Detailed Answer Key GI/Neuro Med Surg
1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in
supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the
next container arrives?
A. Dextrose 5% in water
Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water
could cause rapid shifts in serum levels of some substances.
B. 0.9 % sodium chloride
Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride
could cause rapid shifts in serum levels of some substances.
C. Dextrose 10% in water
Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia,
the nurse should infuse dextrose 10% or 20% in water until the next container of TPN
solution arrives.
D. Lactated Ringer’s solution
Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution
could cause rapid shifts in serum levels of some substances.
2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following
statements by the nurse is appropriate?
A. “You should decrease your caloric intake when abdominal pain is present.”
Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase
their caloric intake in order to maintain weight.
B. “You should increase your daily intake of protein.”
Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein.
C. “You should increase fat intake when experiencing loose stools.”
Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent
stimulation of the pancreas and steatorrhea.
D. “You should limit alcohol intake to 2-3 drinks per week.”
Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation
of the pancreas.
CAA_DetailedAnswerKey created 10/07/2015 page 1 of 42
,Detailed Answer Key GI/Neuro Med Surg
3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm.
If the client manifests increased intracranial pressure, which of the following findings should the nurse
expect? ( Select all that apply )
A. Violent headache
B. Neck pain and stiffness
C. Slurred speech
D. Projectile vomiting
E. Rapid loss of consciousness
Rationale: Violent headache is correct. The client who manifests ICP should display a violent
headache
Neck pain and stiffness is incorrect. The client who manifests ICP should not
display neck pain and stiffness
Slurred speech is correct. The client who manifests ICP may display slurred
speech.
Projectile vomiting is correct. The client who manifests ICP may display sudden
onset of projectile vomiting.
Rapid loss of consciousness is correct. The client who manifests ICP may display a
sudden rapid loss of consciousness.
4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate
finding by the nurse?
A. Severe headache
Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to
meningeal inflammation.
B. Bradycardia
Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not
bradycardia.
C. Increased muscle tone
CAA_DetailedAnswerKey created 10/07/2015 page 2 of 42
,Detailed Answer Key GI/Neuro Med Surg
Rationale: The nurse should find as a sign of meningococcal meningitis decreased not increased
muscle tone.
D. Oriented to time, person, place
Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not
orientation to time, person, and place.
5. A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the
client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a
manifestation considered an early indication of increased intracranial pressure (ICP) is
A. bradycardia.
Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure
and bradycardia may be later signs of increased ICP.
B. ipsilateral pupil dilation.
Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure
displaces the brain against the optic nerve, but pupil dilation is not an early sign of
increased ICP.
C. widening pulse pressure.
Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure
and bradycardia may be later signs of increased ICP.
D. lethargy.
Rationale: Increased intracranial pressure is a condition in which the pressure of the
cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal.
An early sign of increasing ICP is lethargy.
6. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The
nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?
A. NPO until dysphagia subsides
Rationale: Making the client NPO provides no nutritional support and will not likely be prescribed.
B. Supplements via nasogastric tube
Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for
aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional
therapy will likely be prescribed.
CAA_DetailedAnswerKey created 10/07/2015 page 3 of 42
, Detailed Answer Key GI/Neuro Med Surg
C. Initiation of total parenteral nutrition
Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the
ingestion, digestion, and absorption of essential nutrients. This nutritional therapy will
not likely be prescribed.
D. Soft residue diet
Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty swallowing
solids; therefore, this nutritional therapy will not likely be prescribed.
7. A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she
should communicate with the client. Which of the following is an appropriate response by the nurse?
A. "Incorporate nonverbal cues in the conversation."
Rationale: Nonverbal cues enhance the client’s ability to comprehend and use language.
B. "Ask multiple choice questions as part of the conversation."
Rationale: Simple questions requiring yes/no responses are better understood by the client.
C. "Use a higher-pitched tone of voice when speaking."
Rationale: Tone of voice is understood by clients with aphasia, unless they have a hearing
impairment.
D. "Use simple child-like statements when speaking."
Rationale: It is important to respect the client and use age-appropriate communication.
8. A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of
the following outcomes should the nurse expect from this client’s medication therapy?
A. Increased sodium excretion
Rationale: The primary action of spironolactone is to increase sodium excretion in the urines.
B. Decreased urinary output
Rationale: Spironolactone is a diuretic, thus it should increase urine output.
C. Increased potassium excretion
Rationale: Spironolactone is potassium-sparing.
D. Decreased chloride excretion
CAA_DetailedAnswerKey created 10/07/2015 page 4 of 42
1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in
supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the
next container arrives?
A. Dextrose 5% in water
Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water
could cause rapid shifts in serum levels of some substances.
B. 0.9 % sodium chloride
Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride
could cause rapid shifts in serum levels of some substances.
C. Dextrose 10% in water
Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia,
the nurse should infuse dextrose 10% or 20% in water until the next container of TPN
solution arrives.
D. Lactated Ringer’s solution
Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution
could cause rapid shifts in serum levels of some substances.
2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following
statements by the nurse is appropriate?
A. “You should decrease your caloric intake when abdominal pain is present.”
Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase
their caloric intake in order to maintain weight.
B. “You should increase your daily intake of protein.”
Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein.
C. “You should increase fat intake when experiencing loose stools.”
Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent
stimulation of the pancreas and steatorrhea.
D. “You should limit alcohol intake to 2-3 drinks per week.”
Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation
of the pancreas.
CAA_DetailedAnswerKey created 10/07/2015 page 1 of 42
,Detailed Answer Key GI/Neuro Med Surg
3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm.
If the client manifests increased intracranial pressure, which of the following findings should the nurse
expect? ( Select all that apply )
A. Violent headache
B. Neck pain and stiffness
C. Slurred speech
D. Projectile vomiting
E. Rapid loss of consciousness
Rationale: Violent headache is correct. The client who manifests ICP should display a violent
headache
Neck pain and stiffness is incorrect. The client who manifests ICP should not
display neck pain and stiffness
Slurred speech is correct. The client who manifests ICP may display slurred
speech.
Projectile vomiting is correct. The client who manifests ICP may display sudden
onset of projectile vomiting.
Rapid loss of consciousness is correct. The client who manifests ICP may display a
sudden rapid loss of consciousness.
4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate
finding by the nurse?
A. Severe headache
Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to
meningeal inflammation.
B. Bradycardia
Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not
bradycardia.
C. Increased muscle tone
CAA_DetailedAnswerKey created 10/07/2015 page 2 of 42
,Detailed Answer Key GI/Neuro Med Surg
Rationale: The nurse should find as a sign of meningococcal meningitis decreased not increased
muscle tone.
D. Oriented to time, person, place
Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not
orientation to time, person, and place.
5. A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the
client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a
manifestation considered an early indication of increased intracranial pressure (ICP) is
A. bradycardia.
Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure
and bradycardia may be later signs of increased ICP.
B. ipsilateral pupil dilation.
Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure
displaces the brain against the optic nerve, but pupil dilation is not an early sign of
increased ICP.
C. widening pulse pressure.
Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure
and bradycardia may be later signs of increased ICP.
D. lethargy.
Rationale: Increased intracranial pressure is a condition in which the pressure of the
cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal.
An early sign of increasing ICP is lethargy.
6. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The
nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?
A. NPO until dysphagia subsides
Rationale: Making the client NPO provides no nutritional support and will not likely be prescribed.
B. Supplements via nasogastric tube
Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for
aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional
therapy will likely be prescribed.
CAA_DetailedAnswerKey created 10/07/2015 page 3 of 42
, Detailed Answer Key GI/Neuro Med Surg
C. Initiation of total parenteral nutrition
Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the
ingestion, digestion, and absorption of essential nutrients. This nutritional therapy will
not likely be prescribed.
D. Soft residue diet
Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty swallowing
solids; therefore, this nutritional therapy will not likely be prescribed.
7. A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she
should communicate with the client. Which of the following is an appropriate response by the nurse?
A. "Incorporate nonverbal cues in the conversation."
Rationale: Nonverbal cues enhance the client’s ability to comprehend and use language.
B. "Ask multiple choice questions as part of the conversation."
Rationale: Simple questions requiring yes/no responses are better understood by the client.
C. "Use a higher-pitched tone of voice when speaking."
Rationale: Tone of voice is understood by clients with aphasia, unless they have a hearing
impairment.
D. "Use simple child-like statements when speaking."
Rationale: It is important to respect the client and use age-appropriate communication.
8. A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of
the following outcomes should the nurse expect from this client’s medication therapy?
A. Increased sodium excretion
Rationale: The primary action of spironolactone is to increase sodium excretion in the urines.
B. Decreased urinary output
Rationale: Spironolactone is a diuretic, thus it should increase urine output.
C. Increased potassium excretion
Rationale: Spironolactone is potassium-sparing.
D. Decreased chloride excretion
CAA_DetailedAnswerKey created 10/07/2015 page 4 of 42
