SITUATION: Visual impairment is more than a physiologic deficit.

It is a loss
that has physical, emotional, and spiritual effects on the person afflicted.
Even minor changes in vision can provoke feelings of anger and frustration in
people who must rely on clear and sharp vision in their work.

1. Nurse Karla is admitting a patient to the emergency department a client

who is holding his hand over his eye. The client reports being a sheet metal
worker who was injured at work. For which of the following should Nurse
Karla prepare the client prior to seeing the physician?
a. Instillation of flourescein into the eye
b. Slit lamp examination
c. Tonometry examination
d. Instillation of tetracaine into the eye
2. A client has been prescribed pilocarpine HCl for newly diagnosed
glaucoma. What must Nurse Kiko remember to include in the teaching
plan for this client?
a. Pilocarpine increases visual acuity
b. Pilocarpine eye drops do not produce systemic side effects
c. There is no side effect on vision after instillation
d. Place pressure on inner canthus of the eye after administration
3. A client admitted to the hospital has a notation on the medical
record that he has impaired vision from glaucoma. To assist the client’s
compensation, Nurse Isabelle instructs the nursing aide to arrange the
client’s room so that:
a. Objects that he may need will be directly in front of him
b. There is direct light on the overbed table
c. He can use his peripheral vision
d. There are no obstructions between the bed and bathroom
4. The nurse is caring for a client who receives pilocarpine (Pilocar) eye
drops for glaucoma. Which of the following information must Nurse
Daniel include in a teaching plan so the client can self-administer the
eye drops?
1. Instill eye drops into the inner canthus 4. Expect papillary dilation to
occur
2. Wash hands prior to administering the eye drops 5. Instill drops into
lower conjunctival sac
3. Use aseptic technique

a. 2, 3, 1 b. 2, 3, 5
c. 2, 3, 5, 4 d. 2, 3, 1, 4
5. A client who has developed impaired vision because of previously
undiagnosed glaucoma asks Nurse Liane if the lost vision will return.
Which of the following replies by Nurse Liane is most accurate?
a. “Vision that is lost will not return, but compliance with therapy can
help to maintain current vision”
b. “It will take months for vision to return to baseline”
c. “It is difficult to answer that question with accuracy. Some clients
experience return of vision, while others do not”
d. “Vision will not return to normal within a week or so if intraocular
pressure is reduced quickly”
6. When planning care for a client who is legally blind, the nurse should
do which of the following actions as most important to ensure the
client’s safety?
a. Leave doors partially closed
b. Orient client verbally and physically to the room
c. Provide radio and television for stimulation
d. Describe the weather and community events for client
7. Nurse Hannah is giving discharge instructions to a client who had
cataract removed a few hours earlier. Which instructions must Nurse
Hannah include?
a. Report itching and redness
b. Resume all preoperative activities
c. Visual changes should be reported immediately
d. Creamy white discharge is a sign of infection
SITUATION: Hearing loss is not an actual disorder but is a clinical
manifestation of many possible problems.

8. The nurse has conducted discharge teaching for a client diagnosed

with Meniere’s disease. The nurse evaluates that the client understood
the instructions given if the client states to refrain from eating which of
the following favorite foods?
a. Baked eggplant
b. Sherbet
c. Fresh fruits
d. Dried squid
9. Nurse Janice would prioritize that which of the following nursing
diagnosis has the highest priority for a client experiencing an acute
attack of Meniere’s disease?
a. Risk for injury
b. Risk for disturbed sleep pattern
c. Impaired sensory perception: Auditory
d. Risk for ineffective individual coping
10. The nurse is providing instructions to a client who has been
diagnosed with hearing impairment and has just received a hearing aid.
The nurse would include which of the following statements in
discussion with the client?
a. Immerse hearing aid daily in warm water for 15 minutes
b. Leave hearing aid on at all times to keep battery charged
c. Avoid use of aerosol sprays near the aid, because particles can clog
the receiver
d. Adjust the volume control to maximum setting for efficient use
11. The nurse is counseling a client with the diagnosis of glaucoma. She
explains that if left untreated, this condition leads to :
a. Blindness
b. Myopia
c. Retrolental fibroplasias
d. Uveitis
12. Which of the following is the leading cause of visual impairment
and of bilateral or monocular low vision?
A. Errors of refraction
B. Glaucoma
C. Optic atrophy
D. Cataract
13. What is the vision of the National Prevention of Blindness Program?
A. Institutionalize visual acuity screening for all sectors by 2010
B. Strengthen partnership among and with stakeholders to eliminate
avoidable blindness in the Philippines
C. Reduce the prevalence of avoidable blindness in the Philippines
through the provision of quality eye care
D. All Filipinos enjoy the right to sight by year 2020
13. The clinic nurse is preparing to test the visual acuity of a client using
a Snellen chart. Which of the following identifies the accurate
procedure for this visual acuity test?
A. Both eyes are assessed together, followed by the assessment of the
right and then the left eye.
B. The right eye is tested followed by the left eye, and then both eyes
are tested.
C. The client is asked to stand at a distance of 40ft. from the chart and
is asked to read the largest line on the chart.
D. The client is asked to stand at a distance of 40ft from the chart and
to read the line than can be read 200 ft away by an individual with
unimpaired vision.
14. The clinic nurse notes that the following several eye examinations,
the physician has documented a diagnosis of legal blindness in the
client’s chart. The nurse reviews the results of the Snellen’s chart test
expecting to note which of the following?
A. 20/20 vision
B. 20/40 vision
C. 20/60 vision
D. 20/200 vision
 15. The client’s vision is tested with a Snellen’s chart. The results of the
tests are documented as 20/60. The nurse interprets this as:
A. The client can read at a distance of 60 feet what a client with normal
vision can read at 20 feet.
B. The client is legally blind.
C. The client’s vision is normal
D. The client can read only at a distance of 20 feet what a client with
normal vision can read at 60 feet.
16. Tonometry is performed on the client with a suspected diagnosis of
glaucoma. The nurse analyzes the test results as documented in the
client’s chart and understands that normal intraocular pressure is:
A. 2-7 mmHg
B. 10-21 mmHg
C. 22-30 mmHg
D. 31-35 mmHg
17. A client is admitted following a motor vehicle accident where his
left thigh is crushed beneath the vehicle. The nurse must assess for
which of the following complications?
a. Acute renal failure
b. Hypokalemia
c. Hypotension
d. Fat emboli syndrome
18. Nurse Miannie is preparing a client who sustained a hip fracture for
discharge. Nurse Mian should teach the client to avoid which of the
following groups of activities to prevent dislocation of the hip?
a. Crossing legs, bending at hips, sitting on low-toilet sits
b. All exercises, bed rests, and using raised toilet seats
c. Taking leisurely walks, low chair seats, and bending at hips
d. Using a reacher device for applying shoes and socks
19. A client with total hip replacement is concerned about dislocation
of the prosthesis. What can the nurse say to reassure this client?
a. “Avoid activities that cause adduction of the hip to prevent
dislocation”
b. “Use of elevated toilet seats alone will prevent dislocation”
c. “Perform bending exercises as often as able to prevent dislocation”
d. “Remove the foam abduction pillow as soon as possible”
20. A client in traction slides down in the bed so that the feet touch the
foot of the bed. What should Nurse Greta do to ensure that the pull of
traction remains uninterrupted?
a. Release the weights, pull client up in the bed, and then re-apply
weights
b. Ask physician for a change in the amount of weight ordered
c. Move the client up in bed without releasing pull of traction on the
extremity
d. Elevate the client’s feet on pillow
21. The nurse is caring for a client who had open reduction and internal
fixation (ORIF) of the right femur 4 days ago. The client reports intense
pain, swelling, tenderness, and warmth at the site; chills, malaise; and
has a temperature of 39oC. The nurse concludes that this data is
consistent with which of the following?
a. Fat embolism
b. Compartment syndrome
c. Osteomyelitis
d. Malunion of the bone
23. A 12-year-old girl has a long leg cast applied to her leg. She is being
instructed in crutch- walking with no weight bearing on her left leg.
Which of the following observations indicates that the girl needs
further teaching?
a. She is using the three- point gait.
b. Her elbows are slightly flexed.
c. She places the crutches approximately six to eight inches (15 to 20
cm) in front of her with each step.
d. She is supporting her weight on the axillary bass and hand pieces of
the crutches.
25. Which of the following measures would a nurse encourage a
patient in the acute stages of gout to take in order to minimize
complications?
a. Drinking a minimum of 3000 ml of fluid per day
b. Eating a minimum of 2500 calories per day
c. Walking at least three mine per day
d. Resting at least three hours per day
1. A patient with a diagnosis of gout is on allopurinol (Zyloprim)
therapy. Which of the following serum laboratory values should be
monitored to determine the effectiveness of treatment?
a. Glucose
b. Calcium
c. Alkaline phosphatase
d. Uric acid
2. A nurse would explain to a patient who is administered prednisone
(Deltasone) for the treatment of rheumatoid arthritis that the expected
outcome would be to:
a. Enhance the immune system
b. Increase bone density
c. Decrease inflammation
d. Reduce peripheral edema
3. What risk factors if identified by the nurse would put a client at risk
for developing osteoporosis?
a. Menopause, stress, sedentary lifestyle, smoking, excessive alcohol
intake, and diet deficient in calcium and vitamin D
b. Family history, age, history of falls, smoking, alcohol and diet
deficient in protein
c. Diet deficient in protein and carbohydrates, smoking, excessive
alcohol intake, stress and sedentary lifestyle
d. Inadequate sunlight exposure, obesity, depression, poor dietary
intake of calcium, and excessive alcohol intake
4. The nurse is developing a plan of care for the client scheduled for
cataract surgery. The nurse documents which more appropriate nursing
diagnosis in the plan of care?
A. Self-care deficit
B. Imbalanced nutrition
C. Disturbed sensory perception
D. Anxiety
5. The nurse is performing an assessment in a client with a suspected
diagnosis of cataract. The chief clinical manifestation that the nurse
would expect to note in the early stages of cataract formation is:
A. Eye pain
B. Floating spots
C. Blurred vision
D. Diplopia
SITUATION: Nurses must be skilled in the assessment of the neurologic
system, whether the assessment is generalized or focused on specific areas of
function. On-going assessment of the patient’s neurologic function and
health needs, identification of problems, mutual goal setting, development
and implementation of care plans and evaluation of the outcomes of care are
nursing actions integral to the recovery of patient.
6. A client is scheduled for an electroencephalogram (EEG) early in the
morning. The nurse working in the night shift prior to the procedure would
write a note to do which of the following in the early morning on the day of
the test per physician order?
a. Instruct the client to refrain from washing her hair
b. Withhold daily dose of antiepileptic drug
c. Place client on NPO status
d. Reinforce client teaching that the test is only mildly uncomfortable
7. A patient is scheduled for computerized tomography (CT) scan to
detect possible brain lesion. Which of the following statements would a
nurse make to a patient who is scheduled for a computerized
tomography (CAT) scan?
a. “You will experience minimal discomfort”
b. “You will be exposed to a magnetic field”
c. “You will be required to lie still for an hour after the study”
d. “You will need to drink eight glasses of water before the rest”
8. Which of the following statements, if made by a patient who is
scheduled for a magnetic resonance imaging (MRI) scan, would indicate
the need for follow-up by a nurse?
a. “There is a pacemaker in my chest.”
b. “My jewelry will be removed before the procedure.”
c. “I have a nicotine patch.”
d. “I will not wear contact lenses during the procedure.”
9. An adult has a medical diagnosis of increased intracranial pressure
and is being cared for on the Medical-Surgical ward. The nursing care
plan includes elevating the head of bed and positioning the client’s
head in proper alignment. What is the reason for these actions?
a. Makes it easier for the client to breathe
b. It reduces pain
c. It promotes venous drainage
d. Prevents Valsalva maneuver
10. The client with increased intracranial pressure begins to have
Cheyne-Stokes respirations. What is the correct explanation for this
occurrence?
a. Completely irregular breathing pattern with random deep and
shallow respirations
b. Prolonged inspirations with inspiratory and/or expiratory pauses
c. Rhythmic waxing and waning of both rate and depth of respiration
with brief periods of interspersed apnea
d. Sustained, regular, rapid respirations of increased depth
11. Nurse Hannah is caring for an adult client who was admitted unconscious
due to motor vehicular accident. The initial assessment utilized the Glasgow
Coma Scale. Nurse Hannah knows that of the following, which are included
when assessing a client using the Glasgow Coma Scale?
1. Eye opening
2. Motor response
3. Pupillary reaction
4. Verbal response
5. Deep tendon reflex

a. 1, 2, 4 b. 1, 3, 4
c. All except 3 d. All of the above
12. When Nurse Hannah tested an unconscious patient for noxious
stimuli, the client responded with decorticate rigidity or posturing.
What is the best description for this action?
a. Flexion of upper and lower extremities into fetal-like position
b. Rigid extension of the upper and lower extremities and plantar
flexion
c. Complete flaccidity of both upper and lower extremities and
hyperextension of the neck
d. Flexion of the upper extremities, extension of the lower extremities
and plantar flexion
13. Nurse Hannah is observing Nurse Maylin doing mouth care to an
unconscious patient. Which of the following actions by Nurse Maylin
would be contraindicated when performing mouth care with an
unconscious patient?
a. Giving oral care using toothettes
b. Brushing teeth with a small (child-sized) toothbrush
c. Positioning the client to one side or the other
d. Using alcohol-based product for most effective cleansing
14. Nurse Vincent is teaching a client with transient ischemic attacks
about aspirin therapy. Which statement indicates understanding of the
reason for his aspirin therapy?
a. “I must take the aspirin regularly to prevent the headache that many
people have with this disorder”
b. “If I take aspirin, I am less likely to develop bleeding in my brain”
c. “The aspirin will help to prevent me from having a stroke”
d. “Taking aspirin regularly will reduce my chances of having a heart
attack”
15. A client is admitted with a C7 complete transection because of fall
from horse riding in Tagaytay. What must nurse Daniel plan for in the
immediate post-injury period?
a. Bladder and bowel training
b. Possible ventilator support
c. Complications of autonomic dysreflexia
d. Diaphragmatic pacing
16. A client who experienced a spinal cord injury at the level of T5 rings
the bell for assistance. Upon entering the room, Nurse Hannah finds
the client to have a flushed head and neck, complaining of severe
headache, and being diaphoretic. The pulse is 47 and BP is 220/114
mm Hg. Nurse Hannah concludes that immediate treatment is needed
for:
a. Malignant hypertension
b. Pulmonary embolism
c. Autonomic dysreflexia
d. Spinal shock
17. A client with spinal cord injury develops signs and symptoms of
autonomic dysreflexia. What would Nurse Bing’s initial action?
a. Administer an analgesic to relieve headache
b. Instruct the client on preventive measures
c. Examine the rectum for a fecal mass
d. Sit the client up to lower the blood pressure
18. A patient who has a spinal cord transection is in spinal shock. On
the assessment, the nurse would expect the patient to describe which
of the following findings in the lower extremities?
a. Loss of sensation
b. Complaints of tingling
c. Excessive diaphoresis
d. Constant tremors
19. A homeless man is brought to the emergency room in a confused
state following a seizure in public. Witnesses report the seizure as
occurring suddenly and lasting at least 2 or 3 minutes. A first responder
on the scene says “he swung his arms and his entire body shook.”
Physician ordered phenytoin (Dilantin). Nurse Jason infuses phenytoin
(Dilantin) with which of the following solutions to control seizures?
a. Normal saline solution
b. D5W
c. Lactated ringer’s solution
d. D5W 0.5 normal saline
20. Nurse Miannie is giving discharge instructions to an adult client
taking Phenytoin (Dilantin). Which of the following is correct and must
be included in the discharge teaching?
a. If there are problems while taking Dilantin orally, the drug is easily
given intramuscularly
b. Alcohol interferes with the absorption of Dilantin. Do not drink
alcohol while taking dilantin
c. Dilantin builds up in the body and achieves blood levels that prevent
seizures. Skipping a day or two will not affect the Dilantin blood levels
d. Slurred speech and confusion are side effects of Dilantin and are
normal while taking Dilantin
21. A 16-year-old boy is brought to the emergency room while seizing.
The neighbors who called for help report that he has a long-standing
seizure disorder and add that he is seizing for at least 30 minutes when
they called. What is the drug of choice for the client’s condition?
a. Phenytoin (Dilantin)
b. Carbamazepine (Tegretol)
c. Phenobarbital (Luminal)
d. Diazepam (Valium)
22. An elderly client has suffered a cerebrovascular accident (CVA) and
as a result has left homonymous hemianopsia. Based on this fact, what
measure will Nurse Michael include in this client’s plan of care?
a. Supporting the client’s left arm and hand with pillows
b. Applying a patch to the client’s left eye
c. Encouraging the client to use his right hand for activities of daily
living
d. Placing the client’s meal on the right side of the overbed table
23. The client has right hemiplegia as a result of a cerebrovascular
accident (CVA). Which finding indicates that the caregivers understand
the importance of positioning a client with hemiplegia?
a. The right shoulder is adducted and internally rotated
b. The right hip is externally rotated with knee flexion
c. The right foot shows plantar flexion
d. The right fingers are extended with the thumb abducted
24. An adult has been receiving physical therapy following a
cerebrovascular accident (CVA). His left leg is weak and he is instructed
in the use of cane. What documentation by Nurse Isabelle shows the
client’s ability to use the cane correctly?
a. Holds the cane in his left hand
b. Leans his body toward the cane when walking
c. Advances the left leg and cane simultaneously
d. Advances the right leg and cane simultaneously
25. A client newly diagnosed with trigeminal neuralgia asks the nurse to
explain why it hurts so much when an episode occurs. Which of the
following is the best response by the nurse? “The pain is caused by:
a. Stimulation of the nerve by temperature or pressure
b. Irritation due to cellular effects of hypoglycemia
c. Release of epinephrine during “fight or flight response”
d. An immune system reaction to cold and influenza