Chapter 20 Medical Surgical Nursing 2nd Edition By Osborn Wraa Watson

Chapter 20 Medical Surgical Nursing 2nd Edition By Osborn Wraa Watson

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

When assessing the patient’s cognitive function, the nurse would evaluate which parameter?

1. Ability to smell items placed under the nose while eyes are closed
2. Orientation to time, place, and person, and ability to recall recent and past events
3. Ability to walk with a smooth, steady gait
4. Level of consciousness

Correct Answer: 2

Rationale 1: This assessment method is used to test for cranial nerve 1, the olfactory nerve.

Rationale 2: Orientation to time, place, and person and ability to recall recent and past events is part of cognitive ability.

Rationale 3: Gait is not reflective of cognitive ability.

Rationale 4: Level of consciousness is not reflective of cognitive ability.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 2

Type: MCSA

When testing cranial nerve XI (spinal accessory), the nurse should ask the patient to perform which activity?

1. Shrug the shoulders and turn the head against resistance.
2. Stick out the tongue and move it from side to side.
3. Taste foods and distinguish sweet from sour.
4. Identify smells correctly with one side of the nares blocked.

Correct Answer: 1

Rationale 1: Cranial nerve XI, the spinal accessory nerve, is tested by asking the patient to shrug the shoulders and turn the head against resistance.

Rationale 2: Cranial nerve XII, the hypoglossal nerve, is tested by asking the patient to stick out the tongue and move it from side to side.

Rationale 3: Cranial nerve VII, the facial nerve, is tested by asking the patient to distinguish between different tastes.

Rationale 4: Cranial nerve I, the olfactory nerve, is tested by having the patient identify smells correctly with one side of the nose blocked.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 3

Type: MCSA

The nurse observes a patient who has a lack of coordination, clumsy movements, and an unbalanced gait. How would the nurse document this observation?

1. As flaccidity
2. As paralysis
3. As hemiparesis
4. As ataxia

Correct Answer: 4

Rationale 1: Flaccidity is an abnormal condition in which movement does not occur at all in a part or is impaired.

Rationale 2: Paralysis is an abnormal condition in which movement does not occur at all in a part.

Rationale 3: Hemiparesis is an abnormal condition in which movement does not occur at all in half of the body.

Rationale 4: In ataxia, there is a lack of coordination, clumsy movements, and an unbalanced gait.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-1

Question 4

Type: MCSA

What precaution must the nurse take when performing the Romberg test?

1. Have the patient remain seated.
2. Stand close to the patient.
3. Have the patient keep the eyes open.
4. Warn the patient that a sharp object is being used for the test.

Correct Answer: 2

Rationale 1: The Romberg test is not done with the patient in a seated position.

Rationale 2: The patient may lose balance during this test. Injury is a possibility, so the nurse should stand close to the patient.

Rationale 3: The Romberg test is done with the eyes closed.

Rationale 4: The Romberg test does not require use of a sharp object.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1