1. Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause: a. Nasal congestion b. Nervousness c. Lethargy d. Hyperkalemia 2. Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In a acute rhinitis, nasal drainage normally is: a. Yellow b. Green c. Clear d. Gray 3. A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a. Nausea or vomiting b. Abdominal pain or diarrhea c. Hallucinations or tinnitus d. Lightheadedness or paresthesia 4. Before administering ephedrine, Nurse Tony assesses the patients history. Because of ephedrines central nervous system (CNS) effects, it is not recommended for: a. Patients with an acute asthma attack b. Patients with narcolepsy c. Patients under age 6 d. Elderly patients 5. A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patients condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high pressure alarm? a. Kinking of the ventilator tubing b. A disconnected ventilator tube c. An endotracheal cuff leak d. A change in the oxygen concentration without resetting the oxygen level alarm 6. A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose? a. Leg movement b. Finger movement c. Lip movement d. Fighting the ventilator 7. On auscultation, which finding suggests a right pneumothorax? a. Bilateral inspiratory and expiratory crackles b. Absence of breaths sound in the right thorax

c. Inspiratory wheezes in the right thorax d. Bilateral pleural friction rub. 8. Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase a in ABG value present? a. Acid-base balance b. Arterial Blood c. Arterial oxygen saturation d. Alveoli 9. A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? a. Activity intolerance related to fatigue b. Anxiety related to actual threat to health status c. Risk for infection related to retained secretions d. Impaired gas exchange related to airflow obstruction 10. Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: a. Contralateral side in a simple pneumothorax b. Affected side in a hemothorax c. Affected side in a tension pneumothorax d. Contralateral side in hemothorax 11. After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: a. Monitor fluctuations in the water-seal chamber b. Clamp the chest tube once every shift c. Encourage coughing and deep breathing d. Milk the chest tube every 2 hours 12. When caring for a male patient who has just had a total laryngectomy, the nurse should plan to: a. Encourage oral feeding as soon as possible b. Develop an alternative communication method c. Keep the tracheostomy cuff fully inflated d. Keep the patient flat in bed 13. A male patient has a sucking stab wound to the chest. Which action should the nurse take first? a. Drawing blood for a hematocrit and hemoglobin level b. Applying a dressing over the wound and taping it on three sides c. Preparing a chest tube insertion tray d. Preparing to start an I.V. line 14. For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a. Encouraging the patient to drink three glasses of fluid daily b. Keeping the patient in semi-fowlers position

c. Using a high-flow venture mask to deliver oxygen as prescribe d. Administering a sedative, as prescribe 15. A male patients X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: a. Cardiogenic pulmonary edema b. Respiratory alkalosis c. Increased pulmonary capillary permeability d. Renal failure 16. For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? a. Restricting fluid intake to 1,000 ml per day b. Enforcing absolute bed rest c. Teaching the patient how to perform controlled coughing d. Administering prescribe sedatives regularly and in large amounts 17. Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding b. Immediately clamp the chest tube and notify the physician c. Check for an air leak because the bubbling should be intermittent d. Increase the suction pressure so that the bubbling becomes vigorous 18. Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? a. Inform the physician b. Continue to monitor the client c. Reinforce the occlusive dressing d. Encourage the client to deep-breathe 19. Nurse Ryan caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician b. Place the tube in bottle of sterile water c. Immediately replace the chest tube system d. Place a sterile dressing over the disconnection site 20. A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: a. Exhale slowly b. Stay very still c. Inhale and exhale quickly d. Perform the Valsalva maneuver 21. While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube b. Grasp the retention sutures to spread the opening

c. Call the respiratory therapy department to reinsert the tracheotomy d. Cover the tracheostomy site with a sterile dressing to prevent infection 22. Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate 24 breaths/min 23. An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury 24. Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increased oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray 25. An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? a. Face tent b. Venturi mask c. Aerosol mask d. Tracheostomy collar 26. Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum 27. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis? a. Bronchoscopy b. Sputum culture c. Chest x-ray d. Tuberculin skin test 28. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min

b. 2 L/min c. 6 L/min d. 10 L/min 29. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake b. Strengthen the diaphragm c. Strengthen the intercostal muscles d. Promote carbon dioxide elimination 30. A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? a. Pallor b. Low arterial PaO2 c. Elevated arterial PaO2 d. Decreased respiratory rate View Questions 1. Answer B. Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Otther adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps. 2. Answer C. Normally, nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection. 3. Answer D. The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance. 4. Answer D. Ephedrine is not recommended for elderly patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older. 5. Answer A. Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and the patients being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would tigger the oxygen alarm. 6. Answer D. Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every

20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose. 7. Answer B. In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation. 8. Answer B. A lowercase a in an ABG value represents arterial blood. For instance, the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase A represents alveolar conditions: for example, PA02 indicates the partial pressure of oxygen in the alveoli. 9. Answer D. A patient airway and an adequate breathing pattern are the top priority for any patient, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis. The other options also may apply to this patient but less important. 10. Answer D. The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side. 11. Answer C. When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage. 12. Answer B. A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the patient in semi-fowlers position. 13. Answer B. The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line. 14. Answer C. The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowlers position and should not receive sedatives or other drugs that may further depress the respiratory center. 15. Answer C. ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs

secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either. 16. Answer C. Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patients ability to maintain a patent airway, causing a high risk for infection from pooled secretions. 17. Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. 18. Answer B. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect. 19. Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action. 20. Answer D. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions. 21. Answer B. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation. 22. Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician. 23. Answer B. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. 24. Answer B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. 25. Answer B. The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen

concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity. 26. Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement. 27. Answer B. Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy. 28. Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. 29. Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing. 30. Answer B. The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.Top of Form Bottom of Form

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1. Whats the first intervention for a patient experiencing chest pain and an 5p02 of 89%?1. Administer morphine. 2. Administer oxygen. 3. Administer sublingual nitroglycerin. 4. Obtain an electrocardiogram (ECC) 2. Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? 1. Abdominal pain. 2. Absent pedal pulses. 3. Chest pain. 4. Lower back pain. 1. In which of the following types of cardiomyopathy does cardiac output remain normal? 1. Dilated. 2. Hypertrophic. 3. Obliterative. 4. Restrictive. 1. Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking? 1. Have the patient sit down. 2. Get the patient back to bed. 3. Obtain an ECG. 4. Administer sublingual nitroglycerin.

1. Which of the following positions would best aid breathing for a patient with acute pulmonaryedema? 1. Lying flat in bed. 2. Left side-lying position. 3. High Fowlers position. 4. Semi-Fowlers position. 1. A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks gestation. Shes at risk for which of the following blood dyscrasias? 1. Thrombocytopenia. 2. Idiopathic thrombocytopenic purpura (ITP). 3. Disseminated intravascular coagulation (DIC). 4. Heparin-associated thrombosis and thrombocytopenia (HATT). 1. A 16-year-old patient involved in a motor vehicle accident arrives in the ED unconscious and severely hypotensive. Hes suspected to have several fractures of his pelvis and legs. Which of the following parenteral fluids is the best choice for his current condition? 1. Fresh frozen plasma. 2. 0.9% sodium chloride solution. 3. Lactated Ringers solution. 4. Packed red blood cells. 1. Corticosteroids are potent suppressors of the bodys inflammatory response. Which of the following conditions or actions do they suppress? 1. Cushing syndrome. 2. Pain receptors. 3. Immune response. 4. Neural transmission. 1. A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drugs action? 1. It destroys the outer wall of the virus and kills it. 2. It interferes with viral replication. 3. It stimulates the immune system. 4. It promotes excretion of viral antibodies. 1. A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What could you tell him to help him reduce his discomfort? 1. "Hold your cough as much as possible." 2. "Place the head of your bed flat to help with coughing." 3. "Restrict fluids to help decrease the amount of sputum." 4. "Splint your chest wall with a pillow for comfort." 1. A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should you take first? 1. Take a full medical history. 2. Give a bronchodilator by nebulizer.

3. Apply a cardiac monitor to the patient. 4. Provide emotional support for the patient. 1. A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed? 1. Acute respiratory distress syndrome (ARDS). 2. Atelectasis. 3. Bronchitis. 4. Pneumonia. 1. Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube? 1. You see a lot of drainage from the chest tube. 2. Arterial blood gas (ABG) levels are normal. 3. The chest X-ray continues to show the lung is 35% deflated. 4. The water-seal chamber doesnt fluctuate when no suction is applied. 1. Which of the following nursing interventions should you use to prevent footdrop and contractures in a patient recovering from a subdural hematoma? 1. High-top sneakers. 2. Low-dose heparin therapy. 3. Physical therapy consultation. 4. Sequential compressive device. Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? 1. Bradycardia. 2. Large amounts of very dilute urine. 3. Restlessness and confusion. 4. Widened pulse pressure. When giving intravenous (I.V.) phenytoin, which of the following methods should you use? 1. Use an in-line filter. 2. Withhold other anticonvulsants. 3. Mix the drug with saline solution only. 4. Flush the I.V. catheter with dextrose solution. After surgical repair of a hip, which of the following positions is best for the patients legs and hips? 1. Abduction. 2. Adduction. 3. Prone. 4. Subluxated. Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis? 1. Nutrition management. 2. Fluid and electrolyte balance. 3. Management of hypoglycemia.

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4. Pain control. 1. After a liver biopsy, place the patient in which of the following positions? 1. Left side-lying, with the bed flat. 2. Right side-lying, with the bed flat. 3. Left side-lying, with the bed in semi-Fowlers position. 4. Right side-lying, with the bed in semi-Fowlers position. 1. Which of the following potentially serious complications could occur with therapy for hypothyroidism? 1. Acute hemolytic reaction. 2. Angina or cardiac arrhythmia. 3. Retinopathy. 4. Thrombocytopenia. 1. Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes? 1. Diabetes mellitus. 2. Diabetes insipidus. 3. Diabetic ketoacidosis. 4. syndrome of inappropriate antidiuretic hormone secretion (SIADH). 1. Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection? 1.No changes. 2. Less insulin. 3. More insulin. 4. Oral diabetic agents. 1. On a follow-up visit after having a vaginal hysterectomy, a 32-year-old patient has a decreased hematocrit level. Which of the following complications does this suggest? 1.Hematoma. 2.Hypovolemia. 3.Infection. 4.Pulmonary embolus (PE). 1. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first? 1. Albumin. 2. D5W. 3. Lactated Ringers solution. 4. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml. 1. Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site? 1. Thoroughly irrigate the wound before collecting the specimen. 2. Use a sterile swab and wipe the crusty area around the outside of the wound. 3. Gently roll a sterile swab from the center of the wound outward to collect drainage. 4. Use a sterile swab to collect drainage from the dressing.

View the Sample NCLEX Questions 1. B Administering supplemental oxygen to the patient is the first priority. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage. Sublingual nitroglycerin and morphine are commonly administered after oxygen. 2. D Lower back pain results from expansion of the aneurysm. The expansion applies pressure in the abdomen, and the pain is referred to the lower back. Abdominal pain is the most common symptom resulting from impaired circulation. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Chest pain usually is associated with coronary artery or pulmonary disease. 3. B Cardiac output isnt affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. Dilated cardiomyopathy, obliterative cardiomyopathy, and restrictive cardiomyopathy all decrease cardiac output. 4. A The initial priority is to decrease oxygen consumption by sitting the patient down. Administer sublingual nitroglycerin as you simultaneously do the ECG. When the patients condition is stabilized, he can be returned to bed. 5. C High Fowlers position facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen breathing and increase the hearts workload. 6. C Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage. Thrombocytopenia results from decreased production of platelets. ITP doesnt have a definitive cause. A patient with abruptio placentae wouldnt get heparin and, as a result, wouldnt be at risk for HATT. 7. D In a trauma situation, the first blood product given is unmatched (0 negative) packed red blood cells. Fresh frozen plasma often is used to replace clotting factors. Lactated Ringers solution or 0.9% sodium chloride is used to increase volume and blood pressure, but too much of these crystalloids will dilute the blood and wont improve oxygen-carrying capacity. 8. C Corticosteroids suppress eosinophils, lymphocytes, and natural-killer cells, inhibiting the natural inflammatory process in an infected or injured part of the body. This helps resolve inflammation, stabilizes lysosomal membranes, decreases capillary permeability, and depresses phagocytosis of tissues by white blood cells, thus blocking the release of more inflammatory materials. Excessive corticosteroid therapy can lead to Cushing syndrome. 9. B Zidovudine inhibits DNA synthesis in HIV, thus interfering with viral replication. The drug doesnt destroy the viral wall, stimulate the immune system, or promote HIV antibody excretion. 10. D Showing this patient how to splint his chest wall will help decrease discomfort when coughing. Holding in his coughs will only increase his pain. Placing the head of the bed flat may increase the frequency of his cough and his work of breathing. Increasing fluid intake will help thin his secretions, making it easier for him to clear them. 11. B The patient having an acute asthma attack needs more oxygen delivered to his lungs and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. The patient may

not need cardiac monitoring because hes only 19 years old, unless he has a medical history of cardiac problems. 12. A Severe hypoxia after smoke inhalation typically is related to ARDS. The other choices arent typically associated with smoke inhalation. 13. D The chest tube isnt removed until the patients lung has adequately reexpanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isnt applied. The chest X-ray should show that the lung is reexpanded. Drainage should be minimal before the chest tube is removed. An ABG test isnt necessary if clinical assessment criteria are met. 14. A High-top sneakers are used to prevent footdrop and contractures in patients with neurologic conditions. A consult with physical therapy is important to prevent footdrop, but you can use high-top sneakers independently. 15. C The earliest sign of increased ICP is a change in mental status. Bradycardia and widened pulse pressure occur later. The patient may void a lot of very dilute urine if his posterior pituitary is damaged. 16. C Phenytoin is compatible only with saline solutions; dextrose causes an insoluble precipitate to form. You neednt withhold additional anticonvulsants or use an in-line filter. 17. A After surgical repair of the hip, keep the legs and hips abducted to stabilize the prosthesis in the acetabulum. 18. B Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is a major concern. Therefore, your priority is to manage hypovolemia and restore electrolyte balance. Pain control and nutrition also are important. Patients are at risk for hyperglycemia, not hypoglycemia. 19. B Positioning the patient on his right side with the bed flat will splint the biopsy site and minimize bleeding. The other positions wont do this and may cause more bleeding at the site or internally. 20. B Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment. Acute hemolytic reaction is a complication of blood transfusions. Retinopathy typically is a complication of diabetes mellitus. Thrombocytopenia doesnt result from treating hypothyroidism. 21. B Maintaining adequate fluid and replacing vasopressin are the main objectives in treating diabetes insipidus. An excess of antidiuretic hormone leads to SIADH, causing the patient to retain fluid. Diabetic ketoacidosis is a result of severe insulin insufficiency. 22. C During periods of infection or illness, patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels. 23. A A decreased hematocrit level is a sign of hematoma, a delayed complication of abdominal and vaginal hysterectomy. Symptoms of hypovolemia include increased hematocrit and hemoglobin values. Symptoms of a PE include dyspnea, chest pain, cough, hemoptysis, restlessness, and signs of shock. 24. C Lactated Ringers solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not primary fluid replacement. Dextrose isnt given to burn patients during the first 24 hours because it can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental. 25. C Rolling a swab from the center outward is the right way to obtain a culture specimen from a wound. Irrigating the wound washes away drainage, debris, and many of the colonizing or infecting

microorganisms. The outside of the wound and the dressing may be colonized with microorganisms that havent affected the wound, so specimens from these sites could give inaccurate results. 1. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. body temperature control. b. balance and equilibrium. c. visual acuity. d. thinking and reasoning. 2. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? a. phenytoin (Dilantin) b. mannitol (Osmitrol) c. lidocaine (Xylocaine) d. furosemide (Lasix) 3. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. Hes unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? a. Give him a barbiturate. b. Place him on mechanical ventilation. c. Perform a lumbar puncture. d. Elevate the head of his bed. 4. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: a. light flashes and floaters in front of the eye. b. a recent driving accident while changing lanes. c. headaches, nausea, and redness of the eyes. d. frequent episodes of double vision. 5. Which nursing diagnosis takes highest priority for a client with Parkinsons crisis? a. Imbalanced nutrition: Less than body requirements b. Ineffective airway clearance c. Impaired urinary elimination d. Risk for injury 6. To encourage adequate nutritional intake for a female client with Alzheimers disease, the nurse should: a. stay with the client and encourage him to eat. b. help the client fill out his menu. c. give the client privacy during meals. d. fill out the menu for the client. 7. The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following?

a. Cerebellar function b. Intellectual function c. Cerebral function d. Sensory function 8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? a. In 30 to 45 seconds b. In 10 to 15 minutes c. In 30 to 45 minutes d. In 1 to 2 hours 9. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil a condition resulting from acute iris inflammation (iritis). As part of the clients therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? a. Parasympathomimetic agent b. Sympatholytic agent c. Adrenergic blocker d. Cholinergic blocker 10. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and hes comatose. We intubated him and hes maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manualresuscitation bag. Which intervention by the nurse has the highest priority? a. Assessing the left leg b. Assessing the pupils c. Placing the client in Trendelenburgs position d. Assessing level of consciousness 11. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: a. increasing the exudative reaction of ocular tissue. b. decreasing leukocyte infiltration at the site of ocular inflammation. c. inhibiting the action of carbonic anhydrase. d. producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris. 12. Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal? a. More back pain than the first postoperative day b. Paresthesia in the dermatomes near the wounds

c. Urine retention or incontinence d. Temperature of 99.2 F (37.3 C) 13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: a. instilling one drop of pilocarpine 0.25% into both eyes daily. b. instilling one drop of pilocarpine 0.25% into both eyes four times daily. c. instilling one drop of pilocarpine 0.25% into the right eye daily. d. instilling one drop of pilocarpine 0.25% into the left eye four times daily. 14. A female client whos paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? a. The client leaves the side rails down. b. The client uses a mirror to inspect the skin. c. The client repositions only after being reminded to do so. d. The client hangs the left arm over the side of the wheelchair. 15. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the clients feet make a half circle. To document the clients gait, the nurse should use which term? a. Ataxic b. Dystrophic c. Helicopod d. Steppage 16. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? a. A private room down the hall from the nurses station b. An isolation room three doors from the nurses station c. A semiprivate room with a 32-year-old client who has viral meningitis d. A two-bed room with a client who previously had bacterial meningitis 17. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the clients history. Which preexisting condition would contraindicate the use of pyridostigmine? a. Ulcerative colitis b. Blood dyscrasia c. Intestinal obstruction d. Spinal cord injury 18. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Mnires disease. When assessing this client, the nurse expects to note: a. vertigo, tinnitus, and hearing loss. b. vertigo, vomiting, and nystagmus c. vertigo, pain, and hearing impairment. d. vertigo, blurred vision, and fever.

19. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? a. Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours. b. Try to ambulate independently after about 24 hours. c. Shampoo your hair every day for 10 days to help prevent ear infection. d. Dont fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days. 20. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? a. Excessive tearing b. Urine retention c. Muscle weakness d. Slurred speech 21. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? a. Tachycardia b. Increased salivation c. Hypotension d. Apnea 22. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this clients care, the nurse should assign highest priority to which nursing diagnosis? a. Impaired physical mobility b. Ineffective breathing pattern c. Disturbed sensory perception (tactile) d. Self-care deficient: Dressing/grooming 23. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for: a. long-term treatment of epilepsy. b. postoperative pain management of laminectomy clients. c. postoperative pain management of diskectomy clients d. treatment of spasticity associated with spinal cord lesions. 24. A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the clients oculocephalic (dolls eye) response by: a. introducing ice water into the external auditory canal. b. touching the cornea with a wisp of cotton. c. turning the clients head suddenly while holding the eyelids open. d. shining a bright light into the pupil. 25. While reviewing a clients chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this

condition? a. The client may be less sensitive to the effects of a neuromuscular blocking agent. b. Succinylcholine shouldnt be used; pancuronium may be used in a lower dosage. c. Pancuronium shouldnt be used; succinylcholine may be used in a lower dosage. d. Pancuronium and succinylcholine both require cautious administration. 26. A male client is color blind. The nurse understands that this client has a problem with: a. rods. b. cones. c. lens. d. aqueous humor. 27. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? a. Diencephalon b. Medulla c. Midbrain d. Cortex 28. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? a. Vision changes b. Absent deep tendon reflexes c. Tremors at rest d. Flaccid muscles 29. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? a. Sit with the client for a few minutes. b. Administer an analgesic. c. Inform the nurse manager. d. Call the physician immediately. 30. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the clients swallowing ability once each shift. This assessment evaluates: a. cranial nerves I and II. b. cranial nerves III and V. c. cranial nerves VI and VIII. d. cranial nerves IX and X. 1. Answer A. The bodys thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum. 2. Answer C. Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, theyre administered

parenterally, not endotracheally. Phenytoin doesnt reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isnt administered endotracheally. 3. Answer C. The clients history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldnt be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. 4. Answer A. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts. 5. Answer B. In Parkinsons crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they arent immediately life-threatening. 6. Answer A. Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimers disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesnt ensure adequate nutritional intake. 7. Answer C. The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Intellectual functioning isnt the only cerebral activity. Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Sensory function testing involves assessment of pain, light-touch sensation, and temperature discrimination. 8. Answer B. When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldnt exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose cant be repeated in 30 to 45 seconds because the first dose wouldnt have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the clients risk of complications associated with status epilepticus. 9. Answer D. Atropine sulfate is a cholinergic blocker. It isnt a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker. 10. Answer A. In the scenario, airway and breathing are established so the nurses next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic assessment is a secondary concern to airway, breathing, and circulation. The nurse doesnt have enough data to warrant putting the client in Trendelenburgs position.

11. Answer B. Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Dexamethasone and other anti-inflammatory agents dont inhibit the action of carbonic anhydrase or produce any type of miotic reaction. 12. Answer C. Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. An increase in pain on the second postoperative day is common because the longacting local anesthetic, which may have been injected during surgery, will wear off. While paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if it reaches 101 F (38.3 C). 13. Answer B. The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, OU signifies both eyes, and "q.i.d." means four times a day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily. 14. Answer B. Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if needed. A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this to the clients attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long. 15. Answer C. A helicopod gait is an abnormal gait in which the clients feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes raise high off the floor and the heel comes down heavily with each step. 16. Answer B. A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the others disease. Immunity to bacterial meningitis cant be acquired; therefore, a client who previously had bacterial meningitis shouldnt be put at risk by rooming with a client who has just been diagnosed with this disease. 17. Answer C. Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury dont contraindicate use of the drug. 18. Answer A. Mnires disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. Mnires disease rarely causes pain, blurred vision, or fever. 19. Answer D. For 30 days after a stapedectomy, the client should avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high

altitudes). Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The clients first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry. 20. Answer C. The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle weakness is rarely severe enough to cause slurring of speech, drooling, and enuresis. Although excessive tearing and urine retention are adverse reactions associated with dantrolene use, they arent as common as muscle weakness 21. Answer A. Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isnt known to cause hypotension or apnea. 22. Answer B. Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a client with a spinal cord injury particularly during the course of recovery but dont take precedence over a diagnosis of Ineffective breathing pattern. 23. Answer D. In addition to relieving painful muscle spasms, diazepam also is recommended for treatment of spasticity associated with spinal cord lesions. Diazepams use is limited by its central nervous system effects and the tolerance that develops with prolonged use. The parenteral form of diazepam can treat status epilepticus, but the drugs sedating properties make it an unsuitable choice for long-term management of epilepsy. Diazepam isnt an analgesic agent. 24. Answer C. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the clients head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the clients eyes deviate to the side of ice water introduction. The nurse touches the clients cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the clients pupil helps evaluate brain stem and cranial nerve III functions; normally, the pupil responds by constricting. 25. Answer D. The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client isnt less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis. 26. Answer B. Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but cant discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isnt involved with color perception. 27. Answer C. Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion

(decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity. 28. Answer A. Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive not absent. Babinskis sign may be positive. Tremors at rest arent characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in clients with multiple sclerosis. Affected muscles are spastic, rather than flaccid. 29. Answer D. The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the clients condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isnt necessary. 30. Answer D. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII dont possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement. More NCLEX questions next