Advertisement Upgrade to remove ads

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?
a.
The patient smokes a pack of cigarettes daily.
b.
The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg.
c.
The patient works at a desk and relaxes by watching television.
d.
The patient is 25 pounds above the ideal weight.

Correct Answer: B
Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension.

Cognitive Level: Application Text Reference: p. 1503
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first?
a.
Noncontrast computed tomography (CT) scan
b.
Chest radiograph
c.
Complete blood count (CBC)
d.
Electrocardiogram (ECG)

Correct Answer: A
Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include
a.
heparin via continuous intravenous infusion.
b.
prophylactic clipping of cerebral aneurysms.
c.
therapy with tissue plasminogen activator (tPA).
d.
oral administration of ticlopidine (Ticlid).

Correct Answer: D
Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for TIA.

Cognitive Level: Application Text Reference: p. 1505
Nursing Process: Implementation NCLEX: Physiological Integrity

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
a.
The patient has atrial fibrillation.
b.
The patient has dysphasia.
c.
The patient states, "I suddenly developed a terrible headache."
d.
The patient has a history of brief episodes of right hemiplegia.

Correct Answer: C
Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

Cognitive Level: Application Text Reference: p. 1507
Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's
a.
ability to follow commands.
b.
visual fields.
c.
right-sided reflexes.
d.
emotional state.

Correct Answer: A
Rationale: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities.

Cognitive Level: Application Text Reference: p. 1508
Nursing Process: Assessment NCLEX: Physiological Integrity

6. The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have
a.
visual deficits.
b.
dysphasia.
c.
confusion.
d.
poor judgment.

Correct Answer: A
Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

Cognitive Level: Application Text Reference: p. 1507
Nursing Process: Assessment NCLEX: Physiological Integrity

The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient
a.
that Plavix will reduce cerebral artery plaque formation.
b.
to monitor and record the blood pressure daily.
c.
to call the health care provider if stools are tarry.
d.
that Plavix will dissolve clots in the cerebral arteries.

Correct Answer: C
Rationale: Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

Cognitive Level: Application Text Reference: p. 1510
Nursing Process: Implementation NCLEX: Physiological Integrity

The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?
a.
"The diseased portion of the artery in the brain is removed and replaced with a synthetic graft."
b.
"The carotid endarterectomy involves surgical removal of plaque from an artery in the neck."
c.
"A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
d.
"A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."

Correct Answer: B
Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response (beginning, "A wire is threaded through the artery") describes the Merci procedure.

Cognitive Level: Application Text Reference: p. 1510
Nursing Process: Implementation NCLEX: Physiological Integrity

On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question?
a.
Infuse normal saline at 75 ml/hr.
b.
Keep head of bed elevated at least 30 degrees.
c.
Administer tissue plasminogen activator (tPA) per protocol.
d.
Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

Correct Answer: D
Rationale: Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 ml daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

Cognitive Level: Application Text Reference: p. 1511
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for
a.
intravenous heparin administration.
b.
transluminal angioplasty.
c.
surgical endarterectomy.
d.
tissue plasminogen activator (tPA) infusion.

Correct Answer: D
Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke.

Cognitive Level: Application Text Reference: p. 1512
Nursing Process: Planning NCLEX: Physiological Integrity

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
a.
ask simple questions that the patient can answer with "yes" or "no."
b.
develop a list of words that the patient can read and practice reciting.
c.
have the patient practice facial and tongue exercises to improve motor control necessary for speech.
d.
prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.

Correct Answer: A
Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

Cognitive Level: Application Text Reference: p. 1520
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is
a.
risk for impaired skin integrity related to immobility.
b.
disturbed sensory perception related to brain injury.
c.
risk for aspiration related to inability to protect airway.
d.
impaired physical mobility related to weakness.

Correct Answer: C
Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

Cognitive Level: Application Text Reference: p. 1515
Nursing Process: Diagnosis NCLEX: Physiological Integrity

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of
a.
impaired physical mobility related to right hemiplegia.
b.
impaired verbal communication related to speech-language deficits.
c.
risk for injury related to denial of deficits and impulsiveness.
d.
ineffective coping related to depression and distress about disability.

Correct Answer: C
Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

Cognitive Level: Application Text Reference: p. 1508
Nursing Process: Diagnosis NCLEX: Physiological Integrity

14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should
a.
apply an eye patch to the affected eye.
b.
approach the patient on the unaffected side.
c.
place objects necessary for activities of daily living on the patient's affected side.
d.
have the patient use the eye muscles to move the eyes through the entire visual field.

Correct Answer: C
Rationale: During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side. Because homonymous hemianopsia affects half the visual field in each eye, use of an eye patch is not appropriate. Approaching the patient on the affected side is appropriate during the acute period but does not help the patient learn skills needed to compensate for the visual defect. The problem is with the visual field, not with the eye muscles, so practice moving the eyes through the visual field will not be effective.

Cognitive Level: Application Text Reference: p. 1517
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?
a.
The patient complains of an ongoing severe headache.
b.
The patient's blood pressure is 90/50 mm Hg.
c.
The cerebrospinal fluid (CFS) report shows red blood cells (RBCs).
d.
The patient complains about having a stiff neck.

Correct Answer: B
Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a high level after a subarachnoid hemorrhage. A low or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

Cognitive Level: Analysis Text Reference: p. 1515
Nursing Process: Assessment NCLEX: Physiological Integrity

he nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to
a.
assist the patient to eat with the left hand.
b.
provide oral care before and after meals.
c.
teach the patient the "chin-tuck" technique.
d.
provide a wide variety of food choices.

Correct Answer: A
Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

Cognitive Level: Application Text Reference: p. 1522
Nursing Process: Implementation NCLEX: Physiological Integrity

17. The nurse is assisting the patient who is recovering from an acute stroke and has right-side hemiplegia to transfer from the bed to the wheelchair. Which action by the nurse is appropriate?
a.
Positioning the wheelchair next to the bed on the patient's right side
b.
Placing the wheelchair parallel to the bed on the patient's left side
c.
Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed
d.
Moving the wheelchair a few steps from the bed and having the patient walk to the chair

Correct Answer: B
Rationale: Placing the wheelchair on the patient's left side will allow the patient to use the left hand to grasp the left arm of the chair to transfer. If the chair is placed on the patient's right side or in front of the patient, it will be awkward to use the strong arm, and the patient will be at increased risk for a fall. Because the patient has hemiplegia, it is not appropriate to place the chair where the patient will need to walk to it.

Cognitive Level: Application Text Reference: p. 1522
Nursing Process: Implementation NCLEX: Physiological Integrity

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a.
Encouraging patient to cough and deep breath every 4 hours
b.
Inserting an oropharyngeal airway to prevent airway obstruction
c.
Assisting to dangle on edge of bed and assess for dizziness
d.
Applying intermittent pneumatic compression stockings

Correct Answer: D
Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep vein thrombosis (DVT). Activities (such as coughing and sitting up) that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

Cognitive Level: Application Text Reference: p. 1518
Nursing Process: Planning NCLEX: Physiological Integrity

A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then
a.
offer the patient a sip of juice.
b.
order a varied pureed diet.
c.
assess the patient's appetite.
d.
assist the patient into a chair.

Correct Answer: D
Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.

Cognitive Level: Application Text Reference: pp. 1518-1519
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." A nursing diagnosis that is most appropriate in this situation is
a.
situational low self-esteem related to increasing dependence on others.
b.
interrupted family processes related to effects of illness of a family member.
c.
disabled family coping related to inadequate understanding by patient's spouse.
d.
ineffective therapeutic regimen management related to hemiplegia and aphasia.

Correct Answer: C
Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient's attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately.

Cognitive Level: Application Text Reference: p. 1523
Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. A bladder retraining program for the patient should include
a.
limiting fluid intake to 1000 ml daily to reduce urine volume.
b.
assisting the patient onto the bedside commode every 2 hours.
c.
performing intermittent catheterization after each voiding to check for residual urine.
d.
using an external "condom" catheter to protect the skin and prevent embarrassment.

Correct Answer: B
Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.

Cognitive Level: Application Text Reference: p. 1523
Nursing Process: Planning NCLEX: Physiological Integrity

A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but needs help with hygiene, dressing, and eating. Which statement by the patient's wife indicates that discharge planning goals have been met?
a.
"I can provide the care my husband needs if I use the support and resources available in the community."
b.
"Because my husband will have continuous improvement in his condition, I won't need outside assistance in his care for very long."
c.
"I can handle all of my husband's needs thanks to the instructions you've given me."
d.
"I have arranged for a home health aide to provide all the care my husband will need."

Correct Answer: A
Rationale: The statement that community resources will be used indicates a realistic outcome. The patient is unlikely to continue to improve to the point of needing no assistance. The wife is likely to be overwhelmed by the patient's needs if she attempts to manage without assistance. There is no indication that the patient will need a home health aide to meet all of his care needs.

Cognitive Level: Application Text Reference: p. 1524
Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take?
a.
Document that the aspirin was refused by the patient.
b.
Call the health care provider to clarify the medication order.
c.
Explain that the aspirin is ordered to decrease stroke risk.
d.
Tell the patient that the aspirin is used to prevent aches.

Correct Answer: C
Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

Cognitive Level: Application Text Reference: pp. 1505, 1510
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
a.
alteplase (tPA).
b.
aspirin (Ecotrin).
c.
warfarin (Coumadin).
d.
nimodipine (Nimotop).

Correct Answer: B
Rationale: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

Cognitive Level: Application Text Reference: pp. 1505, 1510
Nursing Process: Planning NCLEX: Physiological Integrity

The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
a.
The pulse rate is 104 beats/min.
b.
There are fine crackles at the lung bases.
c.
The patient has difficulty talking.
d.
The blood pressure is 142/88 mm Hg.

Correct Answer: C
Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual as a result of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.

Cognitive Level: Application Text Reference: p. 1510
Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
a.
Obtain the Glasgow Coma Scale score.
b.
Check the respiratory rate.
c.
Monitor the blood pressure.
d.
Send the patient for a CT scan.

Correct Answer: B
Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.

Cognitive Level: Application Text Reference: p. 1511

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
a.
The patient has atrial fibrillation and takes warfarin (Coumadin).
b.
The patient takes a diuretic because of a history of hypertension.
c.
The patient's blood pressure is 144/90 mm Hg.
d.
The patient's speech is difficult to under

Correct Answer: A
Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

Cognitive Level: Application Text Reference: p. 1512
Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should
a.
explain to the family that depression is normal following a stroke.
b.
have the family members leave the patient alone for a few minutes.
c.
teach the family that emotional outbursts are common after strokes.
d.
use a calm voice to ask the patient to stop the crying behavior.

Correct Answer: C
Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.

Cognitive Level: Application Text Reference: p. 1523
Nursing Process: Implementation NCLEX: Psychosocial Integrity

A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has constant severe pain and is hospitalized for pain control and development of a pain-management program. When doing the initial assessment, which question will be most appropriate to ask first?
a.
How would you describe your pain?
b.
How much medication do you take for the pain?
c.
How long have you had this pain?
d.
How many times a day do you medicate for pain?

Correct Answer: A
Rationale: Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best first question.

Cognitive Level: Application Text Reference: pp. 126, 131
Nursing Process: Assessment NCLEX: Physiological Integrity

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests "something for pain that will work quickly." The best way for the nurse to document this information is as
a.
breakthrough pain.
b.
neuropathic pain.
c.
somatic pain.
d.
referred pain.

Correct Answer: A
Rationale: Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.

Cognitive Level: Application Text Reference: p. 132
Nursing Process: Implementation NCLEX: Physiological Integrity

The health care provider tells a patient to use ibuprofen (Motrin, Advil) to relieve pain after treating a laceration on the patient's forearm from a dog bite. The patient asks the nurse how ibuprofen will control the pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the
a.
production of pain-sensitizing chemicals.
b.
spinal cord transmission of pain impulses.
c.
sensitivity of the brain to painful stimuli.
d.
modulating effect of descending nerves.

Correct Answer: A
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by the NSAIDs.

Cognitive Level: Application Text Reference: p. 128
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient being treated for chronic musculoskeletal pain tells the nurse, "I feel depressed because I can't even go out and play a round of golf." The patient describes the pain as "aching" and says it is usually at a level 7 of a scale of 1 to10. Based on these assessment data, which patient goal is most appropriate? After treatment, the patient will
a.
state that pain is at a level 2 of 10.
b.
be able to play 1 to 2 rounds of golf.
c.
exhibit fewer signs of depression.
d.
say that the aching has decreased.

Correct Answer: B
Rationale: For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 or 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse should also assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate.

Cognitive Level: Application Text Reference: p. 135
Nursing Process: Planning NCLEX: Physiological Integrity

A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use the incentive spirometer unless specifically reminded. The patient rates the pain severity as an 8 on a 10-point scale but tells the nurse, "I can tough it out." In encouraging the patient to use pain medication, the best explanation by the nurse is that
a.
very few patients become addicted to opioids when using them for acute pain control.
b.
there is little need to worry about side effects because these problems decrease over time.
c.
there are many pain medications and if one drug is ineffective, other drugs may be tried.
d.
unrelieved pain can be harmful due to the effect on respiratory function and activity level.

Correct Answer: D
Rationale: The patient's low activity level, lack of spirometer use, and statement to the nurse indicate that there is a lack of understanding about the purpose of postoperative pain management. The patient did not indicate a concern about becoming addicted, a desire for alternate medications, or anxiety about analgesic side effects.

Cognitive Level: Application Text Reference: pp. 126, 131, 145
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient is receiving morphine sulfate intravenously (IV) for right flank pain associated with a kidney stone in the right ureter. The patient also complains of right inner thigh pain and asks the nurse whether something is wrong with the right leg. In responding to the question, the nurse understands that the patient
a.
is experiencing referred pain from the kidney stone.
b.
has neuropathic pain from nerve damage caused by inflammation.
c.
has acute pain that may be progressing into chronic pain.
d.
is experiencing pain perception that has been affected by the morphine received earlier.

Correct Answer: A
Rationale: The spread of pain to uninjured tissue is termed referred pain. Neuropathic pain refers to pain caused by nerve damage rather than by tissue injury or damage. When pain has lasted less than 3 months and is associated with an acute event (such as a kidney stone), it is acute pain. Morphine administration will decrease the perception of pain intensity, but it will not change the location of the pain.

Cognitive Level: Application Text Reference: p. 129
Nursing Process: Assessment NCLEX: Physiological Integrity

A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic pain complains of nausea and abdominal fullness. The most appropriate initial action by the nurse is to
a.
consult with the health care provider about using a different opioid.
b.
administer the ordered metoclopramide (Reglan) 10 mg IV.
c.
tell the patient that the nausea will subside in about a week.
d.
order the patient a clear liquid diet until the nausea decreases.

Correct Answer: B
Rationale: Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics are usually prescribed to treat this expected side effect. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops (in about a week), the nausea will subside; therefore, it would not be appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the metoclopramide and allow the patient to eat.

Cognitive Level: Application Text Reference: p. 138
Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse is evaluating the effectiveness of imipramine (Tofranil), a tricyclic antidepressant, for a patient who is receiving the medication to help relieve chronic cancer pain. Which information is the best indicator that the imipramine is effective?
a.
The patient states, "I feel much less depressed since I've been taking the imipramine."
b.
The patient sleeps 8 hours every night.
c.
The patient says that the pain is manageable and that he or she can accomplish desired activities.
d.
The patient has no symptoms of anxiety.

Correct Answer: C
Rationale: Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level.

Cognitive Level: Application Text Reference: p. 130

A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply will be based on the information that these strategies
a.
impact the cognitive and affective components of pain.
b.
prevent transmission of nociceptive stimuli to the cortex.
c.
increase the modulating effect of the efferent pathways.
d.
slow the release of transmitter chemicals in the dorsal horn.

Correct Answer: A
Rationale: Cognitive therapies impact on the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.

Cognitive Level: Comprehension Text Reference: p. 144
Nursing Process: Implementation NCLEX: Physiological Integrity

A home health patient has a prescription for pentazocine (Talwin,) a mixed opioid agonist-antagonist. When teaching the patient and family about adverse effects, the nurse will plan to focus on how to monitor for
a.
agitation.
b.
respiratory depression.
c.
hypotension.
d.
physical dependence.

Correct Answer: A
Rationale: This category of opioids causes more neurologic side effects, such as agitation, than the pure opioid opioids. The benefits to this category include less hypotension and respiratory depression and the absence of physical dependence.

Cognitive Level: Application Text Reference: p. 138
Nursing Process: Planning NCLEX: Physiological Integrity

All the following medications are included in the admission orders for an 86-year-old patient with moderate degenerative arthritis in both hips. Which medication will the nurse use as an initial therapy?
a.
Aspirin (Bayer) 650 mg orally
b.
Oxycodone (Roxicodone) 5 mg orally
c.
Acetaminophen (Tylenol) 650 mg orally
d.
Naproxen (Aleve) 200 mg orally

Correct Answer: C
Rationale: Acetaminophen is the best first-choice medication. The principle of "start low, go slow" is used to guide therapy when treating elderly adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Non-opioid analgesics are used first, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in elderly patients.

Cognitive Level: Application Text Reference: pp. 135, 148
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with chronic cancer pain experiences breakthrough pain (level 9 of 10) and anxiety while receiving sustained-release morphine sulfate (MS Contin) 160 mg every 12 hours. All these medications are ordered for the patient. Which one will be most appropriate for the nurse to administer first?
a.
Ibuprofen (Motrin) 400-800 mg orally
b.
Immediate-release morphine 30 mg orally
c.
Amitriptyline (Elavil) 10 mg orally.
d.
Lorazepam (Ativan) 1 mg orally

Correct Answer: B
Rationale: The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. The ibuprofen and amitriptyline may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of anti-anxiety agents for pain control is inappropriate because this patient's anxiety for this patient is caused by the pain.

Cognitive Level: Analysis Text Reference: pp. 137, 140
Nursing Process: Implementation NCLEX: Physiological Integrity

To obtain the most complete assessment data about a patient's chronic pain pattern, the nurse asks the patient
a.
"Can you describe where your pain is the worst?"
b.
"What is the intensity of your pain on a scale of 0 to 10?"
c.
"Would you describe your pain as aching, throbbing, or sharp?"
d.
"Can you describe your daily activities in relation to your pain?"

Correct Answer: D
Rationale: The assessment of chronic pain should focus on the impact of the pain on patient function and daily activities. The other questions are also appropriate to ask, but will not give as complete information.

Cognitive Level: Application Text Reference: p. 134
Nursing Process: Assessment NCLEX: Physiological Integrity

Morphine 10 mg IV every 4 to 6 hours prn is ordered for a patient with a pancreatic tumor who has a distant history of opioid abuse. After 3 days of receiving the morphine every 6 hours, the patient tells the nurse that the medication is needed more frequently to control the pain. The best initial action by the nurse is to
a.
administer the morphine every 4 hours as needed.
b.
consult with the doctor about initiating an appropriate weaning protocol for the morphine.
c.
remind the patient that the previous substance abuse increases the risk for addiction.
d.
use alternative therapies such as heat or cold.

correct Answer: A
Rationale: These patient data indicate that tolerance for the morphine is developing and more frequent administration is needed to maintain pain control. A weaning protocol is not indicated, since the patient still has the pancreatic tumor and there is no indication that the physiologic basis of the pain has changed. Although the patient may be at risk for addiction, adequate pain management is the priority at present. Alternative therapies may be a useful adjuvant to the morphine but should not be the first nursing action.

Cognitive Level: Application Text Reference: p. 148
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with extensive second-degree burns on the legs and trunk is using patient-controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour to regain pain relief. The most appropriate action by the nurse is to
a.
request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain.
b.
consult with the patient's health care provider about adding a continuous morphine infusion to the PCA regimen at night.
c.
teach the patient to push the button every 10 minutes for an hour before going to sleep even if the pain is minimal.
d.
administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

Correct Answer: B
Rationale: Adding a continuous dose of the morphine at night will allow the patient to sleep without being awakened by the pain. Administering a dose of morphine when the patient awakens would not address the problem. Teaching the patient to administer unneeded medication before going to sleep might result in oversedation and respiratory depression. It is inappropriate for the nurse to administer the morphine while the patient sleeps because the nurse could not assess the pain level.

Cognitive Level: Application Text Reference: p. 140
Nursing Process: Implementation NCLEX: Physiological Integrity

When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication?
a.
The patient complains of a "pounding" headache.
b.
The patient becomes restless and agitated.
c.
The patient has not voided for over 10 hours.
d.
The patient has cramping abdominal pain.

Correct Answer: C
Rationale: Urinary retention is a common side effect of epidural opioids. Headache is not an anticipated side effect of morphine, although if there is a cerebrospinal fluid leak, the patient may develop a "spinal" headache. Sedation (rather than restlessness or agitation) would be a possible side effect. Hypotonic bowel sounds and constipation (rather than abdominal cramping) are concerns.

Cognitive Level: Application Text Reference: p. 142
Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient receiving prn intermittent IV administration of opiates following gastric surgery watches a favorite television program every morning. The patient does not request pain medication during this time and when questioned denies the need for medication. The nurse's evaluation of this situation is that
a.
lying quietly in bed is the best method of controlling the patient's incisional pain.
b.
encouraging the patient to watch other television programs will decrease the pain.
c.
the distraction of the television enables the patient to decrease the perception of pain.
d.
the patient's dose of opiates needs to be decreased because her pain is well controlled.

Correct Answer: C
Rationale: The distraction of watching a favorite program decreases the perception of pain by various brain structures. Immobilization may help to reduce pain, but it is not the best method for pain relief because immobility can lead to multiple postoperative complications. Other television programs are not likely to provide an adequate level of distraction. The patient will continue to require opioid analgesics when not watching the favorite program.

Cognitive Level: Application Text Reference: p. 144
Nursing Process: Evaluation NCLEX: Physiological Integrity

A hospice patient is in continuous pain, and the health care provider has left orders to administer morphine at a rate that controls the pain. When the nurse visits the patient, the patient is awake but moaning with severe pain and asks for an increase in the morphine dosage. The respiratory rate is 10 breaths per minute. The most appropriate action by the nurse is to
a.
titrate the morphine dose upward until the patient states there is adequate pain relief.
b.
administer a nonopioid analgesic, such as ibuprofen, to improve patient pain control.
c.
tell the patient that additional morphine can be administered when the respirations are 12.
d.
inform the patient that increasing the morphine will cause the respiratory drive to fail.

Correct Answer: A
Rationale: The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient's respiratory rate.

A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient's home medications, which of these will be of most concern to the admitting nurse?
a.
Oxycodone (OxyContin) 80 mg twice daily
b.
Ibuprofen (Advil) 800 mg three times daily
c.
Amitriptyline (Elavil) 50 mg at bedtime
d.
Meperidine (Demerol) 25 mg every 4 hours

Correct Answer: D
Rationale: Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management.

Cognitive Level: Application Text Reference: p. 138
Nursing Process: Assessment NCLEX: Physiological Integrity

he hospice RN obtains the following information about a 72-year-old terminally ill patient with cancer of the colon. The patient takes oxycodone (OxyContin) 100 mg twice daily for level 6 abdomen pain on a 10-point scale. The pain has made it difficult to continue with favorite activities such as playing cards with friends twice a week. The patient's children are supportive of the patient's wish to stop chemotherapy but express sadness that the patient does not have long to live. Based on this information, which nursing diagnosis has priority in planning the patient's care?
a.
Impaired social interaction related to disabling pain
b.
Anxiety related to poor patient coping skills
c.
Disabled family coping related to patient-family conflict
d.
Risk for aspiration related to opioid use

Correct Answer: A
Rationale: The assessment data indicate that the patient's priority is to be able to continue with favorite activities and that decreasing the pain level would accomplish this goal. There is no indication of anxiety, and the patient's and family's coping skills appear to be good. Although the patient is taking a large dose of oxycodone, there is no evidence that this has suppressed the respiratory rate or the gag/cough reflexes.

Cognitive Level: Analysis Text Reference: p. 145

The health care provider plans to titrate a patient-controlled opioid infusion (PCA) to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which of the following nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.)
a.
Monitoring for therapeutic and adverse effects of opioid administration
b.
Teaching about the need to decrease opioid doses by the second postoperative day
c.
Assessing for signs that the patient is becoming addicted to the opioid
d.
Educating the patient about how analgesics improve postoperative activity level
e.
Emphasizing that the risk of opioid side effects increases over time

Correct Answer: A, D
Rationale: Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need decreasing amount of opioids by the second postoperative day, each patient's response is individual. Although tolerance may occur, addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects.

Cognitive Level: Application Text Reference: pp. 138, 142
Nursing Process: Implementation NCLEX: Physiological Integrity

1. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumors
a. do not cause damage to adjacent tissue.
b. do not spread to other tissues and organs.
c. are simply an overgrowth of normal cells.
d. frequently recur in the same site.

B
Rationale: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. Both types of tumors may cause damage to adjacent tissues. The cells differ from normal in both benign and malignant tumors. Benign tumors usually do not recur.

Cognitive Level: Comprehension Text Reference: pp. 274-275
Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient who has been told by the health care provider that the cells in a bowel tumor are poorly differentiated asks the nurse what is meant by "poorly differentiated." Which response should the nurse make?
a. "The cells in your tumor do not look very different from normal bowel cells."
b. "The tumor cells have DNA that is different from your normal bowel cells."
c. "Your tumor cells look more like immature fetal cells than normal bowel cells."
d. "The cells in your tumor have mutated from the normal bowel cells."

C
Rationale: An undifferentiated cell has an appearance more like a stem cell or fetal cell and less like the normal cells of the organ or tissue. The DNA in cancer cells is always different from normal cells, whether the cancer cells are well differentiated or not. All tumor cells are mutations form the normal cells of the tissue.

Cognitive Level: Application Text Reference: p. 274
Nursing Process: Implementation NCLEX: Physiological Integrity

3. A patient who smokes tells the nurse, "I want to have a yearly chest x-ray so that if I get cancer, it will be detected early." Which response by the nurse is most appropriate?
a. "Chest x-rays do not detect cancer until tumors are already at least a half-inch in size."
b. "Annual x-rays will increase your risk for cancer because of exposure to radiation."
c. "Insurance companies do not authorize yearly x-rays just to detect early lung cancer."
d. "Frequent x-rays damage the lungs and make them more susceptible to cancer."

A
Rationale: A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time. Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk. Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray. A yearly x-ray is not a risk factor for lung cancer.

Cognitive Level: Application Text Reference: p. 276
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

4. In teaching about cancer prevention to a community group, the nurse stresses promotion of exercise, normal body weight, and low-fat diet because
a. most people are willing to make these changes to avoid cancer.
b. dietary fat and obesity promote growth of many types of cancer.
c. people who exercise and eat healthy will make other lifestyle changes.
d. obesity and lack of exercise cause cancer in susceptible people.

B
Rationale: Obesity and dietary fat promote the growth of malignant cells, and decreasing these risk factors can reduce the chance of cancer development. Many people are not willing to make these changes. Good diet and exercise habits are not a guarantee that other healthy lifestyle changes will then occur. Obesity and lack of exercise do not cause cancer, but they promote the growth of altered cells.

Cognitive Level: Application Text Reference: p. 276
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

5. During a routine health examination, a 30-year-old patient tells the nurse about a family history of colon cancer. The nurse will plan to
a. teach the patient about the need for a colonoscopy at age 50.
b. ask the patient to bring in a stool specimen to test for occult blood.
c. schedule a sigmoidoscopy to provide baseline data about the patient.
d. have the patient ask the doctor about specific tests for colon cancer.

D
Rationale: The patient is at increased risk and should talk with the health care provider about needed tests, which will depend on factors such as the exact type of family history and any current symptoms. Colonoscopy at age 50 is used to screen for individuals without symptoms or increased risk, but earlier testing may be needed for this patient because of family history. For fecal occult blood testing, patients use a take-home multiple sample method rather than bring one specimen to the clinic. The health care provider will take multiple factors into consideration before determining whether a sigmoidoscopy is needed at age 30.

Cognitive Level: Application Text Reference: pp. 276, 282
Nursing Process: Planning NCLEX: Physiological Integrity

6. When reviewing the chart for a patient with cervical cancer, the nurse notes that the cancer is staged as Tis, N0, M0. The nurse will teach the patient that
a. the cancer cells are well-differentiated.
b. it is difficult to determine the original site of the cervical cancer.
c. further testing is needed to determine the spread of the cancer.
d. the cancer is localized to the cervix.

D
Rationale: Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.

Cognitive Level: Application Text Reference: p. 280
Nursing Process: Implementation NCLEX: Physiological Integrity

7. Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the patient understands the purpose of a biopsy?
a. "The biopsy will tell the doctor whether the cancer has spread to my other organs."
b. "The biopsy will help the doctor decide what treatment to use for my enlarged prostate."
c. "The biopsy will determine how much longer I have to live."
d. "The biopsy will indicate the effect of the cancer on my life."

B
Rationale: A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. Biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life; the three remaining statements indicate a need for patient teaching.

Cognitive Level: Application Text Reference: p. 283
Nursing Process: Evaluation NCLEX: Physiological Integrity

8. The nurse is teaching a postmenopausal patient with breast cancer about the expected outcomes of her cancer treatment. The nurse evaluates that the teaching has been effective when the patient says
a. "After cancer has not recurred for 5 years, it is considered cured."
b. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured."
c. "Cancer is considered cured if the entire tumor is surgically removed."
d. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."

B
Rationale: The risk of recurrence varies by the type of cancer; for breast cancer in postmenopausal women, the patient needs at least 20 disease-free years to be considered cured. Some cancers (e.g., leukemia) are cured by nonsurgical therapies such as radiation and chemotherapy.

Cognitive Level: Application Text Reference: p. 284
Nursing Process: Evaluation NCLEX: Physiological Integrity

9. A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. The nurse explains that the expected outcome of this surgery is
a. control of the tumor growth by removal of malignant tissue.
b. promotion of better nutrition by relieving the pressure in the stomach.
c. relief of pain by cutting sensory nerves in the stomach.
d. reduction of the tumor burden to enhance adjuvant therapy.

D
Rationale: A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.

Cognitive Level: Application Text Reference: p. 285
Nursing Process: Implementation NCLEX: Physiological Integrity

10. External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient that an important measure to prevent complications from the effects of the radiation is to
a. test all stools for the presence of blood.
b. inspect the mouth and throat daily for the appearance of thrush.
c. perform perianal care with sitz baths and meticulous cleaning.
d. maintain a high-residue, high-fat diet.

C
Rationale: Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.

Cognitive Level: Application Text Reference: pp. 297-298
Nursing Process: Planning NCLEX: Physiological Integrity

11. Which action by a nursing assistant (NA) caring for a patient with a temporary radioactive cervical implant indicates that the RN should intervene?
a. The NA places the patient's bedding in the laundry container in the hallway.
b. The NA flushes the toilet once after emptying the patient's bedpan.
c. The NA stands by the patient's bed for an hour talking with the patient.
d. The NA gives the patient an alcohol-containing mouthwash for oral care.

C
Rationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.

Cognitive Level: Application Text Reference: p. 294
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

12. A patient with Hodgkin's lymphoma is undergoing external radiation therapy on an outpatient basis. After 2 weeks of treatment, the patient tells the nurse, "I am so tired I can hardly get out of bed in the morning." An appropriate intervention for the nurse to plan with the patient is to
a. exercise vigorously when fatigue is not as noticeable.
b. consult with a psychiatrist for treatment of depression.
c. establish a time to take a short walk every day.
d. maintain bed rest until the treatment is completed.

C
Rationale: Walking programs are used to keep the patient active without excessive fatigue. Vigorous exercise when the patient is less tired may lead to increased fatigue. Fatigue is expected during treatment and is not an indication of depression. Bed rest will lead to weakness and other complications of immobility.

Cognitive Level: Application Text Reference: p. 297
Nursing Process: Planning NCLEX: Physiological Integrity

13. Which information obtained by the nurse about a patient with colon cancer who is scheduled for external radiation therapy to the abdomen indicates a need for patient teaching?
a. The patient swims a mile 5 days a week.
b. The patient eats frequently during the day.
c. The patient showers with Dove soap daily.
d. The patient has a history of dental caries.

A
Rationale: The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change the habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation.

Cognitive Level: Application Text Reference: p. 300
Nursing Process: Assessment NCLEX: Physiological Integrity

14. A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse knows that teaching about management of the skin reaction has been effective when the patient says
a. "I can use ice packs to relieve itching in the treatment area."
b. "I can buy a steroid cream to use on the itching area."
c. "I will expose the treatment area to a sun lamp daily."
d. "I will scrub the area with warm water to remove the scales."

B
Rationale: Steroid (over-the-counter [OTC] hydrocortisone) cream may be used to reduce itching in the area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.

Cognitive Level: Application Text Reference: pp. 299-300
Nursing Process: Evaluation NCLEX: Physiological Integrity

15. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to
a. teach about the importance of nutrition during treatment.
b. have the patient eat large meals when nausea is not present.
c. administer prescribed antiemetics 1 hour before the treatments.
d. offer dry crackers and carbonated fluids during chemotherapy.

C
Rationale: Treatment with antiemetics before chemotherapy may help to prevent anticipatory nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.

Cognitive Level: Application Text Reference: pp. 295, 297
Nursing Process: Planning NCLEX: Physiological Integrity

16. When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to
a. stop the infusion if swelling is observed at the site.
b. infuse the medication over a short period.
c. administer the chemotherapy through small-bore catheter.
d. hold the medication unless a central venous line is available.

A
Rationale: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication should generally be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.

Cognitive Level: Application Text Reference: pp. 286-288
Nursing Process: Implementation NCLEX: Physiological Integrity

17. A chemotherapeutic agent known to cause alopecia is prescribed for a patient. To maintain the patient's self-esteem, the nurse plans to
a. suggest that the patient limit social contacts until regrowth of the hair occurs.
b. encourage the patient to purchase a wig or hat and wear it once hair loss begins.
c. have the patient wash the hair gently with a mild shampoo to minimize hair loss.
d. inform the patient that hair loss will not be permanent and that the hair will grow back.

B
Rationale: The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem.

Cognitive Level: Application Text Reference: pp. 295, 300
Nursing Process: Planning NCLEX: Psychosocial Integrity

18. A patient with ovarian cancer tells the nurse, "I don't think my husband cares about me anymore. He rarely visits me." On one occasion when the husband was present, he told the nurse he just could not stand to see his wife so ill and never knew what to say to her. An appropriate nursing diagnosis in this situation is
a. compromised family coping related to disruption in lifestyle and role changes.
b. impaired home maintenance related to perceived role changes.
c. risk for caregiver role strain related to burdens of caregiving responsibilities.
d. interrupted family processes related to effect of illness on family members.

D
Rationale: The data indicate that this diagnosis is most appropriate because the family members are impacted differently by the patient's cancer diagnosis. There are no data to suggest a change in lifestyle or role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities.

Cognitive Level: Application Text Reference: pp. 309-310
Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

19. A patient receiving head and neck radiation and systemic chemotherapy has ulcerations over the oral mucosa and tongue and thick, ropey saliva. An appropriate intervention for the nurse to teach the patient is to
a. remove food debris from the teeth and oral mucosa with a stiff toothbrush.
b. use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth.
c. gargle and rinse the mouth several times a day with an antiseptic mouthwash.
d. rinse the mouth before and after each meal and at bedtime with a saline solution.

D
Rationale: The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended.

Cognitive Level: Application Text Reference: p. 298
Nursing Process: Implementation NCLEX: Physiological Integrity

20. A patient who is receiving interleukin-2 (IL-2) therapy (Proleukin) complains to the nurse about all of these symptoms. Which one is most important to report to the health care provider?
a. Generalized aches
b. Dyspnea
c. Decreased appetite
d. Insomnia

B
Rationale: Dyspnea may indicate capillary leak syndrome and pulmonary edema, which requires rapid treatment. The other symptoms are common with IL-2 therapy, and the nurse should teach the patient that these are common adverse effects that will resolve at the end of the therapy.

Cognitive Level: Application Text Reference: pp. 302-303
Nursing Process: Assessment NCLEX: Physiological Integrity

21. A 32-year-old male patient is to undergo radiation therapy to the pelvic area for Hodgkin's lymphoma. He expresses concern to the nurse about the effect of chemotherapy on his sexual function. The best response by the nurse to the patient's concerns is
a. "Radiation does not cause the problems with sexual functioning that occur with chemotherapy or surgical procedures used to treat cancer."
b. "It is possible you may have some changes in your sexual function, and you may want to consider pretreatment harvesting of sperm if you want children."
c. "The radiation will make you sterile, but your ability to have sexual intercourse will not be changed by the treatment."
d. "You may have some temporary impotence during the course of the radiation, but normal sexual function will return."

B
Rationale: The impact on sperm count and erectile function depends on the patient's pretreatment status and on the amount of exposure to radiation. The patient should consider sperm donation before radiation. Radiation (like chemotherapy or surgery) may affect both sexual function and fertility either temporarily or permanently.

Cognitive Level: Application Text Reference: p. 301
Nursing Process: Implementation NCLEX: Physiological Integrity

22. A 40-year-old divorced mother of four school-age children is hospitalized with metastatic cancer of the ovary. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. The most appropriate response by the nurse is
a. "Why don't we talk about the options you have for the care of your children?"
b. "Many patients with cancer live for a long time, so there is time to plan for your children."
c. "For now you need to concentrate on getting well, not worry about your children."
d. "Perhaps your ex-husband will take the children when you can't care for them."

A
Rationale: This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's ex-husband will take the children, more assessment information is needed before making plans.

Cognitive Level: Application Text Reference: pp. 281, 310
Nursing Process: Implementation NCLEX: Psychosocial Integrity

23. A patient who has terminal cancer of the liver and is cared for by family members at home tells the nurse, "I have intense pain most of the time now." The nurse recognizes that teaching regarding pain management has been effective when the patient
a. uses the ordered opioid pain medication whenever the pain is greater than 5 on a 10-point scale.
b. states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.
c. agrees to take the medications by the IV route to improve effectiveness.
d. takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.

D
Rationale: For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics may also be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route and the oral route is preferred.

Cognitive Level: Application Text Reference: p. 309
Nursing Process: Evaluation NCLEX: Physiological Integrity

24. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. The nurse teaches the patient that the purpose of therapy with this agent is to
a. protect normal kidney cells from the damaging effects of chemotherapy.
b. enhance the patient's immunologic response to tumor cells.
c. stimulate malignant cells in the resting phase to enter mitosis.
d. prevent the bone marrow depression caused by chemotherapy.

B
Rationale: IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.

Cognitive Level: Comprehension Text Reference: pp. 302-303
Nursing Process: Planning NCLEX: Physiological Integrity

25. The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient may indicate a need for a change in treatment?
a. "I have frequent muscle aches and pains."
b. "I rarely have the energy to get out of bed."
c. "I take acetaminophen (Tylenol) every 4 hours."
d. "I experience chills after I inject the interferon."

B
Rationale: Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use Tylenol every 4 hours.

Cognitive Level: Application Text Reference: p. 304
Nursing Process: Assessment NCLEX: Physiological Integrity

26. Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider?
a. Hemoglobin of 10 g/L
b. WBC count of 1700/µl
c. Platelets of 65,000/µl
d. Serum creatinine level of 1.2 mg/dl

B
Rationale: Neutropenia places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that white blood cell (WBC) growth factors such as filgrastim (Neupogen) are needed. The other laboratory data do not indicate any immediate life-threatening adverse effects of the chemotherapy.

Cognitive Level: Application Text Reference: p. 297
Nursing Process: Assessment NCLEX: Physiological Integrity

27. A bone marrow transplant is being considered for treatment of a patient with acute leukemia that has not responded to chemotherapy. In discussing the treatment with the patient, the nurse explains that
a. hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT).
b. the transplant of the donated cells is painful because of the nerves in the tissue lining the bone.
c. donor bone marrow cells are transplanted immediately after an infusion of chemotherapy.
d. the transplant procedure takes place in a sterile operating room to minimize the risk for infection.

A
Rationale: The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room required. The HSCT takes place 1 or 2 days after chemotherapy to prevent damage to the transplanted cells by the chemotherapy drugs.

Cognitive Level: Application Text Reference: p. 306
Nursing Process: Implementation NCLEX: Physiological Integrity

28. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
a. Fresh fruit salad
b. Orange sherbet
c. Strawberry yogurt
d. French fries

C
Rationale: Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. French fries are high in calories from fat but low in protein.

Cognitive Level: Application Text Reference: p. 306
Nursing Process: Evaluation NCLEX: Physiological Integrity

29. The nurse has identified the nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation in a patient with lung cancer who has had a 10% loss in weight. An appropriate nursing intervention that addresses the etiology of this problem is to
a. provide foods that are highly spiced to stimulate the taste buds.
b. avoid presenting foods for which the patient has a strong dislike.
c. add strained baby meats to foods such as soups and casseroles.
d. teach the patient to eat whatever is nutritious since food is tasteless.

B
Rationale: The patient will eat more if disliked foods are avoided and foods that patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. Patients will not improve intake by eating foods that are beneficial but have unpleasant taste.

Cognitive Level: Application Text Reference: p. 307
Nursing Process: Planning NCLEX: Physiological Integrity

30. After the nurse has explained the purpose of and schedule for chemotherapy to a 23-year-old patient who recently received a diagnosis of acute leukemia, the patient asks the nurse to repeat the information. Based on this assessment, which nursing diagnosis is most likely for the patient?
a. Acute confusion related to infiltration of leukemia cells into the central nervous system
b. Knowledge deficit: chemotherapy related to a lack of interest in learning about treatment
c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis
d. Risk for ineffective adherence to treatment related to denial of need for chemotherapy

C
Rationale: The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors.

Cognitive Level: Application Text Reference: p. 281
Nursing Process: Diagnosis NCLEX: Physiological Integrity

31. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the RN caring for the patient indicates that the nurse should take action?
a. The patient's visitors bring in some fresh peaches from home.
b. The patient ambulates several times a day in the room.
c. The patient uses soap and shampoo to shower every other day.
d. The patient cleans with a warm washcloth after having a stool.

A
Rationale: Fresh, thinned-skin peaches are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help to prevent perineal skin breakdown and infection.

Cognitive Level: Application
Text Reference: p. 307, Neutropenic Diet, and Precautions to Minimize Risks from Neutropenia tables on Evolve website
Nursing Process: Evaluation NCLEX: Physiological Integrity

32. Which action by a nursing assistant (NA) when caring for a patient who is pancytopenic indicates a need for the nurse to intervene?
a. The NA assists the patient to use dental floss after eating.
b. The NA makes an oral rinse using 1 teaspoon of salt in a liter of water.
c. The NA adds baking soda to the patient's saline oral rinses.
d. The NA puts fluoride toothpaste on the patient's toothbrush.

A
Rationale: Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient.

Cognitive Level: Application
Text Reference: p. 298, Precautions to Minimize Risks from Neutropenia table on Evolve website
Nursing Process: Implementation NCLEX: Physiological Integrity

33. A with tumor lysis syndrome (TLS) is taking allopurinol (Xyloprim). Which laboratory value should the nurse monitor to determine the effectiveness of the medication?
a. Blood urea nitrogen (BUN)
b. Serum phosphate
c. Serum potassium
d. Uric acid level

D
Rationale: Allopurinol is used to decrease uric acid levels. BUN, potassium, and phosphate levels are also increased in TLS but are not affected by allopurinol therapy.

Cognitive Level: Application Text Reference: p. 308
Nursing Process: Evaluation NCLEX: Physiological Integrity

34. When assessing a patient's needs for psychologic support after the patient has been diagnosed with stage I cancer of the colon, which question by the nurse will provide the most information?
a. "Can you tell me what has been helpful to you in the past when coping with stressful events?"
b. "How long ago were you diagnosed with this cancer?"
c. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"
d. "How do you feel about having a possibly terminal illness?"

A
Rationale: Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. The patient with stage I cancer is not considered to have a terminal illness at this time, and this question is likely to worry the patient unnecessarily.

Cognitive Level: Application Text Reference: p. 310
Nursing Process: Assessment NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in patient teaching about cancer? (Select all that apply.)
a. Alcohol use
b. Physical activity
c. Body weight
d. Colorectal screening
e. Tobacco use
f. Mammography
g. Pap testing
h. Sunscreen use

D, F, G, H
Rationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.

Cognitive Level: Application Text Reference: p. 282
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

In a patient with a disease that affects the myelin sheath of the nerves such as multiple sclerosis, the glial cells affected are the

a.microglia
b.astrocytes
c.ependymal cells
d.oligodendrocytes

D

Drugs or diseases the impair the function of the extrapyramidal system may cause loss of

a. sensations of pain and temperature
b. regulation of the autonomic nervous system
c. integration of somatic and special sensory inputs
d. automatic movements associated with skeletal muscle activity

D

An obstruction of the anterior cerebral arteries will affect functions of

a. visual imaging
b. balance and coordination
c. judgment, insight, and reasoning
d. visual and auditory integration for language comprehension

C

Paralysis of lateral gaze indicates a lesion of cranial nerve

a. II
b. III
c. IV
d.VI

D

A result of stimulation of the parasympathetic nervous system is (select all that apply)

a. constriction of the bronchi
b. dilation of skin blood vessels
c. increased secretion of insulin
d. increased blood glucose levels
e. relation of the urinary sphincters

A,B,C,E

Assessment of muscle strength of older adults cannot be compared with that of younger adults because

a. stroke is more common in older adults
b. nutritional status is better in young adults
c. most young people exercise more than older people
d. aging leads to a decrease in muscle bulk and strength

D

Data regarding mobility, strength, coordination, and activity tolerance are important for the nurse to obtain because

a. many neurologic diseases affect one or more of these areas
b. patients are less able to identify other neurologic impairments
c. these are the first functions to be affected by neurologic disease
d. aspects of movement are the most important function of the nervous system

A

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for

a. position sense
b. patellar reflexes
c. temperature perception
d. heel-to-shin movements

C

A patient's eyes jerk while the patient looks to the left. You will record this finding as

a.nystagmus
b. CN VI palsy
c. oculocephalia
d. ophthalmic dyskinesia

A

The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should

a. ensure the patient has an empty bladder
b. instruct the patient that there is no risk of electric shock
c. ensure the patient has no metallic jewelry or metal fragments
d. instruct the patient that she or he may experience pain during the study

B

Vasogenic cerebral edema increases intracranial pressure by

a. shifting fluid in the gray matter
b. altering the endothelial lining of cerebral capillaries
c. leaking molecules from the intracellular fluid to the capillaries

B

A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects

a. a severe decrease in cerebral perfusion pressure
b. an alteration in the production of cerebrospinal fluid
c. the loss of autoregulatory control of intracranial pressure.
d. a normal balance between brain tissue, blood, and cerebrospinal fluid

D

The nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to

a. keep the head of the bed flat
b. elevate the head of the bed to 30 degrees
c. maintain patient of the left side with the head supported on a pillow
d. use a continuous rotation bed to continuously change patient position

B

The nurse is alerted to a possible acute subdural hematoma in the patient who

a. has a linear skull fracture crossing a major artery
b. has focal symptoms of brain damage with no recollection of a head injury
c. develops decreased level of consciousness and a headache within 48 hours of a head injury
d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness

C

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for

a. patency of airway
b. presence of a neck injury
c. neurologic status with the glasgow coma scale
d. cerebrospinal fluid leakage from the ears or nose

A

A patient is suspected of havbiong a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the

a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe

A

Nursing management of a patient with a brain tumor includes (select all that apply)

a. discussing with the patient methods to control inappropriate behavior
b. using diversion techniques to keep the patient stimulated and motivated
c. assisting and supporting the family in understanding any changes in behavior
d. limiting self-care activities until the patient has regained maximum physical functioning
e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs

C,E

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?

a. patient with a skull fracture whose nose is bleeding
b. elderly patient with a stroke who is confused and whose daughter is present
c. patient with meningitis who is suddenly agitated and reporting a headache of 10 on a zero to ten scale
d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

C

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is

a. administering codeine for relief of head and neck pain
b. controlling fever with prescribed drugs and cooling techniques
c. keeping the room darkened and quite to minimize environmental stimulation
d. maintaining the patient on strict bed rest with the head of the bed slightly elevated

B

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is

a. an obese 45 year old native american
b. a 35 year old asian american woman who smokes
c. a 32 year old white woman taking oral contraceptives
d. a 65 years old African American man with hypertension

D

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the
a. amount of cardiac output
b. oxygen content of the blood
c. degree of collateral circulation
d. level of carbon dioxide in the blood

C

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes

a. sensory disturbance
b. a history of hypertension
c. presence of motor weakness
d. sudden onset of severe headache

D

A patient with right sided hemiplegia and asphasia resulting from a stroke most likely has involvement of the

a. brainstem
b. vertebral artery
c. left middle cerebral artery
d. right middle cerebral artery

C

The nurse explains to the patient with a stroke who is scheduled for aniography that this test is used to determine

a. presence of increased ICP
b. site and size of the infarction
c. patency of the cerebral blood vessels
d. presence of blood in the cerebrospinal fluid

C

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to

a. decreased cerebral edema
b. reduce the brain damage that occurs during a stroke in evolution
c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow
d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation

C

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is

a. time of the patient's last meal
b. time at which stroke symptoms first appeared
c. patient's hypertension history and management
d. family history of stroke and other cardiovascular diseases

B

Bladder training in a male patient who has urinary incontinence after a stroke includes

a. limiting fluid intake
b. keeping a urinal in place at all times
c. assisting the patient to stand to void
d. catherizing the patient every four hours

C

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply)

a. depression
b. disassociation
c. intellectualization
d. sleep disturbances
e. denial of the severity of the stroke

A,D,E

A 50 year old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his eye seems to swell and get teary when these headaches occur. Based on this history you suspect that he has

a. cluster headaches
b. tension headaches
c. migraine headaches
d. medication overuse headaches

A

A 65 year old woman was just diagnosed with parkinson's disease. The priority nursing intervention is

a. searching the internet for educational videos
b. evaluating the home for environmental safety
c. promoting physical exercise and a well balanced diet
d. designing an exercise program to strengthen and stretch specific muscles

C

The nurse assesses that a n 87 year old woman with alzheimers disease is continually rubbing, flexing, and kicking out her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to

a. ask the physician for a daytime sedative for the patient
b. request soft restraints to prevent her from falling out of her bed
c. ask the physician for a nighttime sleep medication for the patient
d. assess the patient more closely, suspecting a disorder such as restless leg syndrome

D

Social effects of a chronic neurologic disease include (select all that apply)

a. divorce
b. job loss
c. depression
d. role changes
e. loss of self esteem

A,B,C,D,E

One major goal of treatment for a patient with huntingtons disease is

a. disease cure
b. symptomatic relief
c. maintaining employment
d. improving muscle strength

B

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply)

a. inspect all aspects of the mouth and teeth
b. assess the gag reflex and respiratory rate and depth
c. lightly palpate the affected side of the face for edema
d. test for temperature and sensation perception n the face
e. ask the patient to describe factors that initiate an episode

A,D,E

During routine assessment of a patient with guillain-barre syndrome, the nurse finds the patient to be short of breath. The patient's respiratory distress is caused by

a. elevated protein levels in the CSF
b. immobility resulting from ascending paralysis
c. degeneration of motor neurons in the brainstem and spinal cord
d. paralysis ascending to the nerves that stimulate the thoracic area

D

A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with brown-sequard syndrome. On physical examination, the nurse would most likely find

a. upper extremity weakness only
b. complete motor and sensory loss below C7
c. loss of position sense and vibration in both lower extremities
d.ipsilateral motor loss and contralateral sensory loss below C7

D

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49 mm Hg, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by

a. increased vasomotor tone after injury
b. a temporary loss of sensation and flaccid paralysis below the level of injury
c.loss of parasympathetic nervous system innervation resulting in vasoconstriction
d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D

Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply)

a. stand erect with leg brace
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from wheelchair

B,C,D,E

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he as had a bad headache and nausea. The initial action of the nurse is to

a. call the physician
b. check the patient's temperature
c. take the patient's blood pressure
d. elevate the head of the bed to 90 degrees

C

For a 65 year old woman who has lived with a T1 spinal cord injury for 20 years, which of the following health teaching instructions should the nurse emphasize?

a. a mammogram needed every year
b. bladder function tends to improve with age
c. heart disease is not common in persons with spinal cord injury
d. as a person ages the need to change body position is less important

A

The most common early symptom of a spinal cord tumor is

a. urinary incontinence
b. back pain that worsens with activity
c. paralysis below the level of involvement
d. impaired sensation of pain, temperature, and light touch

B

The bone cells that function in the resorption and formation of bone tissue are called (select all that apply)

a. osteoids
b. osteocytes
c. osteoblasts
d. osteoclasts

C,D

While performing passive pange of motion for a patient, the nurse puts a synovial joint through the movements of

a. inversion and eversion
b. pronation and supination
c. flexion, extension, abduction, and adduction
d, flexion, extension, rotation, and circumduction

C

To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform

a. flexion contractions
b. tetanic contractions
c. isotonic contractions
d. isometric contractions

D

A patient with bursitis of the should asks what the bursa does. The nurse's response is based on the knowledge that bursae.

a. connect bone to muscle
b. provide strength to muscle
c. lubricate joints with synovial fluid
d. relieve friction between moving parts

D

The increased risk for falls in the older adult is most likely due to

a. changes in balance
b. decreased in bone mass
c. loss of ligament elasticity
d. erosion of articular cartilage

A

While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as

a. hemophilia
b. hypertension
c. thyroid problems
d. pulmonary disease

A

When grading muscle strength, the nurse records a score of 1, which indicates

a. no detection of muscular contraction
b. a barely detectable flicker of contraction
c. active movement against gravity with some resistance
d. active movement against full resistance without fatigue

B

A normal assessment finding of the musculoskeletal system is

a. muscle and bone strength of 4
b. ulnar deviation and subluxation
c. angulation of bone toward midline
d. no tenderness with spine palpation

D

A patient is scheduled for an arthrocentesis. The nurse explains that this diagnostic test involves

a. incision or puncture of the joint capsule
b. measurement of heat from muscle contractions
c. administration of a radioisotope before the procedure
d. placement of skin electrodes to record muscle activity

A

The nurse suspects an ankle sprain when a patient at the urgent care center relates

a. being hit by another soccer player during a game
b. having ankle pain after sprinting around the track
c. dropping a 10 pound weight on his lower leg at the health center
d. twisting his ankle while running bases during a baseball game

D

The nurse explains to a patient with a distal tibial fracture who is returning for a three week checkup that healing is indicated by
a. formation of callus
b. complete bony union
c. hematoma at fracture site
d. presence of granulation tissue

A

A patient with a comminuted fracture of the femur is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when
a. the patient is unable to tolerate prolonged immobilization
b. the patient cannot tolerate the surgery of a closed reduction
c. a temporary cast would be too unstable to provide normal motility
d. adequate alignment cannot be obtained by other nonsurgical methods

D

An indication of a neurovascular problem noted during assessment of the patient with a fracture is
a. exaggeration of strength with movement
b. increased redness and heat below the injury
c.decreased sensation distal to the fracture site
d. purulent drainage at the site of an open fracture

C

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences
a. increasing edema of the limb
b. muscle spasms of the lower arm
c. rebounding pulse at the fracture site
d. pain when passively extending the fingers

D

A patient with a fracture of the pelvis should be monitored for
a. changes in urinary output
b. petechiae on the abdomen
c. a palpable lump in the buttock
d. sudden decrease in blood pressure

A

During the postoperative period, the nurse instructs the patient with an above the knee amputation that the residual limb should not be routinely elevated because this position promotes
a. hip flexion contractures
b. skin irritation and breakdown
c. clot formation at the incision site
d. increased risk of wound dehiscence

A

A patient with rheumatoid arthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply)
a. fuse the joint
b. replace the joint
c. prevent further damage
d. improve or maintain ROM
e. decrease the amount of destruction in the joint

B,D

In teaching a patient scheduled for a total ankle replacement it is important that the nurse tell the patient that after surgery he should avoid
a. lifting heavy objects
b. sleeping on the back
c. abduction exercises of the affected ankle
d. bearing weight on the affected leg for 6 weeks

D

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. In responding to the patient who asks why the beads are used, the nurse answers (select all that apply)

a. the beads are used to directly deliver antibiotics to the site of infection
b. there are no effective oral or IV antibiotics to treat most cases of bone infection
c. the beads are adjunct to debridement and oral and IV antibiotics for deep infections
d. The ischemia and bone death that occurs with osteomyelitis are impenetrable to IV antibiotics

A,C

A patient has been diagnosed with osteosarcoma of the femur. He shows an understanding of his treatment options when he states
a. I accept that I have to lose my leg with surgery
b. the chemotherapy before surgery will shrink the tumor
c. this tumor is related to the colon cancer I had 3 years ago
d. I'm glad they can take out the cancer with such a small scar

B

In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply)
a. bony ankylosis following inflammation of the joints
b. the deterioration of cartilage by proteolytic enzymes
c. the development of heberdens nodes in the joint capsule
d. increased cartilage and bony growth at the joint margins
e. invasion of pannus into the joint causing a loss of cartilage

A,E

Assessment data in the patient with osteoarthritis commonly include
a. gradual weight loss
b. elevated WBC count
c. joint pain that worsens with use
d. straw colored synovial fluid

C

Teach the patient with ankylosing spondylitis the importance of
a. regular exercise and maintaining proper posture
b. continuing with physical activity during flare ups
c. avoiding extremes in environmental temperatures
d. applying cool compresses for relief of local symptoms

A

When administering medications to the patient with gout, the nurse would recognize which of the following as a treatment for chronic disease?
a. colchicine
b. febuxostat
c. sulfasalazine
d. cyclosporine

B

See More

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording