy is a minimal risk factor for CVA.

17. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium.  A bruit in the carotid artery would predispose a client to an embolic or ischemic stroke.  High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic.  Cancer is not a precursor to stroke. 

18. 3.  This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety.  All the other actions are appropriate.

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Neuro – Seizures1)      An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?24. Reposition the client to avoid neck flexion25. Administer 1 g Mannitol IV as ordered26. Increase the ventilator’s respiratory rate to 20 breaths/minute27. Administer 100mg of pentobarbital IV as ordered.2)      A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

19. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.20. Rapid dilantin administration can cause cardiac arrhythmias.21. Dilantin should be mixed in dextrose in water before administration.22. Dilantin should be administered through an IV catheter in the client’s hand.

3)      A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

9. Evaluate urine specific gravity10. Anticipate treatment for renal failure11. Provide emollients to the skin to prevent breakdown12. Slow down the IV fluids and notify the physician

4)      When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?

9. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).10. Emergent; the client is poorly oxygenated.11. Normal12. Significant; the client has alveolar hypoventilation.

5)      A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs?

9. Bloody drainage from the ears10. Frequent swallowing11. Guaiac-positive stools12. Hematuria

6)      After a hypophysectomy, vasopressin is given IM for which of the following reasons?9. To treat growth failure10. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)11. To reduce cerebral edema and lower intracranial pressure12. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

7)      A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first?

9. Assess full ROM to determine extent of injuries10. Call for an immediate chest x-ray11. Immobilize the client’s head and neck12. Open the airway with the head-tilt chin-lift maneuver

8)      A client with a C6 spinal injury would most likely have which of the following symptoms?9. Aphasia10. Hemiparesis11. Paraplegia12. Tetraplegia

9)      A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

9. Bladder distension10. Neurological deficit11. Pulse ox readings12. The client’s feelings about the injury

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10)  While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?

9. Autonomic dysreflexia10. Hemorrhagic shock11. Neurogenic shock12. Pulmonary embolism

11)  A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?

9. Acetazolamide (Diamox)10. Furosemide (Lasix)11. Methylprednisolone (Solu-Medrol)12. Sodium bicarbonate

12)  A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

9. Place the client flat in bed10. Assess patency of the indwelling urinary catheter11. Give one SL nitroglycerin tablet12. Raise the head of the bed immediately to 90 degrees

13)  A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?9. To hasten wound healing10. To immobilize the surgical spine11. To prevent autonomic dysreflexia12. To hold bony fragments of the skull together

14)  Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?

9. Insert an indwelling urinary catheter to straight drainage10. Schedule intermittent catherization every 2 to 4 hours11. Perform a straight catherization every 8 hours while awake12. Perform Crede’s maneuver to the lower abdomen before the client voids.

15)  A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?

9. Laceration of the middle meningeal artery10. Rupture of the carotid artery11. Thromboembolism from a carotid artery12. Venous bleeding from the arachnoid space

16)  A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?

9. Position the client flat in bed10. Check the fluid for dextrose with a dipstick11. Suction the nose to maintain airway patency12. Insert nasal and ear packing with sterile gauze

17)  When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval?

9. An interval when the client’s speech is garbled10. An interval when the client is alert but can’t recall recent events11. An interval when the client is oriented but then becomes somnolent12. An interval when the client has a “warning” symptom, such as an odor or visual disturbance.

18)  Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?11. A client with a brain injury12. A client with a herniated nucleus pulposus13. A client with a high cervical spine injury14. A client with a stroke

19)  Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?9. Absence of pain sensation in chest

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10. Spasticity11. Spontaneous respirations12. Urinary continence

20)  A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

9. Headache10. Lumbar spinal cord injury11. Neurogenic shock12. Noxious stimuli

21)  During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?

9. Elevate the client’s legs10. Put the client flat in bed11. Put the client in the Trendelenburg’s position12. Put the client in the high-Fowler’s position

22)  A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?

9. Autonomic dysreflexia10. Hypervolemia11. Neurogenic shock12. Sepsis

23)  A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?

9. Absent corneal reflex10. Decerebate posturing11. Movement of only the right or left half of the body12. The need for mechanical ventilation

24)  A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated?

9. Decreased urine output or oliguria10. Hypertension and bradycardia11. Respiratory depression12. Symptoms of shock

25)  A 40-year-old paraplegic must perform intermittent catherization of the bladder. Which of the following instructions should be given?

14. “Clean the meatus from back to front.”15. “Measure the quantity of urine.”16. “Gently rotate the catheter during removal.”17. “Clean the meatus with soap and water.”

26)  An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions?

14. “Watch him for keyhole pupil the next 24 hours.”15. “Expect profuse vomiting for 24 hours after the injury.”16. “Wake him every hour and assess his orientation to person, time, and place.”17. “Notify the physician immediately if he has a headache.”

27)  Which neurotransmitter is responsible for may of the functions of the frontal lobe?27. Dopamine28. GABA29. Histamine30. Norepinephrine

28)  The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?

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5. Extent of intracranial bleeding6. Sites of brain injury7. Activity of the brain8. Percent of functional brain tissue

29)  A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?

5. Subdural hematoma6. Subarachnoid hemorrhage7. Epidural hematoma8. Contusion

30)  After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect?

5. Quadriplegia with gross arm movement and diaphragmic breathing6. Quadriplegia and loss of respiratory function7. Paraplegia with intercostal muscle loss8. Loss of bowel and bladder control

31)  A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client’s airway for rescue breathing?

5. By inserting a nasopharyngeal airway6. By inserting a oropharyngeal airway7. By performing a jaw-thrust maneuver8. By performing the head-tilt, chin-lift maneuver

32)  The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

5. Elevate the HOB to 90 degrees6. Loosen constrictive clothing7. Use a fan to reduce diaphoresis8. Assess for bladder distention and bowel impaction9. Administer antihypertensive medication10. Place the client in a supine position with legs elevated

33)  The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:

5. Desmopressin (DDAVP, stimate)6. Dexamethasone (Decadron)7. Ethacrynic acid (Edecrin)8. Mannitol (Osmitrol)

34)  The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with:

5. Skull fracture6. Concussion7. Subdural hematoma8. Epidural hematoma

35)  The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for:

5. A flattened abdomen6. Hematest positive nasogastric tube drainage7. Hyperactive bowel sounds8. A history of diarrhea

36)  A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

5. Strict adherence to a bowel retraining program

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6. Limiting bladder catherization to once every 12 hours7. Keeping the linen wrinkle-free under the client8. Preventing unnecessary pressure on the lower limbs

37)  The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?

1. Monitoring vital signs before and during position changes2. Using vasopressor medications as prescribed3. Moving the client quickly as one unit4. Applying Teds or compression stockings.

38)  The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by:

5. Keeping the client on a stretcher6. Logrolling the client on a firm mattress7. Logrolling the client on a soft mattress8. Placing the client on a Stryker frame

39)  The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?

5. Positive reflexes6. Hyperreflexia7. Inability to elicit a Babinski’s reflex8. Reflex emptying of the bladder

40)  A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, list in order of priority, the nurse’s actions (Number 1 being the first priority and number 5 being the last priority).

5. Check for bladder distention6. Raise the head of the bed7. Contact the physician8. Loosen tight clothing on the client9. Administer an antihypertensive medication

41)  A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?5. Unequal pupil size6. Decreasing systolic blood pressure7. Tachycardia8. Decreasing body temperature

42)  Which of the following respiratory patterns indicate increasing ICP in the brain stem?5. Slow, irregular respirations6. Rapid, shallow respirations7. Asymmetric chest expansion8. Nasal flaring

43)  Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?10. Give the client a warming blanket11. Administer low-dose barbiturate12. Encourage the client to hyperventilate13. Restrict fluids

44)  A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition?

1. Widening pulse pressure2. Decrease in the pulse rate3. Dilated, fixed pupil4. Decrease in LOC

45)  A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?

1. Place her in a jacket restraint2. Wrap her hands in soft “mitten” restraints

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3. Tuck her arms and hands under the draw sheet4. Apply a wrist restraint to each arm

46)  Which of the following describes decerebrate posturing?1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the

feet3. Supination of arms, dorsiflexion of feet4. Back arched; rigid extension of all four extremities.

47)  A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

1. Count the rate to be sure the ventilations are deep enough to be sufficient2. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma

score.3. Call the physician to adjust the ventilator settings.4. Check deep tendon reflexes to determine the best motor response

48)  In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicates when positioning the client?

1. Keeping the client flat on one side or the other2. Elevating the head of the bed to 30 degrees3. Log rolling or turning as a unit when turning4. Keeping the head in neutral position

49)  A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply.1. Decerebrate posturing2. Dilated non reactive pupils3. Deep tendon reflexes4. Absent corneal reflex

ANSWERS1. 1. The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck

flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.

2. 2. Dilantin IV shouldn’t be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldn’t be mixed in solution for administration. However, because it’s compatible with normal saline solution, it can be injected through an IV line containing normal saline. When given through an IV catheter hand, dilantin may cause purple glove syndrome.

3. 1. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There’s no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn’t need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

4. 1. A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

5. 2. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture.

6. 4. After hypophysectomy, or removal of the pituitary gland, the body can’t synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema.

7. 3. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. There is no indication that the client needs a chest x-ray. The airway doesn’t need to be opened since the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldn’t be used until the cervical spine injury is ruled out.

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8. 4. Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.

9. 3. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.

10.  3. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn’t be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.11.  3. High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren’t indicated in this circumstance.12.  4. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn’t used for hypertension or dysreflexia.13.  2. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.14.  2. Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Crede’s maneuver is not used on people with spinal cord injury.15.  1. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.16.  2. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn’t be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.17.  3. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can’t recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.18.  3. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren’t prone to dysreflexia.19.  3. Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn’t apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.20.  4. Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock isn’t a cause of dysreflexia.21.  4. Putting the client in the high-Fowler’s position will decrease cerebral blood flow, decreasing hypertension. Elevating the client’s legs, putting the client flat in bed, or putting the bed in the Trendelenburg’s position places the client in positions that improve cerebral blood flow, worsening hypertension.22.  3. Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.23.  4. The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. Absent corneal reflexes, decerebate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.24.  2. Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.

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25.  4. Intermittent catherization may be performed chronically with clean technique, using soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. It isn’t necessary to measure the urine. The catheter doesn’t need to be rotated during removal.26.  3. Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches should be reported.27.  1. The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it’s such an important neurotransmitter in schizophrenia.28.  3. An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. Percent of functional brain tissue would be determined by a series of tests.29.  3. An epidural hematoma occurs when blood collects between the skull and the dura mater. In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. A contusion is a bruise on the brain’s surface.30.  1. A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.31.  3. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury.32.  1, 2, 4, 5. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.33.  1. A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may be ordered for the head injured patient. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.34.  4. The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client’s neurological status deteriorates quickly.35.  2. After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. A history of diarrhea is irrelevant.36.  2. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catherization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.37.  3. Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during

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position changes, use of a tilt-table with early mobilization, and changing the client’s position slowly. Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots. Vasopressor medications are administered per protocol.38.  4. Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.39.  3. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski’s reflex.40.  3, 1, 4, 2, 5. Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.41.  1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.42.  1. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.43.  3. Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.44.  4. A decrease in the client’s LOC is an early indicator of deterioration of the client’s neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.45.  2. It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client’s arms and hands under the draw sheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.46.  4. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.47.  2. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.48.  2. Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for supratentorial craniotomies.49.  2, 3, 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.

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HIV/AIDS1. You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for P.

carinii pneumonia. Which information is most important to communicate to the physician?1. The blood pressure decreased to 104/76 during administration2. The patient is complaining of pain at the site of infusion3. The patient is not taking in an adequate amount of oral fluids4. Blood glucose is 55 mg/dl after the medication administration.

2. You are working with a student nurse who is assigned to care for an HIV-positive patient with severe esophagitis caused by Candida albicans. Which action by the student indicates that you need to intervene most quickly?

1. The student puts on a mask before entering the patient room2. The student gives the patient a glass of water after the oral nystatin (Mycostatin) suspension. 3. The student offers the patient a choice of chicken soup or chile con carne for lunch. 4. The student places a “No Visitors” sign on the door of the patient’s room

3. A patient with AIDS has a negative TB skin test. Which nursing action is indicated next?1. Obtain a chest x-ray and sputum smear2. No further action is needed after the negative skin test3. Teach about the anti-tuberculosis drug isoniazid (INH)4. Schedule TB testing again in 6 months

4. You are working in an AIDS hospice facility that is also staffed with LPNs and nursing assistants. Which of these nursing actions is best to delegate to the LPN you are supervising?

1. Assess patients’ nutritional needs and individualize diet plans to improve nutrition. 2. Collect data about the patients’ response to medications used for pain and anorexia. 3. Teach the nursing assistants about how to lower the risk of spreading infections. 4. Assist patients with personal hygiene and other ADLs as needed.

5. While caring for an HIV-positive patient who is hospitalized with P. carinii pneumonia, you note that all of these drug therapies are scheduled for 10am. Which nursing action is most essential to accomplish at the scheduled time?

1. Administer the protease inhibitor indinavir (Crixivan) 800 mg PO. 2. Infuse pentamidine (Pentam-300) 300 mg IV over 60 minutes.3. Have the patient “swish and swallow” nystatin (Mycostatin) 5 mL. 4. Apply acyclovir (Zovirax) cream to oral herpes simplex lesions.

6. An HIV-positive patient who has been started on antiretroviral therapy (ART) is seen in the clinic for follow-up. Which test will be most helpful in determining response to therapy?

1. Lymphocyte count2. ELISA testing3. Western blot analysis4. Viral load testing

1. 4. Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy. The low blood pressure suggests that the IV infusion rate may need to be slowed. The other responses indicate need for independent nursing actions (such as obtaining a new IV site and encouraging oral intake) but are not associated with pentamidine infusion.

2. 2. Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet/contact precautions or visitor restrictions for opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections.

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3. 1. Patients with severe immunodeficiency may be unable to produce an immune response, so a negative TB skin test does not completely rule out a TB diagnosis for this patient. The next steps in diagnosis are a chest x-ray and sputum culture. Teaching about INH and follow-up TB testing may be required, depending on the x-ray and sputum culture results.

4. 2. Collecting data used to evaluate the therapeutic and adverse effects of medications is included in the LPN education and scope of practice. Assessment, planning, and teaching are more complex skills that will require RN education. Assistance with hygiene and ADLs should be delegated to the nursing assistants.

5. 1. Taking antiretroviral medications such as indinavir on a rigid time schedule is essential for the effective treatment of HIV infection and to avoid development of drug-resistant strains of the virus. The other medications should also be given within the time frame indicated in the hospital policy (usually within 30 minutes of the scheduled time).

6. 4. Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the ART is effective. The lymphocyte count is used to assess the impact of HIV on immune function but will not directly measure the effectiveness of antiretroviral therapy. The ELISA and Western blot tests monitor for the presence of antibodies to HIV, so these will be positive after the patient is infected with HIV even if drug therapy is effective.

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