EXAM 3 COA UPDATED QUESTIONS AND
CORRECT ANSWERS
Question:
1. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions
would the nurse take? *Select all that apply.*
1.Loosening restrictive clothing
2.Restraining the client's limbs
3.Removing the pillow and raising padded side rails
4.Positioning the client to the side, if possible, with the head flexed forward
5.Keeping the curtain around the client and the room door open so that when help arrives, they can quickly
enter to assist
Answer:
1.Loosening restrictive clothing
3.Removing the pillow and raising padded side rails
4.Positioning the client to the side, if possible, with the head flexed forward
Question:
2. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain
attack). Which characteristics are associated with this condition? *Select all that apply.*
1.The client is aphasic
2.The client has weakness on the right side of the body
3.The client has complete bilateral paralysis of the arms and legs
4.The client has weakness on the right side of the face and tongue
5.The client has lost the ability to move the right arm but is able to walk independently
6.The client has lost the ability to ambulate independently but is able to feed and bath self without
assistance
Answer:
1.The client is aphasic
2.The client has weakness on the right side of the body
4.The client has weakness on the right side of the face and tongue
Question:
3. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain
attack). Which observation indicates to the nurse that the client is adapting most successfully?
1.Gets angry with family if they interrupt
2.Experiences bouts of depression and irritability
3.Has difficulty with using modified feeding utensils
4.Consistently uses adaptive equipment in dressing self
Answer:
4.Consistently uses adaptive equipment in dressing self
,Question:
4. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and
cholinergic crises. Which client activity suggests that teaching is most effective?
1.Taking medications as scheduled
2.Eating large, well-balanced meals
3.Doing muscle-strengthening exercises
4.Doing all chores early in the day while less fatigued
Answer:
1.Taking medications as scheduled
Question:
5. The nurse is instructing a client with Parkinson's Disease about preventing falls. Which client statement
reflects a need for further teaching?
1."I can sit down to put on my pants and shoes."
2."I try to exercise every day and rest when I'm tired."
3."My son removed all loose rugs from my bedroom."
4."I don't need to use my walker to get to the bathroom."
Answer:
4."I don't need to use my walker to get to the bathroom."
Question:
6. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical
history finding makes the client most at risk for this disease?
1.Meningitis or encephalitis during the last 5 years
2.Seizures or trauma to the brain within the last year
3.Back injury or trauma to the spinal cord during the last 2 years
4.Respiratory or gastrointestinal infection during the previous month
Answer:
4.Respiratory or gastrointestinal infection during the previous month
Question:
7. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving
mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client
cope with this illness?
1.Giving client full control over care decisions and restricting visitors
2.Providing positive feedback and encouraging active range of motion
3.Providing information, giving positive feedback, and encouraging relaxation
4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors
Answer:
3.Providing information, giving positive feedback, and encouraging relaxation
, Question:
8. The nurse is instituting seizure precautions for a client who is being admitted from the emergency
department. Which measures would the nurse include in planning for the client's safety? *Select all that
apply.*
1.Padding the side rails of the bed
2.Placing an airway at the bedside
3.Placing the bed in the high position
4.Putting a padded tongue blade at the head of the bed
5.Placing oxygen and suction equipment at the bedside
6.Flushing the intravenous catheter to ensure that the site is patent
Answer:
1.Padding the side rails of the bed
2.Placing an airway at the bedside
5.Placing oxygen and suction equipment at the bedside
6.Flushing the intravenous catheter to ensure that the site is patent
Question:
9. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has
complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the
complications of the disorder, the nurse would bring which most essential items into the client's room?
1.Nebulizer and pulse oximeter
2.Blood pressure cuff and flashlight
3.Nasal cannula and incentive spirometer
4.Electrocardiographic monitoring electrodes and intubation tray
Answer:
4.Electrocardiographic monitoring electrodes and intubation tray
Question:
10. Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client
for side and adverse effects of the medication. Which finding indicates that the client is experiencing an
adverse effect?
1.Pruritus
2.Tachycardia
3.Hypertension
4.Impaired voluntary movements
Answer:
4.Impaired voluntary movements
Question:
11. The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates
that the client has an adequate understanding of instructions?
1."Alcohol is not contraindicated while taking this medication."
2."Good oral hygiene is needed, including brushing and flossing."
3."The medication dose may be self-adjusted, depending on side effects."
4."The morning dose of the medication needs to be taken before a medication level is drawn."
Answer:
2."Good oral hygiene is needed, including brushing and flossing."
CORRECT ANSWERS
Question:
1. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions
would the nurse take? *Select all that apply.*
1.Loosening restrictive clothing
2.Restraining the client's limbs
3.Removing the pillow and raising padded side rails
4.Positioning the client to the side, if possible, with the head flexed forward
5.Keeping the curtain around the client and the room door open so that when help arrives, they can quickly
enter to assist
Answer:
1.Loosening restrictive clothing
3.Removing the pillow and raising padded side rails
4.Positioning the client to the side, if possible, with the head flexed forward
Question:
2. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain
attack). Which characteristics are associated with this condition? *Select all that apply.*
1.The client is aphasic
2.The client has weakness on the right side of the body
3.The client has complete bilateral paralysis of the arms and legs
4.The client has weakness on the right side of the face and tongue
5.The client has lost the ability to move the right arm but is able to walk independently
6.The client has lost the ability to ambulate independently but is able to feed and bath self without
assistance
Answer:
1.The client is aphasic
2.The client has weakness on the right side of the body
4.The client has weakness on the right side of the face and tongue
Question:
3. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain
attack). Which observation indicates to the nurse that the client is adapting most successfully?
1.Gets angry with family if they interrupt
2.Experiences bouts of depression and irritability
3.Has difficulty with using modified feeding utensils
4.Consistently uses adaptive equipment in dressing self
Answer:
4.Consistently uses adaptive equipment in dressing self
,Question:
4. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and
cholinergic crises. Which client activity suggests that teaching is most effective?
1.Taking medications as scheduled
2.Eating large, well-balanced meals
3.Doing muscle-strengthening exercises
4.Doing all chores early in the day while less fatigued
Answer:
1.Taking medications as scheduled
Question:
5. The nurse is instructing a client with Parkinson's Disease about preventing falls. Which client statement
reflects a need for further teaching?
1."I can sit down to put on my pants and shoes."
2."I try to exercise every day and rest when I'm tired."
3."My son removed all loose rugs from my bedroom."
4."I don't need to use my walker to get to the bathroom."
Answer:
4."I don't need to use my walker to get to the bathroom."
Question:
6. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical
history finding makes the client most at risk for this disease?
1.Meningitis or encephalitis during the last 5 years
2.Seizures or trauma to the brain within the last year
3.Back injury or trauma to the spinal cord during the last 2 years
4.Respiratory or gastrointestinal infection during the previous month
Answer:
4.Respiratory or gastrointestinal infection during the previous month
Question:
7. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving
mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client
cope with this illness?
1.Giving client full control over care decisions and restricting visitors
2.Providing positive feedback and encouraging active range of motion
3.Providing information, giving positive feedback, and encouraging relaxation
4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors
Answer:
3.Providing information, giving positive feedback, and encouraging relaxation
, Question:
8. The nurse is instituting seizure precautions for a client who is being admitted from the emergency
department. Which measures would the nurse include in planning for the client's safety? *Select all that
apply.*
1.Padding the side rails of the bed
2.Placing an airway at the bedside
3.Placing the bed in the high position
4.Putting a padded tongue blade at the head of the bed
5.Placing oxygen and suction equipment at the bedside
6.Flushing the intravenous catheter to ensure that the site is patent
Answer:
1.Padding the side rails of the bed
2.Placing an airway at the bedside
5.Placing oxygen and suction equipment at the bedside
6.Flushing the intravenous catheter to ensure that the site is patent
Question:
9. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has
complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the
complications of the disorder, the nurse would bring which most essential items into the client's room?
1.Nebulizer and pulse oximeter
2.Blood pressure cuff and flashlight
3.Nasal cannula and incentive spirometer
4.Electrocardiographic monitoring electrodes and intubation tray
Answer:
4.Electrocardiographic monitoring electrodes and intubation tray
Question:
10. Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client
for side and adverse effects of the medication. Which finding indicates that the client is experiencing an
adverse effect?
1.Pruritus
2.Tachycardia
3.Hypertension
4.Impaired voluntary movements
Answer:
4.Impaired voluntary movements
Question:
11. The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates
that the client has an adequate understanding of instructions?
1."Alcohol is not contraindicated while taking this medication."
2."Good oral hygiene is needed, including brushing and flossing."
3."The medication dose may be self-adjusted, depending on side effects."
4."The morning dose of the medication needs to be taken before a medication level is drawn."
Answer:
2."Good oral hygiene is needed, including brushing and flossing."
