Med Surg I Exam 5 ACTUAL UPDATED
QUESTIONS AND CORRECT ANSWERS
*Which action will the nurse include in the plan of care for a patient with impaired
functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)?
a. Withhold oral fluid or foods.
b. Provide highly seasoned foods.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour. - CORRECT ANSWERS✅✅ANS: A
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A
patient with impaired function of these nerves is at risk for aspiration. An oral airway may be
needed when a patient is unconscious and unable to maintain the airway, but it will not
decrease aspiration risk. Taste and eye blink are controlled by the facial nerve
*An unconscious male patient has just arrived in the emergency department after a head
injury caused by a motorcycle crash. Which order should the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes - CORRECT ANSWERS✅✅ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased
intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is
performed. The other orders are appropriate
*A patient with suspected meningitis is scheduled for a lumbar puncture. Before the
procedure, the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position. - CORRECT ANSWERS✅✅ANS: D
,For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does
not usually require a sedative, is done in the patient room, and has no risk for aspiration
*During the neurologic assessment, the patient is unable to respond verbally to the nurse but
cooperates with the nurse's directions to move his hands and feet. The nurse will suspect
a. cerebellar injury.
b. a brainstem lesion.
c. frontal lobe damage.
d. a temporal lobe lesion. - CORRECT ANSWERS✅✅ANS: C
Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe
contains Wernicke's area, which is responsible for receptive speech. The cerebellum and
brainstem do not affect higher cognitive functions such as speech
*A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions
to
a. prevent falls.
b. stabilize mood.
c. avoid aspiration.
d. improve memory. - CORRECT ANSWERS✅✅ANS: A
Because functions of the cerebellum include coordination and balance, the patient with
dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing
ability.
*Which nursing diagnosis is expected to be appropriate for a patient who has a positive
Romberg test?
a. Acute pain
b. Risk for falls
c. Acute confusion
d. Ineffective thermoregulation - CORRECT ANSWERS✅✅ANS: B
, A positive Romberg test indicates that the patient has difficulty maintaining balance with the
eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort
*The nurse will anticipate teaching a patient with a possible seizure disorder about which
test?
a. Cerebral angiography
b. Evoked potential studies
c. Electromyography (EMG)
d. Electroencephalography (EEG) - CORRECT ANSWERS✅✅ANS: D
Seizure disorders are usually assessed using EEG testing. Evoked potential is used for
diagnosing problems with the visual or auditory systems. Cerebral angiography is used to
diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle
*Which nursing action will be included in the care for a patient who has had cerebral
angiography?
a. Monitor for headache and photophobia.
b. Keep patient NPO until gag reflex returns.
c. Check pulse and blood pressure frequently.
d. Assess orientation to person, place, and time. - CORRECT ANSWERS✅✅ANS: C
Because a catheter is inserted into an artery (such as the femoral artery) during cerebral
angiography, the nurse should assess for bleeding after this procedure. The other nursing
assessments are not necessary after angiography
*A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a
myelogram. Which information is most important for the nurse to communicate to the health
care provider before the procedure?
a. The patient is anxious about the test.
b. The patient has an allergy to shellfish.
c. The patient has back pain when lying flat.
d. The patient drank apple juice 4 hours earlier. - CORRECT ANSWERS✅✅ANS: B
QUESTIONS AND CORRECT ANSWERS
*Which action will the nurse include in the plan of care for a patient with impaired
functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)?
a. Withhold oral fluid or foods.
b. Provide highly seasoned foods.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour. - CORRECT ANSWERS✅✅ANS: A
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A
patient with impaired function of these nerves is at risk for aspiration. An oral airway may be
needed when a patient is unconscious and unable to maintain the airway, but it will not
decrease aspiration risk. Taste and eye blink are controlled by the facial nerve
*An unconscious male patient has just arrived in the emergency department after a head
injury caused by a motorcycle crash. Which order should the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes - CORRECT ANSWERS✅✅ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased
intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is
performed. The other orders are appropriate
*A patient with suspected meningitis is scheduled for a lumbar puncture. Before the
procedure, the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position. - CORRECT ANSWERS✅✅ANS: D
,For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does
not usually require a sedative, is done in the patient room, and has no risk for aspiration
*During the neurologic assessment, the patient is unable to respond verbally to the nurse but
cooperates with the nurse's directions to move his hands and feet. The nurse will suspect
a. cerebellar injury.
b. a brainstem lesion.
c. frontal lobe damage.
d. a temporal lobe lesion. - CORRECT ANSWERS✅✅ANS: C
Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe
contains Wernicke's area, which is responsible for receptive speech. The cerebellum and
brainstem do not affect higher cognitive functions such as speech
*A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions
to
a. prevent falls.
b. stabilize mood.
c. avoid aspiration.
d. improve memory. - CORRECT ANSWERS✅✅ANS: A
Because functions of the cerebellum include coordination and balance, the patient with
dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing
ability.
*Which nursing diagnosis is expected to be appropriate for a patient who has a positive
Romberg test?
a. Acute pain
b. Risk for falls
c. Acute confusion
d. Ineffective thermoregulation - CORRECT ANSWERS✅✅ANS: B
, A positive Romberg test indicates that the patient has difficulty maintaining balance with the
eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort
*The nurse will anticipate teaching a patient with a possible seizure disorder about which
test?
a. Cerebral angiography
b. Evoked potential studies
c. Electromyography (EMG)
d. Electroencephalography (EEG) - CORRECT ANSWERS✅✅ANS: D
Seizure disorders are usually assessed using EEG testing. Evoked potential is used for
diagnosing problems with the visual or auditory systems. Cerebral angiography is used to
diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle
*Which nursing action will be included in the care for a patient who has had cerebral
angiography?
a. Monitor for headache and photophobia.
b. Keep patient NPO until gag reflex returns.
c. Check pulse and blood pressure frequently.
d. Assess orientation to person, place, and time. - CORRECT ANSWERS✅✅ANS: C
Because a catheter is inserted into an artery (such as the femoral artery) during cerebral
angiography, the nurse should assess for bleeding after this procedure. The other nursing
assessments are not necessary after angiography
*A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a
myelogram. Which information is most important for the nurse to communicate to the health
care provider before the procedure?
a. The patient is anxious about the test.
b. The patient has an allergy to shellfish.
c. The patient has back pain when lying flat.
d. The patient drank apple juice 4 hours earlier. - CORRECT ANSWERS✅✅ANS: B
