GI/Neuro Med Surg

Detailed Answer Key

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in

supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next

container arrives?

A. Dextrose 5% in water

Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water

could cause rapid shifts in serum levels of some substances.

B. 0.9% sodium chloride

Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride

could cause rapid shifts in serum levels of some substances.

 C. Dextrose 10% in water

Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia,

the nurse should infuse dextrose 10% or 20% in water until the next container of

TPN solution arrives.

D. Lactated Ringer’s solution

Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s

solution could cause rapid shifts in serum levels of some substances.

2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following

statements by the nurse is appropriate?

A. “You should decrease your caloric intake when abdominal pain is present.”

Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase

their caloric intake in order to maintain weight.

 B. “You should increase your daily intake of protein.”

Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein.

C. “You should increase fat intake when experiencing loose stools.”

Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent

stimulation of the pancreas and steatorrhea.

D. “You should limit alcohol intake to 2-3 drinks per week.”

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GI/Neuro Med Surg

Detailed Answer Key

Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent

stimulation of the pancreas.

3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If

the client manifests increased intracranial pressure, which of the following findings should the nurse expect?

(Select all that apply)

 A. Violent headache

B. Neck pain and stiffness

 C. Slurred speech

 D. Projectile vomiting

 E. Rapid loss of consciousness

Rationale: Violent headache is correct. The client who manifests ICP should display a violent

headache

Neck pain and stiffness is incorrect. The client who manifests ICP should not

display neck pain and stiffness

Slurred speech is correct. The client who manifests ICP may display slurred

speech.

Projectile vomiting is correct. The client who manifests ICP may display sudden

onset of projectile vomiting.

Rapid loss of consciousness is correct. The client who manifests ICP may display a

sudden rapid loss of consciousness.

4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate

finding by the nurse?

 A. Severe headache

Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due

to meningeal inflammation.

B. Bradycardia

Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not

bradycardia.

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GI/Neuro Med Surg

Detailed Answer Key

C. Increased muscle tone

Rationale: The nurse should find as a sign of meningococcal meningitis decreased not

increased muscle tone.

D. Oriented to time, person, place

Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not

orientation to time, person, and place.

5. A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the

client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a

manifestation considered an early indication of increased intracranial pressure (ICP) is

A. bradycardia.

Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse

pressure and bradycardia may be later signs of increased ICP.

B. ipsilateral pupil dilation.

Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure

displaces the brain against the optic nerve, but pupil dilation is not an early sign of

increased ICP.

C. widening pulse pressure.

Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse

pressure and bradycardia may be later signs of increased ICP.

 D. lethargy.

Rationale: Increased intracranial pressure is a condition in which the pressure of the

cerebrospinal fluid or brain matter within the skull exceeds the upper limits for

normal. An early sign of increasing ICP is lethargy.

6. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The

nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

A. NPO until dysphagia subsides

Rationale: Making the client NPO provides no nutritional support and will not likely be

prescribed.

 B. Supplements via nasogastric tube

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GI/Neuro Med Surg

Detailed Answer Key

Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk

for aspiration caused by a diminished gag reflex or difficulty swallowing. This

nutritional therapy will likely be prescribed.

C. Initiation of total parenteral nutrition

Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the

ingestion, digestion, and absorption of essential nutrients. This nutritional therapy

will not likely be prescribed.

D. Soft residue diet

Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty

swallowing solids; therefore, this nutritional therapy will not likely be prescribed.

7. A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she

should communicate with the client. Which of the following is an appropriate response by the nurse?

 A. "Incorporate nonverbal cues in the conversation."

Rationale: Nonverbal cues enhance the client’s ability to comprehend and use language.

B. "Ask multiple choice questions as part of the conversation."

Rationale: Simple questions requiring yes/no responses are better understood by the client.

C. "Use a higher-pitched tone of voice when speaking."

Rationale: Tone of voice is understood by clients with aphasia, unless they have a hearing

impairment.

D. "Use simple child-like statements when speaking."

Rationale: It is important to respect the client and use age-appropriate communication.

8. A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of

the following outcomes should the nurse expect from this client’s medication therapy?

 A. Increased sodium excretion

Rationale: The primary action of spironolactone is to increase sodium excretion in the urines.

B. Decreased urinary output

Rationale: Spironolactone is a diuretic, thus it should increase urine output.

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