Solutions
1.A child is diagnosed with severe allergic rhinitis. Which of the
following manifestations would the nurse most likely assess in
this client?
1. Edematous neck glands
2. Reduced hearing
3. Pruritis
4. Frequent wiping of the nose with the palm of the hand
Correct Answer ANS: 4
Frequent wiping of the nose with the palm of the hand is one
symptom seen in the client diagnosed with severe allergic
rhinitis. Edematous neck glands, reduced hearing, and pruritis
are not manifestations of severe allergic rhinitis.
1.A client is diagnosed with a headache from a secondary cause.
The nurse realizes this type of headache can be caused by:
1. a tumor.
2. tension.
3. a migraine.
4. cluster Correct Answer ANS: 1
Primary headaches are identified when no organic cause can be
found. A tumor headache is caused by a tumor and is classified
as a secondary headache.
1.A client is diagnosed with strabismus. Which of the following
will the client most likely experience with this disorder?
1. Nystagmus
2. Diplopia
3. Aphakic vision
,4. Ptosis Correct Answer ANS: 2
Diplopia, or double vision, is the primary symptom of
strabismus. Nystagmus is a disorder that causes involuntarily
rhythmic movements in the eye. Aphakic vision occurs when the
lens of the eye is removed. Ptosis is drooping of the eyelid.
1.A client is diagnosed with tonic-clonic seizures. Which are the
characteristics of these types of seizures? (Select all that apply.)
1. Progressing through all of the seizure phases
2. Beginning before age 5
3. Lasting 2 to 3 minutes
4. Causing injury to the client
5. Occurring at any time, day or night
6. Being highly variable Correct Answer ANS: 1, 3, 4, 5, 6
Tonic-clonic seizures are the most common type of generalized
seizure. The seizure will progress through all of the seizure
phases and last 2 to 3 minutes. Because these seizures begin
suddenly, there is an increased incidence of injury associated
with them. These seizures can occur any time of the day or
night, whether the client is awake or not. Seizure frequency is
highly variable.
1.A client is not able to successfully pass the whisper test.
Which of the following would be indicated for this client?
1. Head CT scan
2. Audiometry
3. MRI of the brain
4. Electroencephalogram Correct Answer ANS: 2
Failure to pass the whisper test would indicate the need for
formal audiometry testing. The client would not need a head CT
or MRI at this time. An electroencephalogram is not necessary.
,1.A client tells the nurse that he does not want to develop
macular degeneration like his mother. Which of the following
should the nurse instruct the client as being risk factors for the
development of this disorder? (Select all that apply.)
1. There is greater risk as people age.
2. Women are at greater risk than men.
3. African Americans are at greater risk than Caucasians.
4. Family history of macular degeneration increases risk.
5. Smoking does not increase risk.
6. Alcohol prevents the onset of this disorder. Correct Answer
ANS: 1, 2, 4
Recent statistics show that macular degeneration is age related
and that women are at greater risk than men. Family history and
smoking are also significant risk factors. Caucasians are at
greater risk than African Americans. Alcohol does not prevent
the onset of this disorder.
1.A client, being tested for a stroke, is not a candidate for tPA.
Which of the following would be contraindicated for the use of
tPA? (Select all that apply.)
1. Minor ischemic stroke within 30 days
2. Glucose level 120 mg/dL
3. Blood pressure 190/120 mmHg
4. Lumbar puncture 2 days ago
5. Stroke onset 5 hours ago
6. INR 1.0 Correct Answer ANS: 1, 3, 4, 5
Contraindications of tPA to treat an embolic stroke include
minor ischemic stroke within the last 30 days, blood pressure
greater an 185 mmHg systolic or greater than 110 mmHg
diastolic, lumbar puncture within the last 3 days, and onset of
, stroke greater than 3 hours. Glucose level of 120 mg/dL and
INR of 1.0 would not be contraindications for tPA therapy.
1.A male client is diagnosed with hyperprolactinemia. The nurse
realizes that which of the following clinical manifestations
occurs less frequently in men?
1. A decrease in testosterone
2. Erectile dysfunction
3. Gynecomastia
4. Infertility Correct Answer ANS: 3
In men, hyperprolactinemia causes a decrease in testosterone
secondary to an inhibition of gonadotropin secretion, leading to
decreased facial and body hair, erectile dysfunction, decreased
libido, small testicles, and infertility. Gynecomastia occurs less
frequently in men.
1.Blood work of a female client shows an increase in the
production of estradiol. The nurse realizes that this hormone is
controlled by:
1. positive feedback.
2. negative feedback.
3. nervous feedback.
4. reverse feedback. Correct Answer ANS: 1
Even though most of the hormones in the endocrine system are
under a negative feedback mechanism, estradiol is not one of
those hormones. Estradiol is controlled by a positive feedback
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mechanism in that when it increases, there will be in an increase
in the production of folliclestimulating hormone by the anterior
pituitary.