1. DRILL 8
1. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe
headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would
be contraindicated in this client in which of the following circumstances?
A. Vomiting continues
B. Intracranial pressure (ICP) is increased
C. The client needs mechanical ventilation
D. Blood is anticipated in the cerebralspinal fluid (CSF)
2. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral
pupil. The physician orders mannitol for which of the following reasons?
A. To reduce intraocular pressure
B. To prevent acute tubular necrosis
C. To promote osmotic diuresis to decrease ICP
D. To draw water into the vascular system to increase blood pressure
3. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP).
Which of the following results would best show the mannitol was effective?
A. Urine output increases
B. Pupils are 8 mm and nonreactive
C. Systolic blood pressure remains at 150 mm Hg
D. BUN and creatinine levels return to normal
4. Which of the following values is considered normal for ICP?
A. 0 to 15 mm Hg
B. 25 mm Hg
C. 35 to 45 mm Hg
D. 120/80 mm Hg
5. Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?
A. Ataxia and confusion
B. Sodium depletion
C. Tonic-clonic seizure
D. Urinary incontinence
6. Which of the following signs and symptoms of increased ICP after head trauma would appear
B. Large amounts of very dilute urine
C. Restlessness and confusion
2. D. Widened pulse pressure
7. Problems with memory and learning would relate to which of the following lobes?
8. While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be
9. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use
which of the following to test the client’s peripheral response to pain?
A. Sternal rub
B. Pressure on the orbital rim
C. Squeezing the sternocleidomastoid muscle
D. Nail bed pressure
10. The client is having a lumbar puncture performed. The nurse would plan to place the client in
which position for the procedure?
A. Side-lying, with legs pulled up and head bent down onto the chest
B. Side-lying, with a pillow under the hip
C. Prone, in a slight Trendelenburg’s position
D. Prone, with a pillow under the abdomen.
11. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold
water is injected into the left auditory canal. The client exhibits eye conjugate movements toward
the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates
the client has:
A. A cerebral lesion
B. A temporal lesion
C. An intact brainstem
D. Brain death
3. 12. The nurse is caring for the client with increased intracranial pressure. The nurse would note
which of the following trends in vital signs if the ICP is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
13. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would
suspect the client is developing meningitis as a complication of surgery if the client exhibits:
A. A positive Brudzinski’s sign
B. A negative Kernig’s sign
C. Absence of nuchal rigidity
D. A Glascow Coma Scale score of 15
14. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds
based on the knowledge that the human body typically and automatically responds to pain first
with attempts to:
A. Tolerate the pain
B. Decrease the perception of pain
C. Escape the source of pain
D. Divert attention from the source of pain.
15. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the
following would be most appropriate to institute?
A. Limiting conversation with the child
B. Keeping extraneous noise to a minimum
C. Allowing the child to play in the bathtub
D. Performing treatments quickly
16. Which of the following would lead the nurse to suspect that a child with meningitis has developed
disseminated intravascular coagulation?
A. Hemorrhagic skin rash
D. Dyspnea on exertion
17. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses
would lead the nurse to suspect pneumococcal meningitis?
4. A. Bladder infection
B. Middle ear infection
C. Fractured clavicle
D. Septic arthritis
18. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is
obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which
of the following results would verify the diagnosis?
A. Cloudy CSF, decreased protein, and decreased glucose
B. Cloudy CSF, elevated protein, and decreased glucose
C. Clear CSF, elevated protein, and decreased glucose
D. Clear CSF, decreased pressure, and elevated protein
19. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of
transmission of this infection, which of the following would be included in the plan of care?
A. No precautions are required as long as antibiotics have been started
B. Maintain enteric precautions
C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
D. Maintain neutropenic precautions
20. A nurse is reviewing the record of a child with increased ICP and notes that the child has
exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to
note which of the following if this type of posturing was present?
A. Abnormal flexion of the upper extremities and extension of the lower extremities
B. Rigid extension and pronation of the arms and legs
C. Rigid pronation of all extremities
D. Flaccid paralysis of all extremities
21. Which of the following assessment data indicated nuchal rigidity?
A. Positive Kernig’s sign
B. Negative Brudzinski’s sign
C. Positive homan’s sign
D. Negative Kernig’s sign
22. Meningitis occurs as an extension of a variety of bacterial infections due to which of the following
A. Congenital anatomic abnormality of the meninges
B. Lack of acquired resistance to the various etiologic organisms
5. C. Occlusion or narrowing of the CSF pathway
D. Natural affinity of the CNS to certain pathogens
23. Which of the following pathologic processes is often associated with aseptic meningitis?
A. Ischemic infarction of cerebral tissue
B. Childhood diseases of viral causation such as mumps
C. Brain abscesses caused by a variety of pyogenic organisms
D. Cerebral ventricular irritation from a traumatic brain injury
24. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular
accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency
anemia. Which history finding is a risk factor for CVA?
a. Caucasian race
b. Female sex
d. Bronchial asthma
25. A male client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed.
b. Restrain the client’s arms and legs.
c. Place a tongue blade in the client’s mouth.
d. Take measures to prevent injury.
26. A female client with a suspected brain tumor is scheduled for computed tomography (CT).
What should the nurse do when preparing the client for this test?
a. Immobilize the neck before the client is moved onto a stretcher.
b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
c. Place a cap over the client’s head.
d. Administer a sedative as ordered.
27. During a routine physical examination to assess a male client’s deep tendon reflexes, the
nurse should make sure to:
a. use the pointed end of the reflex hammer when striking the Achilles tendon.
b. support the joint where the tendon is being tested.
c. tap the tendon slowly and softly
d. hold the reflex hammer tightly.
28. A female client is admitted in a disoriented and restless state after sustaining a concussion
during a car accident. Which nursing diagnosis takes highest priority in this client’s plan of
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
6. c. Impaired verbal communication
d. Risk for injury
29. For a male client with suspected increased intracranial pressure (ICP), a most appropriate
respiratory goal is to:
a. prevent respiratory alkalosis.
b. lower arterial pH.
c. promote carbon dioxide elimination.
d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
30. Nurse Maureen witnesses a neighbor’s husband sustain a fall from the roof of his house.
The nurse rushes to the victim and determines the need to opens the airway in this victim by
using which method?
a. Flexed position
b. Head tilt-chin lift
c. Jaw thrust maneuver
d. Modified head tilt-chin lift
31. The nurse is assessing the motor function of an unconscious male client. The nurse would
plan to use which plan to use which of the following to test the client’s peripheral response to
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle
32. A female client admitted to the hospital with a neurological problem asks the nurse whether
magnetic resonance imaging may be done. The nurse interprets that the client may be
ineligible for this diagnostic procedure based on the client’s history of:
b. Heart failure
c. Prosthetic valve replacement
d. Chronic obstructive pulmonary disorder
33. A male client is having a lumbar puncture performed. The nurse would plan to place the
client in which position?
a. Side-lying, with a pillow under the hip
b. Prone, with a pillow under the abdomen
c. Prone, in slight-Trendelenburg’s position
d. Side-lying, with the legs pulled up and head bent down onto chest.
34. The nurse is positioning the female client with increased intracranial pressure. Which of the
following positions would the nurse avoid?
a. Head mildline
b. Head turned to the side
7. c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees
35. A female client has clear fluid leaking from the nose following a basilar skull fracture. The
nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
36. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The
nurse would avoid which of the following measures to minimize the risk of recurrence?
a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower limbs
d. Limiting bladder catheterization to once every 12 hours
37. The nurse is caring for the male client who begins to experience seizure activity while in bed.
Which of the following actions by the nurse would be contraindicated?
a. Loosening restrictive clothing
b. Restraining the client’s limbs
c. Removing the pillow and raising padded side rails
d. Positioning the client to side, if possible, with the head flexed forward
38. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The
nurse plans care knowing that this condition:
a. The client has complete bilateral paralysis of the arms and legs.
b. The client has weakness on the right side of the body, including the face and tongue.
c. The client has lost the ability to move the right arm but is able to walk independently.
d. The client has lost the ability to move the right arm but is able to walk independently.
39. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated,
the nurse avoids doing which of the following?
a. Giving the client thin liquids
b. Thickening liquids to the consistency of oatmeal
c. Placing food on the unaffected side of the mouth
d. Allowing plenty of time for chewing and swallowing
40. The nurse is assessing the adaptation of the female client to changes in functional status
after a brain attack (stroke). The nurse assesses that the client is adapting most successfully
if the client:
a. Gets angry with family if they interrupt a task
b. Experiences bouts of depression and irritability
c. Has difficulty with using modified feeding utensils
d. Consistently uses adaptive equipment in dressing self
8. 41. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia.
Which of the following actions by the nurse would be least helpful to the client?
a. Speaking to the client at a slower rate
b. Allowing plenty of time for the client to respond
c. Completing the sentences that the client cannot finish
d. Looking directly at the client during attempts at speech
42. The nurse is teaching the female client with myasthenia gravis about the prevention of
myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done
a. Eating large, well-balanced meals
b. Doing muscle-strengthening exercises
c. Doing all chores early in the day while less fatigued
d. Taking medications on time to maintain therapeutic blood levels
43. A male client with Bell’s palsy asks the nurse what has caused this problem. The nurse’s
response is based on an understanding that the cause is:
a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia
c. Primary genetic in origin, triggered by exposure to meningitis
d. Primarily genetic in origin, triggered by exposure to neurotoxins
44. The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone
in the face and preventing denervation. The nurse determines that the client needs additional
information if the client states that he or she will:
a. Exposure to cold and drafts
b. Massage the face with a gentle upward motion
c. Perform facial exercises
d. Wrinkle the forehead, blow out the cheeks, and whistle
45. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse
would plan to do which of the following to ensure client to ensure client safety?
a. Speak loudly to the client
b. Test the temperature of the shower water
c. Check the temperature of the food on the delivery tray.
d. Provide a clear path for ambulation without obstacles
46. A female client has a neurological deficit involving the limbic system. Specific to this type of
deficit, the nurse would document which of the following information related to the client’s
a. Is disoriented to person, place, and time
b. Affect is flat, with periods of emotional lability
c. Cannot recall what was eaten for breakfast today
d. Demonstrate inability to add and subtract; does not know who is president
Situation 1 – Because of the serious consequences of severe burns, management requires a
9. multidisciplinary approach. You have important responsibilities as a nurse.
47. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burns into flames. The
most effective way to extinguish the flames with as little further damage as possible is to:
A. log roll on the grass/ground
B. slap the flames with his hands
C. remove the burning clothes
D. pour cold liquid over the flames
48. Once the flames are extinguished, it is most important to:
A. cover Sergio with a warm blanket
B. give him sips of water
C. calculate the extent of his burns
D. assess the Sergio’s breathing
49. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the
assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk,
right upper extremities and right lower extremities. His wife asks what that means? Your most
accurate response would be:
A. Structures beneath the skin are damage
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged
50. During the first 24 hours after the thermal injury, you should asses Sergio for:
A. hypokalemia and hypernatremia
B. hypokalemia and hyponatremia
C. hyperkalemia and hyponatremia
D. hyperkalemia and hypernatremia
51. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole
anterior chest and both upper extremities two days ago begins to exhibit extreme
restlessness. You recognize that this most likely indicates that Teddy is developing:
A. Cerebral hypoxia C. metabolic acidosis
B. Hypervolemia D. Renal failure
Situation 2 – You are now working as a staff nurse in a general hospital. You have to be prepared to
handle situations with ethico-legal and moral implifications.
52. You are in night duty in surgical ward. One of your patients Martin is a prisoner who
sustained an abdominal gunshot wound. He is being guarded by policeman from the local
police unit. During your rounds you heard a commotion. You saw the policeman trying to hit
Martin. You asked why he was trying to hit Martin. He denied the matter. Which among the
following activities will you do first?
A. Write an accident report
B. Call security officer and report the incident
C. Call your nurse supervisor and report the incident
D. Call the physician on duty
53. You are on morning duty in the medical ward. You have 10 patients assigned to you. During
your endorsement rounds, you found out that one of your patients was not in bed. The patient
10. next to him informed you that he went home without notifying the nurses. Which among the
following will you do first?
A. Make an incident report
B. Call security to report the incident
C. Wait for 2 hours before reporting
D. Report the incident to your supervisor
54. You are on duty in the medical ward. You were asked to check the narcotics cabinet. You
found out that what is on record does not tally with the drugs used. Which among the
following will you do first?
A. Write an incident report and refer the matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your supervisor
D. Find out from the endorsement any patient who might have been given narcotics
55. You are on duty in the medical ward. The mother of your patient who is also a nurse, came
running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.
A. Start basic life support measures
B. Call for the Code
C. Bring the crush cart to the room
D. Go to see Fiolo and assess for airway patency and breathing problems
56. You are admitting Jorge to the ward and you found out that he is positive for HIV. Which
among the following will you do first?
A. Take note of it and plan to endorse this to next shift
B. Keep this matter to yourself
C. Write an incident report
D. Report the matter to your head nurse
Situation 3 - Colorectal cancer can affect old and younger people. Surgical procedures and other
modes of treatment are done to ensure quality of life. You are assigned in the
cancer institute to care of patients with this type of cancer.
57. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After
taking the history and vital signs the physician does which test as a screening test for
A. Barium enema
B. Carcinoembryonic antigen
C. Annual digital rectal examination
58. To confirm his impression of colorectal cancer, Larry will require which diagnostic study?
A. Carcinoembryonic antigen
C. Stool hematologic test
D. Abdominal computed tomography (CT) test
59. The following are risk factors for colorectal cancer, EXCEPT:
A. Inflammatory bowels
B. High fat, high fiber diet
11. D. Genetic factors-familial adenomatous polyposis
60. Symptoms associated with cancer of the colon include:
A. constipation, ascites and mucus in the stool
B. diarrhea, heart burn and eructation
C. blood in the stools, anemia, and “pencil shaped” stools
D. anorexia, hematemesis, and increased peristalasis
61. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin
A. promote rest of the bowel by minimizing peristalsis
B. reduce the bacterial content of the colon
C. empty the bowel of solid waste
D. soften the stool by retaining water in the colon
Situation 4 – ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are
participating in the OSTOMY CARE CLASS.
62. You plan to teach Fermin how to irrigate the colostomy when:
A. The perineal wound heals And Fermin can sit comfortably on the commode
B. Fermin can lie on the side comfortably, about the 3
C. The abdominal incision is closed and contamination is no longer a danger
D. The stools starts to become formed, around the 7
63. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the
A. When Fermin would have normal bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After Fermin accepts alteration in body image
64. When observing a return demonstration of a colostomy irrigation, you know that more
teaching is required if Fermin:
A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when felling uncomfortable
65. You are aware that teaching about colostomy care is understood when Fermin states, “I will
contact my physician and report:
A. If I have any difficulty inserting the irrigating tub into the stoma.”
B. If I noticed a loss of sensation to touch in the stoma tissue.”
C. The expulsion of flatus while the irrigating fluid is running out.”
D. When mucus is passed from the stoma between the irrigations.”