Miami Regional University, MiamiMEDSURGE NUR1200Med Surge 2 Midterm 1
Med-Surg 2 Mid-term
1. Which area of the alimentary canal is the most commonly
... [Show More] affected by Crohn’s disease?
a. Descending colon
b. Ascending colon
c. Terminal ileum
d. Sigmoid colon
Answer: C
2. A client taking the prescribed dose of phenytoin to control seizures. Results of a
phenytoin blood level study reveal a level of 18 mcg/mL. Which finding would be
expected as a result of this laboratory result?
a. Hypotension
b. Slurred speech
c. No abnormal finding
d. Tachycardia
Answer: C
Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20
mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than
30 mcg/mL, ataxia and slurred speech occur
3. Which of the following dietary measures would be useful in preventing esophageal
reflux?
a. Eating small, frequent meals
b. Increasing fluid intake with meals
c. Adding a bedtime snack to the dietary plan
d. Include milk with meals
Answer: A
Rationale: Esophageal reflux worsens when the stomach is overdistended with food.
Therefore, an important measure is to eat small, frequent meals. Fluid intake should be
decreased during meals to reduce abdominal distention. Milk does not prevent
esophageal reflux. Food intake in the evening should be strictly limited to reduce the
incidence of nighttime reflux, so bedtime snacks are not recommended.
4. The nurse is caring for a patient admitted with acute diverticulitis who responded well to
the antibiotic therapy and the inflammation subsided. Prior to discharge the nurse should
instruct the patient to increase which of the following foods in the diet?
a. Oatmeal, barley, whole wheat flakes
b. Tomatoes, peas, corn
c. Cucumbers, popcorn, figs
d. Peas, blackberries, okraAnswer: A
Rationale: During diverticulitis the client consumes a clear liquid diet without fiber.
After the resolution of diverticulitis the client returns to a high fiber diet without food
with seed or cellulose skin.
5. A client is diagnosed with Intracranial Pressure. Nursing interventions include:
a. Avoid: straining, cough, seizures, fever, opioids
b. All other options are correct
c. Head elevated, neck in neutral position
d. Avoid elevation of legs or flexion of the hips
Answer: B
6. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite,
and is having trouble sleeping. What is the priority nursing problem for this client?
a. Disturbed though processes
b. Risk for injury and safety
c. Altered sleep pattern
d. Imbalanced nutrition: less than required
Answer: B
Rationale: Safety is the priority nursing problem because clients with dementia are not
cognitively aware of potential dangers
7. To help prevent aspiration while feeding a patient who has a right-sided paralysis, the
nurse includes which interventions? (Select all that apply)
a. Avoid mixing foods with different textures
b. Place the patient in high Fowler’s position
c. Place food in the left side of the mouth
d. Instruct the patient to tilt the head and neck forward
e. Instruct the patient to drink liquids through a straw
Answer: A,B,C,D
Rationale: Drinking through a straw rather than sipping from a cup increases the risk
for aspiration. All other options will reduce the risk of aspiration in a stroke victim8. Nursing interventions related to Lumbar puncture are all except:
a. Keep the patient in NPO before the procedure
b. No Aspirin, clopidogrel or anticoagulants
c. Empty bladder before the procedure
d. Keep the patient in flat rest several hours after lumbar puncture
Answer: A
Rationale: Nursing interventions for lumbar puncture:
-No need for NPO
-Empty bladder
-R/O ICP
-NO: ASA, clopidogrel or anticoagulants
-Position Post procedure: Flat rest for several hours
9. Following a supratentorial craniotomy to relieve increased intracranial pressure (ICP),
the nurse will implement which intervention?
a. Place drip to absorb cerebrospinal fluid drainage from the nose or ears
b. Decrease frequency of deep breath and cough to every 4 hours
c. Elevate the head of the bed 30 to 45 degrees
d. Keep the patient stimulated to better assess changing level consciousness
Answer: C
Rationale: The head of bed is elevated to aid in reduction of ICP. Drip pads, patient
stimulation, and changing positions frequently may increase ICP.
10. The nurse is assigned to care for a patient with achalasia. The nurse understands that the
patient is likely to have which of the following clinical manifestations related to this
diagnosis?
a. Silent abdomen and lower quad pain
b. Dysphagia and chest pain
c. Frequent nausea and diarrhea
d. Slow peristalsis and constipation
Answer: B
11. A client with which of the following conditions may be likely to develop colo-rectal
cancer?
a. Adenomatous polyps
b. Peptic ulcer disease
c. Hemorrhoidsd. Diverticulitis
Answer: A
12. Risk factors for colon cancer includes all except:
a. High fiber diet
b. Ulcerative colitis/Crohn’s disease
c. Age older than 50 years
d. Family history first degree
Answer: A
13. A child seizure disorder has been prescribed carbamazepine. The child is being
discharged home with the parent. Which statement made by the parent shows that
discharge teaching was effective?
a. “I will reduce the dose if my child becomes too sleepy with this drug.”
b. “I will not allow my child to go swimming at any moment.”
c. “I will place padded tongue blades in the bedroom and kitchen.”
d. “I will call if my child presents sore throat or mouth ulcers.”
Answer: D
Rationale: Carbamazepine can produce leukopenia which manifests with sore throat and
mouth ulcer. Blood testing (CBC) and medical attention are required.
14. The nurse is caring for an infant with a tentative diagnosis of pyloric stenosis. The nurse
would anticipate what test to be done to confirm this diagnosis?
a. Hemoconcentration with increased sodium and potassium
b. Barium swallow (upper GI series)
c. Anterior and lateral x-ray of the abdomen
d. A colonoscopy with biopsy
Answer: B
Rationale: Upper GI series with barium demonstrate the pyloric stenosis and
obstruction
15. A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and
melena. He complains of feeling weak and dizzy. He needs to urinate and move his
bowels. The nurse should intervene by:
a. Asking a male UAP to transfer him to BR for privacy
b. Transferring him to BR in a wheelchair
c. Helping him to bed side commoded. Offering him the bedpan and the urinal
Answer: D
Rationale: The client is weak and presenting symptoms of orthostatic hypotension. The
client should not be allowed to get out of bed because of risk of falling
16. A patient is admitted to the Emergency Department with a large brain tumor is
presenting with Cushing’s triad. A nurse would expect to find which of the following
manifestations? (Select all that apply)
a. Tachypnea
b. Widening pulse pressure
c. Diastolic hypertension
d. Hyperreflexia
e. Systolic hypertension
f. Bradycardia
Answer: B,E,F
17. Which of the following definitions best describes diverticulosis?
a. The partial impairment of the forward flow of intestinal contents
b. An abnormal protrusion of the mucosa in the intestinal lumen
c. An inflamed outpouching of the intestine
d. A non-inflamed outpouching of the intestine
Answer: D
Rationale: Diverticulosis are non inflamed outpouching of the intestine, more frequent
localized in the left side of colon
18. A nurse is assisting a health care provider (HCP) with an assessment of a child with a
diagnosis of suspected appendicitis. In assessing the intensity and progression of the
pain, the health care provider palpates the child at McBurney’s point. The nurse
understands that McBurney’s point is located midway between the:
a. Left anterior superior iliac spine and the umbilicus
b. Left anterior inferior iliac spine and the umbilicus
c. Right posterior inferior iliac spine and the umbilicus
d. Right anterior superior iliac spine and the umbilicus
Answer: D
Rationale: McBurney’s point is midway between the right anterior superior iliac spine
and the umbilicus. It is usually the location of greatest pain in the child with appendicitis19. The nurse is providing postoperative teaching to a patient with transient ischemic attack
(TIA). Which of the following teaching points should the nurse be certain to include in
teaching?
a. The patient will need to have assistance at home for a while.
b. TIAs are a significant warning sign of impending stroke.
c. Rehabilitative therapy may be required for up to 2 months.
d. The patient may need to move to an assisted living facility.
Answer: B
20. Transient ischemic attack (TIA) includes all except:
a. Diplopia
b. Ataxia/vertigo
c. Dysarthria/aphasia
d. Other permanent focal neurologic dysfunction
Answer: D
Rationale: Symptoms of TIA includes:
Amaurosis fugax (retinal ischemia: belief episode of blindness in one eye)
Diplopia
Dysarthria/aphasia
Sensory and/or motor deficits
Ataxia/vertigo
21. The nurse is reviewing the medication record of a client with acute gastritis. Which
medication, if noted on the client’s record, would the nurse question?
a. Indomethacin (NSAID)
b. Digoxin
c. Propranolol hydrochloride
d. Furosemide
Answer: A
22. If a patient’s gastrointestinal tract is functioning but he/she is unable of swallowing
foods by mouth, the preferred method of feeding is:
a. Total parenteral nutrition
b. Peripheral parenteral nutrition
c. Enteral nutrition
d. Oral liquid supplements
Answer: C
Rationale: Enteral nutrition through nasogastric or PEG tube, or by jejunostomy are
alternative to patients with dysphagia but functional enteral tract23. A client begins to experience a tonic-clonic seizure. The nurse takes which of the
following actions? Select all that apply.
a. Loosen any restrictive clothing that the client is wearing
b. Maintain the client’s airway permeable
c. Place a padded tongue blade into the client’s mouth
d. Observe the client’s movement and behaviors and document them
e. Turn the client to the side immediately after the seizure subsides
f. Restrain the client’s movements to avoid hitting the furniture
Answer: A,B,D,E
Rationale: Precautions are taken a client from sustaining injury during a seizure. The
nurse would maintain the client’s airway and turn the client to the side. The nurse would
also protect the client from injury, guide the client’s movements, and loosen any
restrictive clothing. Restraints are never used because they could injure the client during
the seizure. A padded tongue blade or any other object is never placed into the client’s
mouth after a seizure begins because the jaw may clench down.
24. After a head injury, the nurse is assessing the client and notes that he keeps wiping his
nose. There is clear nasal drainage on the tissue. What is an appropriate nursing action?
a. Ask the client if he has allergies and routinely takes medications
b. Obtain a glucose test strip and check for glucose
c. Send the nasal drainage specimen to the laboratory for culture and sensitivity
d. Check the nasal tissue and look for a halo or ring sign
Answer: B
Rationale: Rhinorrhea (CSF leakage) from the nose is indicative of a tear in the dura.
When this occurs, then CSF will be present and can be determined by checking for
glucose using a Dextrostik or Tes-Tape. When blood is in the CSF, then checking for a
halo or ring is performed; blood will coalesce in the center of the 4x4 gauze pad and be
encircled by a yellowish ring if CSF is present. In this question, fluid is clear, which
makes option 2 a better response. No signs of infection exist, which means a culture and
sensitivity are not indicated
25. During your discharge teaching to a patient with multiple sclerosis, you educate the
patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid
all these triggers factors except:
a. Overexertion
b. Salt
c. Hot temperaturesd. Stress
Answer: B
26. The nurse is assessing a client who describes “stomach discomfort.” The most
appropriate sequence for conducting the physical examination of the abdomen is
a. Inspection, percussion, auscultation, palpation
b. Auscultation, percussion, palpation, inspection
c. Inspection, auscultation, palpation, percussion
d. Inspection, auscultation, percussion, palpation
Answer: D
27. Which of the following symptoms is associated with ulcerative colitis?
a. Fistulas
b. Dumping syndrome
c. Rectal bleeding
d. Soft stools
Answer: C
Rationale: Symptoms is associated with ulcerative colitis
Malnutrition
Rectal bleeding
Risk for cancer
28. The nurse is providing discharge instructions to a client following gastrectomy. Which
measure will the nurse instruct the client to follow to assist in preventing dumping
syndrome?
a. Ambulate following a meal
b. Eat high-carbohydrate foods
c. Sit in a high-Fowlers position after meals
d. Limit the fluids taken with meals
Answer: D
Rationale: The nurse should instruct the client to decrease the amount of fluid taken at
meals and to avoid high carbohydrate foods including fluids such as fruit nectars; to
assume a low-Fowler’s position during meals; to lie down for 30 minutes after eating to
delay gastric emptying; and to take antispasmidocs as prescribed29. A client with myasthenia gravis is scheduled to have a edrophonium (Tensilon)
diagnostic test. In anticipation of complications regarding this medication the nurse
understands that the antidote is
a. Naloxone
b. Neostigmine
c. Atropine sulfate
d. Epinephrine
Answer: C
Rationale: The antidote for edrophonium (Tensilon) is an anticholinergic drug, such as
atropine. Edrophonium is used for diagnostic testing because of its rapid onset.
Neostigmine (Prostigmine) is another type of cholinesterase inhibitor and can be used to
perform the test as well. Atropine sulfate is an anticholinergic drug. Narcan (naloxone) is
an opioid antagonist and is used for the complete or partial reversal of opioid
depression, including respiratory depression, caused by medications such as treat
cardiac arrest and other cardiac dysrhythmias resulting in diminished or absent cardiac
output.
30. The nurse is providing treatment for a patient with hepatic encephalopathy. Which of the
following is the desired outcome of providing lactulose?
a. Frequent liquid diarrhea
b. Oriented to place and time
c. Reduced serum potassium levels
d. Tremor when extending fingers
Answer: B
Rationale: Improvement of level of consciousness means reduction of ammonia levels.
Lactulose is indicated to reduce ammonia levels.
31. Nursing interventions for patients with impaired Physical mobility and Self-Care Deficit
includes:
a. All other options are correct
b. Place extremities in functional positions
c. Prevention of pressure ulcers
d. Range-of-motion exercises for the involved extremities
Answer: A
32. The nurse monitors a client who experienced a head injury. Which of the following
nursing interventions are adequate in patients with intracranial pressure (ICP)? Select all
that apply
a. Avoid use of opioids
b. Avoid: straining, cough, seizures and fever
c. Avoid elevation of legs or flexion of the hipsd. Head elevated, neck in neutral position
e. Head flat, neck in right position
f. Elevate the legs and flexion the hips
Answer: A,B,C,D
33. Which of the following interventions should be included in the medical management of
Crohn’s disease?
a. Using long-term immunesuppressive therapy
b. Increasing oral intake of fiber
c. Administering laxatives
d. Increasing physical activity
Answer: A
34. A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain
attack (stroke) about measures to overcome the deficit. The nurse tells the client to:
a. Wear eyeglasses 24 hours a day
b. Turn the head to scan the lost visual field
c. Keep all objects in the impaired field of vision
d. Wear a patch on the affected eye
Answer: B
Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse
instructs the client to scan the environment to overcome the visual deficit. The nurse
encourages the use of personal eyeglasses to improve overall vision, but it is not
necessary to wear the glasses 24 hours a day.
35. A patient was recently diagnosed as having Bell’s palsy. Which nursing intervention will
the nurse include in the care plan for this patient?
a. Medication for pain relief
b. Provision of a fan to cool the face
c. Protection of the cornea on paralyzed side
d. Precautions against aspiration
Answer: C
Rationale: Protection of the eye with a shield or goggles is essential during period of
paralysis. There is no pain or threat of aspiration. Cool air is a trigger for Bell’s palsy
36. What instructions should the client be given before undergoing a paracentesis?
a. Empty bladder before procedure
b. Have to rest flat supine during procedure
c. NPO for 8 hours before procedure
d. Strict bed rest following procedureAnswer: A
Rationale: Empty bladder before procedure to avoid accidental puncture of bladder
37. Which of the following tests could be administered to a client suspected of having
diverticulosis to confirm it?
a. Barium swallow (upper GI series)
b. Gastroscopy
c. Angiography
d. Barium enema
Answer: D
38. The nurse is caring for a patient who experienced basilar skull fractures as a result of a
motor vehicle accident. The nurse is concerned that the client will develop meningitis.
Which of the following clinical manifestations would be most indicate of meningitis?
a. Elevated lymphocytes and monocytes
b. Positive Brudzinski’s sign
c. Negative Kernig’s sign
d. Temperature = 100.4F
Answer: B
Rationale: Kernig and Brudzinski signs are indicative of meningitis
39. Carbidopa-levodopa (Sinemet) is prescribed for s client with Parkinson’s disease. The
nurse monitors the client for side/adverse effects to the medication. Which finding
indicates that the client is experiencing an adverse effect?
a. Hypertension
b. Pruritus
c. Dyskinesia
d. Orange urine
Answer: C
Rationale: Involuntary movements (dyskinesia) may occur with high levodopa dosages.
Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are
frequent side effects of the medication.
40. A patient with cirrhosis complains of the blandness of the low-protein diet and questions
its effectiveness. The nurse reminds the patient that the low-protein diet helps his
condition by:
a. Decreasing the production of ammonia
b. Decreasing the production of albumin
c. Supporting the manufacture of clotting factorsd. Decreasing the production of urea
Answer: A
Rationale: The low-protein diet reduces the production of ammonia, the metabolic toxin
that can cause hepatic coma. Protein is broken down in the bowel and one of its
metabolites is ammonia.
41. A young male client was diagnosed with pneumococcal meningitis and initiated in
penicillin. What response by the patient indicates that he understands the precautions
necessary with this diagnosis?
a. “I will be in isolation for 24 hours.”
b. “I’m so depressed because I can’t have any visitors for a week.”
c. “The nurse told me that my urine and stool are also sources of meningitis bacteria.”
d. “The doctor is a good friend of mine and won’t keep me in isolation.”
Answer: A
42. A nurse is teaching a class of nursing students on the unit about the pathophysiology of
multiple sclerosis. To evaluate their understanding, the nurse asks the students, “Which
part of a neuron would be the most damaged in a patient with multiple sclerosis?” the
students’ best response would be which of the following components of the nervous
system?
a. Dendrite
b. Myelin sheath
c. Cell body
d. Nucleus
Answer: B
Rationale: Multiple sclerosis is a chronic, inflammatory, autoimmune disorder that
damages the myelin sheath of neurons in the central nervous system. Multiple sclerosis
does not damage the dendrite, cell body, or nucleus.
43. The nurse is testing the function of the glossopharyngeal (CN IX) nerve. To perform the
test correctly, the nurse must:
a. Have the patient smile and raise the eyebrows
b. Assess sense of taste in the posterior 1/3 of the tongue
c. Place warm and hot objects on each side of the face
d. Perform both air and bone conduction tests
Answer: B
44. The nurse administers a dose of edrophonium chloride to a client intravenously. The
client demonstrates increased muscle strength for a while following the injection. Thenurse interprets this finding as indicative of which of the following neurologic
problems?
a. Amyotropic lateral sclerosis
b. Cholinergic crisis
c. Myasthenia gravis
d. Multiple sclerosis
Answer: C
45. The nurse is managing the care of a patient who will undergo diagnostic tests of the GI
tract including esophagus-gastro-dudenoscopy (EGD), barium swallow (upper GI
series), and barium enema. The nurse schedules the tests in which order, taking into
consideration the nursing implications for each procedure?
a. Barium swallow, EGD, barium enema
b. Barium enema, barium swallow, EGD
c. Barium swallow, barium enema, EGD
d. EGD, barium enema, barium swallow
Answer: D
Rationale: Barium swallow is last to avoid affecting EGD and barium enema
46. A client presents to the emergency room, reporting that he has been vomiting every 30 to
40mminutes for the past 8 hours. Frequent vomiting puts him at risk for which of the
following?
a. Metabolic alkalosis with hypokalemia
b. Metabolic acidosis with hyperkalemia
c. Metabolic alkalosis with hyperkalemia
d. Metabolic acidosis with hypokalemia
Answer: A
47. Which of the following diets is most commonly associated with colon cancer?
a. Low-fat, high-fiber
b. Low-protein, high-carbohydrate
c. Low carbohydrate, high protein
d. Low-fiber, high fat
Answer: D
48. Myasthenic crisis is due to under-medication. After injection of edrophonium:
a. No improvement in muscle tone
b. Decrease in muscle tone that lasts 4 to 5 minutes
c. Improvement in muscle tone that lasts 24 hours
d. Marked improvement in muscle tone that lasts 4 to 5 minutesAnswer: D
Rationale: Edrophonium Testing
Myasthenic crisis is due under-medication:
After injection of edrophonium: marked improvement in muscle tone that lasts 4 to 5
minutes
Cholinergic crisis is due to overmedication:
After injection of edrophonium: absence of improvement in muscle tone
Atropine is indicated
49. The nurse provides home care instructions for a client with peripheral neuropathy of the
lower extremities. The nurse includes which instructions in the plan? Select all that
apply
a. Wear well-fitted shoes and walk barefoot only when at home
b. Wash the feet and legs with mild soap and water and pat dry them well
c. Wear dark-colored wool socks and change them daily
d. Examine feet everyday using a mirror
e. Check the interior of the shoes each time they are put on
f. Use a heating pad set at low to moderate heat on the feet when they feel cold
Answer: B,D,E
Rationale: Peripheral neuropathy is any functional or organic disorder of the peripheral
nervous system. Clinical manifestations can include muscle weakness, stabbing pain,
paresthesia or loss of sensation, impaired reflexes, and autonomic manifestations. Home
care instructions include washing the feet and legs with mild soap and water and rinsing
and drying them well, applying lanolin or lubricating lotion to the legs and feet daily and
reporting any skin changes or open areas to the physician, wearing white or colorfast
stockings or socks and changing them daily, checking temperature of the bath water with
a thermometer before putting the feet into the water, avoiding the use of heat (hot foot
soaks, heating pad, hot water bottle) on the feet because of the risk of burning, avoiding
the use of sharp devices to cut nails, wearing support or elastic stockings for dependent
edema, and wearing well-fitted shoes and avoiding going barefoot. [Show Less]