EXAM 3 COA UPDATED QUESTIONS AND CORRECT
ANSWERS
Question:
1. The nurse is caring for a client who begins to experi-ence 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 condi-tion? *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 indepen-dently but is able to feed and bath self without assis-tance
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
at-tack). 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 adap-tive 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 Dis-ease 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 bath-room."
,Answer:
4."I don't need to use my walker to get to the bath-room."
Question:
6. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past
medical histo-ry finding makes the client most at risk for this dis-ease?
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 gastroin-testinal 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 incorpo-rate in the plan of care to help the
client cope with this illness?
1.Giving client full control over care decisions and re-stricting 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, re-ducing distractions, and
limiting visitors
Answer:
3.Providing information, giving positive feedback, and encouraging relax-ation
Question:
8. The nurse is instituting seizure precautions for a client who is being admitted from the emergency
depart-ment. 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 bed-side 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 suc-tion
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 syn-drome to the nursing unit. The client has
complaints of inability to move both legs and reports a tingling sensation above the waistline.
Knowing the complica-tions 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 in-tubation 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 find-ing 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 instruc-tions?
1."Alcohol is not contraindicated while taking this med-ication." 2."Good oral hygiene is needed,
including brushing and flossing." 3."The medication dose may be self-adjusted, depend-ing 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 brush-ing and flossing."
Question:
12. A client with myasthenia gravis has become increas-ingly weaker. The primary health care
provider pre-pares to identify whether the client is reacting to an overdose of the medication
(cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of
edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?
1.No change in the condition 2.Complaints of muscle spasms 3.An improvement of the weakness 4.A
temporary worsening of the condition
Answer:
4.A temporary worsening of the condition
Question:
13. Which of the following conditions can cause a hiatal hernia?
1. Increased intrathoracic pressure
2. Weakness of the esophageal muscle
3. Increased esophageal muscle pressure
4. Weakness of the diaphragmatic muscle
Answer:
4. Weakness of the di-
aphragmatic muscle
Question:
14. Risk factors for the development of hiatal hernias are those that lead to increased abdominal
pressure. Which of the following complications can cause in-creased abdominal pressure?
1. Obesity
2. Volvulus
3. Constipation
4. Intestinal obstruction
Answer:
1. Obesity
Question:
15. The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn
following a meal. After administering an ordered antacid, the nurse encourages the client to lie in
which of the fol-lowing positions?
1. Supine with the head of the bed flat
ANSWERS
Question:
1. The nurse is caring for a client who begins to experi-ence 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 condi-tion? *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 indepen-dently but is able to feed and bath self without assis-tance
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
at-tack). 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 adap-tive 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 Dis-ease 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 bath-room."
,Answer:
4."I don't need to use my walker to get to the bath-room."
Question:
6. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past
medical histo-ry finding makes the client most at risk for this dis-ease?
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 gastroin-testinal 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 incorpo-rate in the plan of care to help the
client cope with this illness?
1.Giving client full control over care decisions and re-stricting 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, re-ducing distractions, and
limiting visitors
Answer:
3.Providing information, giving positive feedback, and encouraging relax-ation
Question:
8. The nurse is instituting seizure precautions for a client who is being admitted from the emergency
depart-ment. 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 bed-side 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 suc-tion
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 syn-drome to the nursing unit. The client has
complaints of inability to move both legs and reports a tingling sensation above the waistline.
Knowing the complica-tions 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 in-tubation 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 find-ing 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 instruc-tions?
1."Alcohol is not contraindicated while taking this med-ication." 2."Good oral hygiene is needed,
including brushing and flossing." 3."The medication dose may be self-adjusted, depend-ing 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 brush-ing and flossing."
Question:
12. A client with myasthenia gravis has become increas-ingly weaker. The primary health care
provider pre-pares to identify whether the client is reacting to an overdose of the medication
(cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of
edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?
1.No change in the condition 2.Complaints of muscle spasms 3.An improvement of the weakness 4.A
temporary worsening of the condition
Answer:
4.A temporary worsening of the condition
Question:
13. Which of the following conditions can cause a hiatal hernia?
1. Increased intrathoracic pressure
2. Weakness of the esophageal muscle
3. Increased esophageal muscle pressure
4. Weakness of the diaphragmatic muscle
Answer:
4. Weakness of the di-
aphragmatic muscle
Question:
14. Risk factors for the development of hiatal hernias are those that lead to increased abdominal
pressure. Which of the following complications can cause in-creased abdominal pressure?
1. Obesity
2. Volvulus
3. Constipation
4. Intestinal obstruction
Answer:
1. Obesity
Question:
15. The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn
following a meal. After administering an ordered antacid, the nurse encourages the client to lie in
which of the fol-lowing positions?
1. Supine with the head of the bed flat
