CHII Exam 3 Questions Solved Correctly Latest Update 2025 Graded A+
The nurse assesses an older adult with a diagnosis of severe, late-stage Alzheimer's disease. Which
assessment findings would the nurse expect for this client? Select all that apply.
A. Acute confusion
B. Hallucinations
C. Wandering
D. Urinary incontinence
E. Difficulty eating - Answers a,c,d,e
A client with early dementia asks the nurse to find her mother, who is deceased. What is the nurse's
most appropriate response?
A. "We can call her in a little while if you want."
B. " Your mother died over 20 years ago."
C. "What did your mother look like?"
D. "I'll ask your father to find her when he visits." - Answers c. (open ended questions)
The nurse is caring for a client with chronic confusion who often yells and screams when touched. Which
nursing intervention is most appropriate when caring for this client?
A. Provide a large clock and calendar for the patient to read.
B. Use removable restraints such as a roll-waist belt to prevent wandering.
C. Approach the patient so the nurse can be seen clearly.
D. Place the patient in a room close to the nurses' station for frequent observation. - Answers d.
The nurse is preparing to administer Sinemet to a client whose highest blood pressure is 88/50 while
lying in bed. What is the nurse's priority action at this time?
A. Instruct the client to get out of bed slowly.
B. Withhold the drug until contacting the primary health care provider.
C. Ask the client about the presence of hallucinations.
,D. Take the client's apical pulse and temperature. - Answers b. withhold the drug (BP is way too low to
be getting carbidopa-levodopa and risk the a/e of dizziness)
The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or
food additives that may trigger a migraine will the nurse include in the teaching? Select all that apply.
A. Sugar
B. Salt
C. Monosodium glutamate (MSG)
D. Caffeine
E. Wine
F. Tyramine - Answers c,d,e,f (not sugar, but artificial sugar may cause them)
A client with a history of seizures is placed on seizure precautions. Which emergency equipment will the
nurse provide at the bedside? Select all that apply.
A. Oropharyngeal airway
B. Oxygen
C. Nasogastric tube
D. Suction setup
E. Padded tongue blade - Answers b,d,e
A family member asks the nurse about whether there would be any long-term psychological effects from
a client's mild traumatic brain injury. What is the nurse's best response?
A. "You need to talk with the client's primary health care provider."
B. "Usually any effects last for only a few weeks or months."
C. "Each person's reaction to brain injury is different."
D. "You should expect a change in the client's personality." - Answers c.
Which statements about stroke prevention indicate a client's understanding of health teaching by the
nurse?
Select all that apply.
A. "I will take aspirin every day."
,B. "I have decided to stop smoking."
C. "I will try to walk at least 30 minutes most days of the week."
D. "I need to cut down a lot on my drinking."
E. "I'm going to decrease salt in my diet. - Answers b,c,d,e
A client who recently had laparoscopic surgery to treat a ruptured appendix has developed subsequent
peritonitis. The client currently has two Jackson Pratt drains placed in the abdomen. Which finding(s)
would the nurse report immediately to the surgeon?
Select all that apply.
A. Serosanguineous drainage
B. Fever
C. Cloudy drainage
D. Painful abdominal distention
E. Pain level 3 on a scale of 1 to 10 - Answers b,c,d (signs of infection worsening)
The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the
client to avoid?
A. Popcorn
B. Oatmeal
C. Bran
D. Lettuce - Answers a. popcorn (could get lodged in bowel and cause diverticulitis)
A transient ischemic accident (TIA) is:
A) A temporary neurologic deficit resulting from ischemia
B) A form of pneumonia associated with CVAs
C) A type of brain aneurysm
D) An area of hypoperfused cells in the brain that can be
salvaged if blood flow is restored - Answers a. (D is stroke)
A 45 year old African American female comes into the ER with a diagnosis of a possible CVA. Which of
the following would be considered a modifiable risk factor for stroke:
, A) History of TIA
B) History of diabetes
C) Family history of stroke
D) Race - Answers b. history of diabetes
Your patient is an 75 year old male that has been diagnosed with an ischemic stroke and is being
evaluated for tPA administration. He was last seen normal 2 hours ago. Which of the following would
exclude him from this treatment?
A) His age
B) BP 170/80
C) He takes Coumadin for A fib
D) He is outside the window - Answers c. Coumadin for a. fib (BP for b. at the critical stage is at 185 SBP
and 110 DBP)
A patient is brought into the ED with a high level cervical spine fracture. What is the highest priority for
assessment?
A) BP
B) Neuro status
C) Sensation below the injury
D) Respiratory effort - Answers d. respiratory effort (ABCs baby)
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and
symptom below is the EARLIEST indicator the patient is having this complication?
A) Bradycardia
B) Posturing
C) Restlessness
D) Unequal pupil size - Answers c. restlessness
Your patient has entered the post ictal stage for seizures. The patient's seizure presented with an aura
followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the
mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure
this patient experienced?
A) Crying and anxiety
The nurse assesses an older adult with a diagnosis of severe, late-stage Alzheimer's disease. Which
assessment findings would the nurse expect for this client? Select all that apply.
A. Acute confusion
B. Hallucinations
C. Wandering
D. Urinary incontinence
E. Difficulty eating - Answers a,c,d,e
A client with early dementia asks the nurse to find her mother, who is deceased. What is the nurse's
most appropriate response?
A. "We can call her in a little while if you want."
B. " Your mother died over 20 years ago."
C. "What did your mother look like?"
D. "I'll ask your father to find her when he visits." - Answers c. (open ended questions)
The nurse is caring for a client with chronic confusion who often yells and screams when touched. Which
nursing intervention is most appropriate when caring for this client?
A. Provide a large clock and calendar for the patient to read.
B. Use removable restraints such as a roll-waist belt to prevent wandering.
C. Approach the patient so the nurse can be seen clearly.
D. Place the patient in a room close to the nurses' station for frequent observation. - Answers d.
The nurse is preparing to administer Sinemet to a client whose highest blood pressure is 88/50 while
lying in bed. What is the nurse's priority action at this time?
A. Instruct the client to get out of bed slowly.
B. Withhold the drug until contacting the primary health care provider.
C. Ask the client about the presence of hallucinations.
,D. Take the client's apical pulse and temperature. - Answers b. withhold the drug (BP is way too low to
be getting carbidopa-levodopa and risk the a/e of dizziness)
The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or
food additives that may trigger a migraine will the nurse include in the teaching? Select all that apply.
A. Sugar
B. Salt
C. Monosodium glutamate (MSG)
D. Caffeine
E. Wine
F. Tyramine - Answers c,d,e,f (not sugar, but artificial sugar may cause them)
A client with a history of seizures is placed on seizure precautions. Which emergency equipment will the
nurse provide at the bedside? Select all that apply.
A. Oropharyngeal airway
B. Oxygen
C. Nasogastric tube
D. Suction setup
E. Padded tongue blade - Answers b,d,e
A family member asks the nurse about whether there would be any long-term psychological effects from
a client's mild traumatic brain injury. What is the nurse's best response?
A. "You need to talk with the client's primary health care provider."
B. "Usually any effects last for only a few weeks or months."
C. "Each person's reaction to brain injury is different."
D. "You should expect a change in the client's personality." - Answers c.
Which statements about stroke prevention indicate a client's understanding of health teaching by the
nurse?
Select all that apply.
A. "I will take aspirin every day."
,B. "I have decided to stop smoking."
C. "I will try to walk at least 30 minutes most days of the week."
D. "I need to cut down a lot on my drinking."
E. "I'm going to decrease salt in my diet. - Answers b,c,d,e
A client who recently had laparoscopic surgery to treat a ruptured appendix has developed subsequent
peritonitis. The client currently has two Jackson Pratt drains placed in the abdomen. Which finding(s)
would the nurse report immediately to the surgeon?
Select all that apply.
A. Serosanguineous drainage
B. Fever
C. Cloudy drainage
D. Painful abdominal distention
E. Pain level 3 on a scale of 1 to 10 - Answers b,c,d (signs of infection worsening)
The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the
client to avoid?
A. Popcorn
B. Oatmeal
C. Bran
D. Lettuce - Answers a. popcorn (could get lodged in bowel and cause diverticulitis)
A transient ischemic accident (TIA) is:
A) A temporary neurologic deficit resulting from ischemia
B) A form of pneumonia associated with CVAs
C) A type of brain aneurysm
D) An area of hypoperfused cells in the brain that can be
salvaged if blood flow is restored - Answers a. (D is stroke)
A 45 year old African American female comes into the ER with a diagnosis of a possible CVA. Which of
the following would be considered a modifiable risk factor for stroke:
, A) History of TIA
B) History of diabetes
C) Family history of stroke
D) Race - Answers b. history of diabetes
Your patient is an 75 year old male that has been diagnosed with an ischemic stroke and is being
evaluated for tPA administration. He was last seen normal 2 hours ago. Which of the following would
exclude him from this treatment?
A) His age
B) BP 170/80
C) He takes Coumadin for A fib
D) He is outside the window - Answers c. Coumadin for a. fib (BP for b. at the critical stage is at 185 SBP
and 110 DBP)
A patient is brought into the ED with a high level cervical spine fracture. What is the highest priority for
assessment?
A) BP
B) Neuro status
C) Sensation below the injury
D) Respiratory effort - Answers d. respiratory effort (ABCs baby)
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and
symptom below is the EARLIEST indicator the patient is having this complication?
A) Bradycardia
B) Posturing
C) Restlessness
D) Unequal pupil size - Answers c. restlessness
Your patient has entered the post ictal stage for seizures. The patient's seizure presented with an aura
followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the
mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure
this patient experienced?
A) Crying and anxiety
