Med Surg Nclex 2/4 Exam Questions
With Complete Answers
An elderly client is admitted with a diagnosis of bacterial pneumonia. The
nurse's assessment of the client is most likely to reveal which sign/symptom?
Leukocytosis and febrile.
Polycythemia and crackles.
Pharyngitis and sputum production.
Confusion and tachycardia. - ANSWER Confusion and tachycardia.
The onset of pneumonia in the elderly may be signaled by general deterioration,
confusion, increased heart rate or increased respiratory rate (D). (A, B, and C)
are often absent in the elderly with bacterial pneumonia.
A male client receives a local anesthetic during surgery. During the post-
operative assessment, the nurse notices the client is slurring his speech. Which
action should the nurse take?
Determine the client is anxious and allow him to sleep.
Evaluate his blood pressure, pulse, and respiratory status.
Review the client's pre-operative history for alcohol abuse.
Continue to monitor the client for reactivity to anesthesia. - ANSWER Evaluate
his blood pressure, pulse, and respiratory status.
Slurred speech in the post-operative client who received a local anesthetic is an
atypical finding and may indicate neurological deficits that require further
assessment, so obtaining the client's vital signs (B) will provide information
about possible cardiovascular complications, such as stroke. The client's
anxiety (A), a history of alcohol abuse (D), or local anesthesia (D) are unrelated
to the client's sudden onset of slurred speech.
A client with gastroesophageal reflux disease (GERD) has been experiencing
severe reflux during sleep. Which recommendation by the nurse is most
effective to assist the client?
Losing weight.
Decreasing caffeine intake.
Avoiding large meals.
Raising the head of the bed on blocks - ANSWER Raising the head of the bed on
blocks
, Raising the head of the bed on blocks (D) (reverse Trendelenburg position) to
reduce reflux and subsequent aspiration is the most effective recommendation
for a client experiencing severe gastroesophageal reflux during sleep. (A, B and
C) may be effective recommendations but raising the head of the bed is more
effective for relief during sleep.
What is the correct procedure for performing an ophthalmoscopic examination
on a client's right retina?
Instruct the client to look at examiner's nose and not move his/her eyes during
the exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's
right eye.
From a distance of 8 to 12 inches and slightly to the side, shine the light into the
client's pupil.
For optimum visualization, keep the ophthalmoscope at least 3 inches from the
client's eye. - ANSWER For optimum visualization, keep the ophthalmoscope at
least 3 inches from the client's eye.
The client should focus on a distant object in order to promote pupil dilation. The
ophthalmoscope should be set on the 0 lens to begin (creates no correction at
the beginning of the exam), and should be held in front of the examiner's left eye
when examining the client's right eye. For optimum visualization, the
ophthalmoscope should be kept within one to three inches of the client's eye (D).
(A and B) describe incorrect methods for conducting an ophthalmoscopic
examination. (C) should illicit a red reflex as the light travels through the
crystalline lens to the retina.
Dysrhythmias are a concern for any client. However, the presence of a
dysrhythmia is more serious in an elderly person because
elderly persons usually live alone and cannot summon help when symptoms
appear.
elderly persons are more likely to eat high-fat diets which make them
susceptible to heart disease.
cardiac symptoms, such as confusion, are more difficult to recognize in the
elderly.
elderly persons are intolerant of decreased cardiac output which may result in
dizziness and falls. - ANSWER elderly persons are intolerant of decreased
cardiac output which may result in dizziness and falls.
Cardiac output is decreased with aging (D). Because of loss of contractility and
elasticity, blood flow is decreased and tachycardia is poorly tolerated.
Therefore, if an elderly person experiences dysrhythmia (tachycardia or
bradycardia), further compromising their cardiac output, they are more likely to
experience syncope, falls, transient ischemic attacks, and possibly dementia.
Most elderly persons do not eat high-fat diets (B) and most are not confused (C).
With Complete Answers
An elderly client is admitted with a diagnosis of bacterial pneumonia. The
nurse's assessment of the client is most likely to reveal which sign/symptom?
Leukocytosis and febrile.
Polycythemia and crackles.
Pharyngitis and sputum production.
Confusion and tachycardia. - ANSWER Confusion and tachycardia.
The onset of pneumonia in the elderly may be signaled by general deterioration,
confusion, increased heart rate or increased respiratory rate (D). (A, B, and C)
are often absent in the elderly with bacterial pneumonia.
A male client receives a local anesthetic during surgery. During the post-
operative assessment, the nurse notices the client is slurring his speech. Which
action should the nurse take?
Determine the client is anxious and allow him to sleep.
Evaluate his blood pressure, pulse, and respiratory status.
Review the client's pre-operative history for alcohol abuse.
Continue to monitor the client for reactivity to anesthesia. - ANSWER Evaluate
his blood pressure, pulse, and respiratory status.
Slurred speech in the post-operative client who received a local anesthetic is an
atypical finding and may indicate neurological deficits that require further
assessment, so obtaining the client's vital signs (B) will provide information
about possible cardiovascular complications, such as stroke. The client's
anxiety (A), a history of alcohol abuse (D), or local anesthesia (D) are unrelated
to the client's sudden onset of slurred speech.
A client with gastroesophageal reflux disease (GERD) has been experiencing
severe reflux during sleep. Which recommendation by the nurse is most
effective to assist the client?
Losing weight.
Decreasing caffeine intake.
Avoiding large meals.
Raising the head of the bed on blocks - ANSWER Raising the head of the bed on
blocks
, Raising the head of the bed on blocks (D) (reverse Trendelenburg position) to
reduce reflux and subsequent aspiration is the most effective recommendation
for a client experiencing severe gastroesophageal reflux during sleep. (A, B and
C) may be effective recommendations but raising the head of the bed is more
effective for relief during sleep.
What is the correct procedure for performing an ophthalmoscopic examination
on a client's right retina?
Instruct the client to look at examiner's nose and not move his/her eyes during
the exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's
right eye.
From a distance of 8 to 12 inches and slightly to the side, shine the light into the
client's pupil.
For optimum visualization, keep the ophthalmoscope at least 3 inches from the
client's eye. - ANSWER For optimum visualization, keep the ophthalmoscope at
least 3 inches from the client's eye.
The client should focus on a distant object in order to promote pupil dilation. The
ophthalmoscope should be set on the 0 lens to begin (creates no correction at
the beginning of the exam), and should be held in front of the examiner's left eye
when examining the client's right eye. For optimum visualization, the
ophthalmoscope should be kept within one to three inches of the client's eye (D).
(A and B) describe incorrect methods for conducting an ophthalmoscopic
examination. (C) should illicit a red reflex as the light travels through the
crystalline lens to the retina.
Dysrhythmias are a concern for any client. However, the presence of a
dysrhythmia is more serious in an elderly person because
elderly persons usually live alone and cannot summon help when symptoms
appear.
elderly persons are more likely to eat high-fat diets which make them
susceptible to heart disease.
cardiac symptoms, such as confusion, are more difficult to recognize in the
elderly.
elderly persons are intolerant of decreased cardiac output which may result in
dizziness and falls. - ANSWER elderly persons are intolerant of decreased
cardiac output which may result in dizziness and falls.
Cardiac output is decreased with aging (D). Because of loss of contractility and
elasticity, blood flow is decreased and tachycardia is poorly tolerated.
Therefore, if an elderly person experiences dysrhythmia (tachycardia or
bradycardia), further compromising their cardiac output, they are more likely to
experience syncope, falls, transient ischemic attacks, and possibly dementia.
Most elderly persons do not eat high-fat diets (B) and most are not confused (C).
