PNR201 Med Surg 1 Exam 2 NCLEX
Questions
A 38-year-old woman who has undergone bilateral radical mastectomy is withdrawn and
quiet. She is afebrile with no apparent complaints of pain. Her dressings are dry and
intact. Pulses are full on both upper extremities. Considering the data, the major
problem at this time would be:
1. pain in the surgical area.
2. potential surgical site infection
3. distress over the loss of her breasts.
4. concern about her children at home. - -correct ans--Correct Answer: 3
Because the data say that the patient is withdrawn and quiet, which are indications of
some depression, "Disturbed body image related to loss of body parts" is the best
choice of nursing diagnosis. (1) There is no mention of pain in the data, although pain is
no doubt present and well controlled. (2) The data indicate no signs of infection,
although "Risk for infection" is a correct general nursing diagnosis postoperatively;
however, the data indicate that option 3 is best at this time. (4) There is no mention in
the data of concern about her children.
Apk59-year-
oldpkpatientpkwithpklabyrinthitispkispkrequestingpktopkgetpkuppktopkgopktopkthepkbathroom.pkWhatpknur
singpkinterventionspkarepkappropriate?(Selectpkallpkthatpkapply.)
1.pkMedicatepkforpknausea
2.pkMedicatepkforpkpain
3.pkAssistpkpatientpkwithpkambulation
4.pkKeeppkthepkroompklightspkdim
5.pkHavepkthepkpatientpksitpkuppkslowly
6.pkHavepkthepkpatientpkclosepktheirpkeyespkwhenpkmovingpkthepkheadpk-pk-correctpkans--
CorrectpkAnswers:pk1,pk3,pk5
Nauseapkispkcommon,pkandpkparticularlypkwhenpkmoving,pkpremedicationpkispkappropriate.pkTh
epkpatientpkwillpkprobablypkbepkdizzypkandpkneedspkassistancepkforpksafety.pkSittingpkuppkslowlypkfr
ompkapklyingpkpositionpkcanpkminimizepkthepkseveritypkofpkthepkvertigo.pk(2)pkTherepkispknopkindicati
onpkthatpkpainpkmedicationpkispkneeded.pk(4)pkPhotophobiapkispknotpkapksymptompkofpklabyrinthitis
.pk(6)pkClosingpkthepkeyespkwillpknotpkpreventpkvertigo.
Apkmalepkpatientpkwaspkinformedpkthatpkhepkwouldpkneedpktopkwearpkapkpairpkofpkcorrectivepklense
spkforpkastigmatism.pkWhenpkaskedpkaboutpkthepkcondition,pkthepkpatientpkdemonstratespkunder
standingpkwhenpkhepkstatespkthat:
1.pk"Astigmatismpkispkhardeningpkofpkthepkciliarypkmuscles."
2.pk"Astigmatismpkispkanpkirregularpkcurvaturepkofpkthepkcornea."
,3.pk"Astigmatismpkenablespkfocusingpkofpklightpkinpkfrontpkofpkthepkretina."
4.pk"Astigmatismpkispkanpkincreasedpkopacitypkofpkthepklens."pk-pk-correctpkans--
CorrectpkAnswer:pk2
Astigmatismpkispkcausedpkbypkanpkirregularpkcurvaturepkofpkthepkcornea.pk(1)pkHardeningpkofpkthep
kciliarypkmusclespkispknotpkastigmatism.pk(3)pkAstigmatismpkfocusespklightpkinpkseveralpkpoints.pk(
4)pkCataractspkarepkincreasedpkopacitypkofpkthepklens.
Apknursepkappliespkapkvibratingpktuningpkforkpktopkthepkmiddlepkofpkapkpatient'spkforehead.pkWhatpkr
esponsepkwouldpkindicatepknormalpkhearing?
1.pkHearingpkthepksoundpkinpkthepkbackpkofpkthepkhead
2.pkFeelingpkapkvibrationpkbutpkhearingpknopksound
3.pkHearingpkthepksoundpkinpkthepkmiddlepkofpkthepkhead
4.pkFeelingpkapkvibrationpkandpkhearingpkapksoundpkinpkthepktemporalpkareapk-pk-correctpkans--
CorrectpkAnswer:pk3
ThispkispkthepkWeberpktest,pkandpkhearingpkthepksoundpkinpkthepkmiddlepkofpkthepkheadpkispknormal.p
k(1)pkHearingpkthepksoundpkinpkthepkbackpkofpkthepkheadpkispkabnormal.pk(2)pkHearingpknopksoundpki
spkabnormal.pk(4)pkHearingpkapksoundpkinpkthepktemporalpkareapkispkabnormal.
ApknursepkevaluatespkthepkvisualpkacuitypkofpkapkpatientpkusingpkthepkSnellenpkchart.pkWhichpkstat
ementpkispktruepkregardingpkthepkusepkofpkthepkSnellenpkchart?
1.pkThepkchartpkispkplacedpk40pkfeetpkawaypkfrompkthepkpatient.
2.pkThepkpatientpkreadspkthepkletterspkusingpkonepkeyepkatpkapktime.
3.pkThepknumeratorpk(toppknumber)pkindicatespkthepksmallestpklinepkthatpkthepkpatientpkcouldpkrea
d.
4.pkThepkdenominatorpk(bottompknumber)pkreferspktopkthepkpatient'spkdistancepkfrompkthepkchart.p
k-pk-correctpkans--CorrectpkAnswer:pk2
VisualpkacuitypkispktestedpkbypkhavingpkthepkpatientpkreadpkthepklinespkonpkthepkSnellenpkchartpkwit
hpkonepkeyepkwhilepkthepkotherpkeyepkispkcompletelypkcovered.pkThenpkthepkoppositepkeyepkispktest
edpkinpkthepksamepkmanner.pk(1)pkThepkpatientpkispknormallypk20pkfeetpkawaypkfrompkthepkchart.pk(3
)pkThepktoppknumberpkindicatespkhowpkfarpkawaypkthepkpatientpkis.pk(4)pkThepkbottompknumberpkref
erspktopkthepkdistancepkatpkwhichpkpeoplepkwithpknormalpkvisionpkcanpkreadpkthepklinepkofpkthepkchar
t.
ApknursepkispkreviewingpkmedicationpkorderspkforpkapkfemalepkpatientpkwithpkSLEpkwhopkispkpositiv
epkforpkthepkpresencepkofpkantiphospholipidpkantibodies.pkYoupkwouldpkseekpkclarificationpkfrompk
thepkhealthpkcarepkproviderpkaboutpkwhichpktypepkofpkmedication?
1.pkOralpkcontraceptives
2.pkHydroxychloroquinepk(antimalarial)
3.pkGlucocorticoidpkmedication
4.pkNSAIDpk-pk-correctpkans--CorrectpkAnswer:pk1
Womenpkwithpklupuspkmaypkneedpktopkhavepkbirthpkcontrolpkwithpklowerpklevelspkofpkestrogenpktopk
decreasepkflare-
, upspkofpkSLE.pk(2)pkHydroxychloroquinepkhelpspkpreventpkorganpkdamagepkinpkSLE.pk(3)pkGluco
corticoidspkhelppksuppresspkthepkimmunepksystem,pktherebypklesseningpkthepkriskpkofpkflare-
upspkofpkSLE.pk(4)pkNSAIDspkhelppkinpkcontrollingpkpainpkassociatedpkwithpkSLE.
Apkpatientpkhaspkthepkmedicalpkdiagnosispkofpkfibromyalgia.pkWhichpknursingpkproblempkispkthepkh
ighestpkprioritypkonpkthispkpatient'spkcarepkplan?
1.pkAirwaypkcongestion
2.pkInabilitypktopkcomplypkwithpktreatmentpkregimen
3.pkChronicpkpain
4.pkPotentialpkforpkfluidpkimbalancepk-pk-correctpkans--CorrectpkAnswer:pk3
Patientspkwithpkfibromyalgiapktypicallypkhavepkeitherpkhyperalgesiapkorpkallodyniapkduepktopkthepk
abnormalpkresponsepkinpkthepkpainpkreceptorspkwithinpkthepkcentralpknervouspksystem.pk(1)pkThep
ktracheapkispktypicallypknotpkaffectedpkbypkthispkdisease.pk(2)pkItpkispkunknownpkwhetherpkthepkpatie
ntpkispknoncompliantpkwithpkthepktreatmentpkplanpkgivenpkthepkinformationpkprovided.pk(4)pkItpkispku
nknownpkwhetherpkthepkpatientpkispkatpkriskpkforpkfluidpkimbalancepkgivenpkthepkinformationpkprovi
ded.
Apkpatientpkispknewlypkdiagnosedpkwithpkanpkautoimmunepkthyroidpkdisease.pkWhenpkyoupkdiscu
sspkthepkpatient'spkquestionspkandpkconcerns,pkthepkpatientpkasks,pk"Whatpkdidpkthepkhealthpkcare
pkproviderpkmeanpkbypkautoimmunepkdisease?"pkWhatpkispkthepkmostpkappropriatepkresponse?
1.pk"Thepkbody'spkimmunepkdefensespkfailpktopkrespondpktopkthepkpathogenicpkagents."
2.pk"Immunepkdefensespkarepkattackingpkthepknormalpkbodypkcells."
3.pk"Therepkispkapkbreakpkinpkthepkbody'spkdefenses."
4.pk"Thepkproviderpkwaspkablepktopkidentifypkthepkunderlyingpkcausepkofpkthepkdisorder."pk-pk-
correctpkans--CorrectpkAnswer:pk2
Anpkautoimmunepkdisorderpkoccurspkwhenpkthepkbodypkattackspkitspkownpkcells.pk(1)pkAutoimmu
nepkdisorderspkarepknotpkcausedpkbypkapkpathogen.pk(3)pkApkbreakpkinpkthepkbody'spkdefensespkispk
morepklikelypktopkcausepkanpkinfection,pknotpkanpkautoimmunepkdisorder.pk(4)pkInpkmanypkcases,pkt
hepkactualpkcausepkofpkanpkautoimmunepkdisorderpkispknotpkfullypkknown.
ApkpatientpkknownpktopkbepkpositivepkforpkHIVpkispkadmittedpkwithpkoralpkthrush,pkrecurrentpkvagina
lpkyeastpkinfections,pkandpkskinpkinfections.pkWhatpkdopkthesepksignspkindicate?
1.pkOpportunisticpkinfection
2.pkAntimicrobialpkresistance
3.pkResistantpkstrainpkofpkHIV
4.pkSentinelpkinfectionpk-pk-correctpkans--CorrectpkAnswer:pk1
CandidiasispkispkapkcommonpkopportunisticpkinfectionpkinpkthepkHIV-
positivepkpatient.pk(2)pkAntimicrobialpkresistancepkcanpkbepkdeterminedpkonlypkviapkmicrobiologi
cpkculturepkaccompaniedpkbypkthepkantibiogrampk(testpkthatpkshowspkdrugpksensitivities).pk(3)pkR
esistantpkstrainspkofpkHIVpkarepkmutationspkofpkthepkviruspkthatpkdopknotpkrespondpkwellpktopkchemo
therapy.pk(4)pkSentinelpkinfectionspkarepkseenpkinpkAIDS-
definingpkinfections,pkandpkthepkcurrentpklocationpkofpkthepkcandidiasispkispknotpkindicativepkofpkthi
spktypepkofpkinfection.
Questions
A 38-year-old woman who has undergone bilateral radical mastectomy is withdrawn and
quiet. She is afebrile with no apparent complaints of pain. Her dressings are dry and
intact. Pulses are full on both upper extremities. Considering the data, the major
problem at this time would be:
1. pain in the surgical area.
2. potential surgical site infection
3. distress over the loss of her breasts.
4. concern about her children at home. - -correct ans--Correct Answer: 3
Because the data say that the patient is withdrawn and quiet, which are indications of
some depression, "Disturbed body image related to loss of body parts" is the best
choice of nursing diagnosis. (1) There is no mention of pain in the data, although pain is
no doubt present and well controlled. (2) The data indicate no signs of infection,
although "Risk for infection" is a correct general nursing diagnosis postoperatively;
however, the data indicate that option 3 is best at this time. (4) There is no mention in
the data of concern about her children.
Apk59-year-
oldpkpatientpkwithpklabyrinthitispkispkrequestingpktopkgetpkuppktopkgopktopkthepkbathroom.pkWhatpknur
singpkinterventionspkarepkappropriate?(Selectpkallpkthatpkapply.)
1.pkMedicatepkforpknausea
2.pkMedicatepkforpkpain
3.pkAssistpkpatientpkwithpkambulation
4.pkKeeppkthepkroompklightspkdim
5.pkHavepkthepkpatientpksitpkuppkslowly
6.pkHavepkthepkpatientpkclosepktheirpkeyespkwhenpkmovingpkthepkheadpk-pk-correctpkans--
CorrectpkAnswers:pk1,pk3,pk5
Nauseapkispkcommon,pkandpkparticularlypkwhenpkmoving,pkpremedicationpkispkappropriate.pkTh
epkpatientpkwillpkprobablypkbepkdizzypkandpkneedspkassistancepkforpksafety.pkSittingpkuppkslowlypkfr
ompkapklyingpkpositionpkcanpkminimizepkthepkseveritypkofpkthepkvertigo.pk(2)pkTherepkispknopkindicati
onpkthatpkpainpkmedicationpkispkneeded.pk(4)pkPhotophobiapkispknotpkapksymptompkofpklabyrinthitis
.pk(6)pkClosingpkthepkeyespkwillpknotpkpreventpkvertigo.
Apkmalepkpatientpkwaspkinformedpkthatpkhepkwouldpkneedpktopkwearpkapkpairpkofpkcorrectivepklense
spkforpkastigmatism.pkWhenpkaskedpkaboutpkthepkcondition,pkthepkpatientpkdemonstratespkunder
standingpkwhenpkhepkstatespkthat:
1.pk"Astigmatismpkispkhardeningpkofpkthepkciliarypkmuscles."
2.pk"Astigmatismpkispkanpkirregularpkcurvaturepkofpkthepkcornea."
,3.pk"Astigmatismpkenablespkfocusingpkofpklightpkinpkfrontpkofpkthepkretina."
4.pk"Astigmatismpkispkanpkincreasedpkopacitypkofpkthepklens."pk-pk-correctpkans--
CorrectpkAnswer:pk2
Astigmatismpkispkcausedpkbypkanpkirregularpkcurvaturepkofpkthepkcornea.pk(1)pkHardeningpkofpkthep
kciliarypkmusclespkispknotpkastigmatism.pk(3)pkAstigmatismpkfocusespklightpkinpkseveralpkpoints.pk(
4)pkCataractspkarepkincreasedpkopacitypkofpkthepklens.
Apknursepkappliespkapkvibratingpktuningpkforkpktopkthepkmiddlepkofpkapkpatient'spkforehead.pkWhatpkr
esponsepkwouldpkindicatepknormalpkhearing?
1.pkHearingpkthepksoundpkinpkthepkbackpkofpkthepkhead
2.pkFeelingpkapkvibrationpkbutpkhearingpknopksound
3.pkHearingpkthepksoundpkinpkthepkmiddlepkofpkthepkhead
4.pkFeelingpkapkvibrationpkandpkhearingpkapksoundpkinpkthepktemporalpkareapk-pk-correctpkans--
CorrectpkAnswer:pk3
ThispkispkthepkWeberpktest,pkandpkhearingpkthepksoundpkinpkthepkmiddlepkofpkthepkheadpkispknormal.p
k(1)pkHearingpkthepksoundpkinpkthepkbackpkofpkthepkheadpkispkabnormal.pk(2)pkHearingpknopksoundpki
spkabnormal.pk(4)pkHearingpkapksoundpkinpkthepktemporalpkareapkispkabnormal.
ApknursepkevaluatespkthepkvisualpkacuitypkofpkapkpatientpkusingpkthepkSnellenpkchart.pkWhichpkstat
ementpkispktruepkregardingpkthepkusepkofpkthepkSnellenpkchart?
1.pkThepkchartpkispkplacedpk40pkfeetpkawaypkfrompkthepkpatient.
2.pkThepkpatientpkreadspkthepkletterspkusingpkonepkeyepkatpkapktime.
3.pkThepknumeratorpk(toppknumber)pkindicatespkthepksmallestpklinepkthatpkthepkpatientpkcouldpkrea
d.
4.pkThepkdenominatorpk(bottompknumber)pkreferspktopkthepkpatient'spkdistancepkfrompkthepkchart.p
k-pk-correctpkans--CorrectpkAnswer:pk2
VisualpkacuitypkispktestedpkbypkhavingpkthepkpatientpkreadpkthepklinespkonpkthepkSnellenpkchartpkwit
hpkonepkeyepkwhilepkthepkotherpkeyepkispkcompletelypkcovered.pkThenpkthepkoppositepkeyepkispktest
edpkinpkthepksamepkmanner.pk(1)pkThepkpatientpkispknormallypk20pkfeetpkawaypkfrompkthepkchart.pk(3
)pkThepktoppknumberpkindicatespkhowpkfarpkawaypkthepkpatientpkis.pk(4)pkThepkbottompknumberpkref
erspktopkthepkdistancepkatpkwhichpkpeoplepkwithpknormalpkvisionpkcanpkreadpkthepklinepkofpkthepkchar
t.
ApknursepkispkreviewingpkmedicationpkorderspkforpkapkfemalepkpatientpkwithpkSLEpkwhopkispkpositiv
epkforpkthepkpresencepkofpkantiphospholipidpkantibodies.pkYoupkwouldpkseekpkclarificationpkfrompk
thepkhealthpkcarepkproviderpkaboutpkwhichpktypepkofpkmedication?
1.pkOralpkcontraceptives
2.pkHydroxychloroquinepk(antimalarial)
3.pkGlucocorticoidpkmedication
4.pkNSAIDpk-pk-correctpkans--CorrectpkAnswer:pk1
Womenpkwithpklupuspkmaypkneedpktopkhavepkbirthpkcontrolpkwithpklowerpklevelspkofpkestrogenpktopk
decreasepkflare-
, upspkofpkSLE.pk(2)pkHydroxychloroquinepkhelpspkpreventpkorganpkdamagepkinpkSLE.pk(3)pkGluco
corticoidspkhelppksuppresspkthepkimmunepksystem,pktherebypklesseningpkthepkriskpkofpkflare-
upspkofpkSLE.pk(4)pkNSAIDspkhelppkinpkcontrollingpkpainpkassociatedpkwithpkSLE.
Apkpatientpkhaspkthepkmedicalpkdiagnosispkofpkfibromyalgia.pkWhichpknursingpkproblempkispkthepkh
ighestpkprioritypkonpkthispkpatient'spkcarepkplan?
1.pkAirwaypkcongestion
2.pkInabilitypktopkcomplypkwithpktreatmentpkregimen
3.pkChronicpkpain
4.pkPotentialpkforpkfluidpkimbalancepk-pk-correctpkans--CorrectpkAnswer:pk3
Patientspkwithpkfibromyalgiapktypicallypkhavepkeitherpkhyperalgesiapkorpkallodyniapkduepktopkthepk
abnormalpkresponsepkinpkthepkpainpkreceptorspkwithinpkthepkcentralpknervouspksystem.pk(1)pkThep
ktracheapkispktypicallypknotpkaffectedpkbypkthispkdisease.pk(2)pkItpkispkunknownpkwhetherpkthepkpatie
ntpkispknoncompliantpkwithpkthepktreatmentpkplanpkgivenpkthepkinformationpkprovided.pk(4)pkItpkispku
nknownpkwhetherpkthepkpatientpkispkatpkriskpkforpkfluidpkimbalancepkgivenpkthepkinformationpkprovi
ded.
Apkpatientpkispknewlypkdiagnosedpkwithpkanpkautoimmunepkthyroidpkdisease.pkWhenpkyoupkdiscu
sspkthepkpatient'spkquestionspkandpkconcerns,pkthepkpatientpkasks,pk"Whatpkdidpkthepkhealthpkcare
pkproviderpkmeanpkbypkautoimmunepkdisease?"pkWhatpkispkthepkmostpkappropriatepkresponse?
1.pk"Thepkbody'spkimmunepkdefensespkfailpktopkrespondpktopkthepkpathogenicpkagents."
2.pk"Immunepkdefensespkarepkattackingpkthepknormalpkbodypkcells."
3.pk"Therepkispkapkbreakpkinpkthepkbody'spkdefenses."
4.pk"Thepkproviderpkwaspkablepktopkidentifypkthepkunderlyingpkcausepkofpkthepkdisorder."pk-pk-
correctpkans--CorrectpkAnswer:pk2
Anpkautoimmunepkdisorderpkoccurspkwhenpkthepkbodypkattackspkitspkownpkcells.pk(1)pkAutoimmu
nepkdisorderspkarepknotpkcausedpkbypkapkpathogen.pk(3)pkApkbreakpkinpkthepkbody'spkdefensespkispk
morepklikelypktopkcausepkanpkinfection,pknotpkanpkautoimmunepkdisorder.pk(4)pkInpkmanypkcases,pkt
hepkactualpkcausepkofpkanpkautoimmunepkdisorderpkispknotpkfullypkknown.
ApkpatientpkknownpktopkbepkpositivepkforpkHIVpkispkadmittedpkwithpkoralpkthrush,pkrecurrentpkvagina
lpkyeastpkinfections,pkandpkskinpkinfections.pkWhatpkdopkthesepksignspkindicate?
1.pkOpportunisticpkinfection
2.pkAntimicrobialpkresistance
3.pkResistantpkstrainpkofpkHIV
4.pkSentinelpkinfectionpk-pk-correctpkans--CorrectpkAnswer:pk1
CandidiasispkispkapkcommonpkopportunisticpkinfectionpkinpkthepkHIV-
positivepkpatient.pk(2)pkAntimicrobialpkresistancepkcanpkbepkdeterminedpkonlypkviapkmicrobiologi
cpkculturepkaccompaniedpkbypkthepkantibiogrampk(testpkthatpkshowspkdrugpksensitivities).pk(3)pkR
esistantpkstrainspkofpkHIVpkarepkmutationspkofpkthepkviruspkthatpkdopknotpkrespondpkwellpktopkchemo
therapy.pk(4)pkSentinelpkinfectionspkarepkseenpkinpkAIDS-
definingpkinfections,pkandpkthepkcurrentpklocationpkofpkthepkcandidiasispkispknotpkindicativepkofpkthi
spktypepkofpkinfection.
